Role of Clinical Decision and Management of Patients Admitted with Perforated Peptic Ulcer to Damascus Hospital ( Al Moujta-hed ) , Damascus , Syria

Citation: Kubtan MA, Alsharif AM, Al Sharif MN (2018) Role of Clinical Decision and Management of Patients Admitted with Perforated Peptic Ulcer to Damascus Hospital (Al Moujtahed), Damascus, Syria. Int J Surg Res Pract 5:087. doi.org/10.23937/2378-3397/1410087 Accepted: October 22, 2018 ; Published: October 24, 2018 Copyright: © 2018 Kubtan MA, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. International Journal of Surgery Research and Practice Open Access ISSN: 2378-3397


Introduction
Peptic ulcer disease (PUD) is characterized by focal defects in the gastric or duodenal mucosa that extend to the submucosa or deeper.It is caused by an imbalance between gastric acid-pepsin and mucosal defense barriers (48,49).Globally, at least 4 million people are affected by peptic ulcer diseases annually [1].Its incidence ranged from 1.5%-3% [2].
Usually, 10%-20% of patients with PUD may have complications and only 2%-14% of those will have perforation causing severe illness [3].On review of the international literature, it was found that PUD had a morbidity rate of up to 50% and mortality rate of up to 30% globally [4], while the mortality rate in our study was (13.4%).It is reported that about 5% of patients with PUD will have a perforation during their life [5].ers, 10.4% were alcoholic, 32.8% had stimulants intake (tea, coffee) and 38.8% were taking NSAIDS.Table 3 shows the patients' relation to PUD risk factor's.Only 26 patients (38.8%) have been taking NSAIDS and 9 of them (out of the 26, 34.6%) were between 60-69 years old.
Erect abdomen X-ray including the dome of diaphragm proved that 39 patients (58.2%) with free air under the diaphragm the X-ray report based on the Radiologist experience in reviewing the radiological finding from the monitor due to the lack of X-ray films.Patients were treated either by laparotomy (95.5%) of all patients and by laparoscopy (4.5%), the surgical intervention consisted of the closure of perforation with an omental patch on also four quadrant biopsies taken in PGU.

Discussion
It is a serious complication of PUD characterized by (PPU) which occurs in about 5% of PUD.PPU is considered a serious insult due to its high morbidity rates and its (1.3% to 20%) mortality rates [1].
This study aimed to analyze and identify the prevalence of PUD in 67 patients whom they have been reviewed at Damascus Hospital (AL Mujtahid) between 24/7/2015-4/5/2017.

Materials and Methods
This was a retrospective study of the patients who admitted as an emergency to Damascus hospital between 24/11/2015 to 4/11/2017.Our study included all the patients who were diagnosed with gastric or duodenal perforated ulcer (67 patients).All The data were collected by authors to ensure the privacy and all the names were blinded.The data collected included the age of the participants, the time onset of symptoms and history of PUD risk factors.A careful clinical history, physical examination were the core factors in making up the diagnosis, diagnostic procedures were done according to availability, including checking erect chest and abdomen X-rays on X-ray monitor, abdominal ultrasound,) as well as routine laboratory tests (blood count and formula, bleeding and coagulating time, prothrombin time, creatinine, urea & electrolytes, blood sugar, and urinalysis).Surgical interventions was based on clinical impression whether it was compatible with investigational finding or not, since the seriousness of the clinical impression was the most important factor in deciding the steps of the management, Furthermore, days of hospitalization and mortality.Statistical Analysis was done using SPSS 23.0 (SPSS Inc.,).

Results
67 patients were admitted to the surgical department at Damascus Hospital (Al-Mujtahid) with PPU.They were between 15-80 years old; the mean age was 48-years-old.58 patients were males (87%) compared to only 9 females (13%) with a prevalence ratio male: female (6:1).
On review we found 48 patients (71.6% of all patients) had perforated duodenal ulcer (P.D.U), 19 patients (28.4%) with perforated gastric ulcer (P.G.U) and 22 patients (32.8%) either duodenal or gastric (13 and 9 cases, respectively) had a drug-induced ulcer (D.I.U), and one patient with P.G.U proved to be malignant and excluded from the current study (Table 1).
All the patients had abrupt onset of acute abdominal pain on presentation.In addition, half of them complained of vomiting, 38.8% had constipation, 17.9% had a fever, 3% had hematemesis and 4.5% had melena.Table 2 summarizes the symptoms of patients at presentation.
Patients taking NSAIDS had an increased chance of having D.I.U (p < 0.05)79.1% of all patients were smok- ed after more than 24 hours from the onset of symptoms.In our study, we found that 100% of patients complained of abdominal pain.
23% of PUD is related to smoking [19].Most likely, due to its effect on pancreatic bicarbonate secretion, which increases gastric acidity [19,20].In our study, 79.1% (53 patients) were smokers.Alcohol and stimulants also increase PUD risk and, in our study, 10.4% and 32.8% of all patients were ingesting alcohol, respectively.
All patients referred to Radiology Dept for chest and abdomen screening in the erect position urgently and reviewed by an expert Radiologist on the monitor only due to a lack of X-ray films, in the case of acute abdomen presentation with serum amylase/lipase [21].75% of PPU have free air under the diaphragm [22].In our study, 58.2% of patients had free air under the diaphragm.
Closure of perforation is the treatment of choice for PPU [2].Sixty-four patients (95.5%) were treated with classical surgery while only 3 patients (4.5%) were treated with laparoscopic surgery.
The size of PPU played a major factor in switching to conventional from laparoscopic surgery treatment when the ulcer size is larger than 9 mm [23].In our study, most of the patients' ulcers were 2-10 mm while only two had an ulcer wider than 15 mm.

Conclusion
In our study, the mean age of participants was 48-years-old with a predominance of males > females 87% with a male to female ratio 6:1.The most common PPU was duodenal 71.6% of all patients.In our study it was proved that making the diagnosis must be made on the clinical suspicion and experiences of the examining physician when X-ray finding may be unreliable due to shortage of accessory elements (Having only to review radiological Monitor).It is clear that making a prompt clinical diagnosis represent the land stone in the management of the clinical problem in saving the patient and averting the risk of morbidity and mortality associated with PPU.
Patients taking NSAIDs have a higher risk of developing gastric ulcer (P = 0.045) and D.I.U (P = 0.000).Our study demonstrates that abdominal pain and vomiting are the two major and early clinical predictors of the diagnosis and risk.

Table 1 :
Distribution of types of PPU among patients in this study.

Table 2 :
Occurrence of different symptoms in patients of this study.

Table 3 :
Relation between patients of this study and PUD risk factors.