Clinical Profile and Outcome of the Patients with Spontaneous Duodenal Perforation and Their Association with H Pylori Infection

Abstract

Background: Peptic ulcer disease (PUD) results from an imbalance of acid secretion and mucosal defences. The strong association between H. pylori infection and PUD exists. The overall prevalence of H pylori infection and peptic ulcer has decreased by use of PPI’S and therefore of duodenal perforation but the prevalence in third world countries is still more. PPU used to be a disorder mainly of younger patients (predominantly males). Need for surgery and mortality has remained stable.

Pathology is divided into (1) H. pylori-positive (2) H. pylori-negative and non-NSAID associated (3) NSAID associated.

Management includes Non-operative Management and Operative Management by a) Simple Closure by Cellan Jones repair and Grahams patch and b) Definitive Surgery in H. pylori-negative, or those with recurrent ulcers despite triple therapy.

Objectives: Clinical profile of patients presenting with spontaneous duodenal perforation.

The outcome of patients undergoing omentoplasty.

 H pylori association in patients with duodenal perforation.

Study Design: Hospital-based retrospective observational study from January 2015 to June 2017 and prospective observational study from July 2017 to June 2019.

Participants: Department of Surgery and Minimal Invasive Surgery; and Department of Gastroenterology, SKIMS Soura.

Methods: Questionnaire was used to collect data from patients. All patients with the diagnosis of perforated spontaneous duodenal ulcer were included. A biopsy was taken after 06 weeks of surgery from body and antrum (2 from each).

Results:  Total of 44(12 retrospective and 32 prospective) were enrolled. Age varied from 18- 75 years with a peak incidence between   21- 30 years. 95.5 % were males. 29(65.9%) belong to a rural area. 22 are working class. Maximum incidence was during April- June 40.9%. 93.2 % had pain epigastrium.  97.7 % had abdominal signs. 31(70.5%) were smokers. 11(25.0%) had history and 4.5% of patients were taking NSAIDS. 17 cases (38.6%) had psychological stress. 25 (56.8%) were taking spicy foods. 14 (31.8%) had history suggestive of peptic ulcer and 06(13.6) were diagnosed cases. 27 (61.4%) presented within the first 24 hours of presentation of symptoms. In 23(52.3%) pulse rate was between 100-120/minute and in 20(45.5%) was less than 100/minute. BP was normal in 91.0%. Gas under diaphragm was noticed in 41 patients. 04(9.0%) were hypertensive, 01 (2.27%) had T2DM, 01 had B Asthma and 01 was CKD. In 26 Cellan Jones procedure was done and in 16 Grahams patch was put. In all cases anterior surface was involved and with solitary perforation. In 41 first part of duodenum was involved. 43 were operated. 41 underwent omentoplasty and were uneventful in 40 patients. In 23(88.4%) biopsy was H pylori induced chronic gastritis.

Conclusions: From this study, we concluded that 88.4% of patients are H pylori-positive which is equal to the prevalence of H pylori in the general population.

Implications:  H. pylori infection should be treated in all patients with spontaneous duodenal perforation.