Duodenal Ulcer Perforation

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Safety of Non-surgical Treatment of Duodenal Ulcer Perforation 1 Safety of Non-operative Treatment of Duodenal Ulcer Perforation AA Ashraf Ali; M Monowarul Department of Surgery, Dhaka Medical College Hospital

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Safety of Non-surgical Treatment of Duodenal Ulcer Perforation 2 Abstract The surgical treatment of perforated peptic ulcer dates from the year 1880, when Mikulicz sutured a perforated gastric ulcer for the first time. The first two cases of primary-gastric resection for ulcer perforation were described by von Haberer as early in 1919. During the 1970s and 1980s suture supplemented with vagotomy was an alternative surgical procedure. Conservative management of ulcer perforation as an alternative to surgery in selected patients was first advocated by Taylor in 1946.

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Safety of Non-surgical Treatment of Duodenal Ulcer Perforation 3 Abstract Contd. The introduction of antibiotics improved the prognosis of ulcer perforation surgery greatly. Postoperative lethality decreased until 1950 but had remained stable since then. The delay before surgical treatment is a strong determinant for lethality, complication rates, and hospital costs.

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Safety of Non-surgical Treatment of Duodenal Ulcer Perforation 4 Introduction: Some patients with perforated peptic ulcers can be managed non-operatively with a successful outcome. A good percentage of people who receives operative treatment for peptic ulcer perforation, develop intestinal obstruction and need surgery again.

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Safety of Non-surgical Treatment of Duodenal Ulcer Perforation 5 Introduction contd. To find out who are those , can be treated non-surgically, need a precise clinical decision. Clinical parameters like - intensity of pain, muscle guarding, general toxic features, amount of peritoneal fluids (soiling), pneumoperitoneum, over all general outlook of patients, probable cause of perforation all are important to consider for a decision of non-surgical treatment of those perforations.

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Safety of Non-surgical Treatment of Duodenal Ulcer Perforation 6 Introduction contd. A policy of naso-gastric suction, intravenous fluids, antibiotics and analgesics will allow many perforations to seal spontaneously and the ileus to resolve. An H2-blocker administered parenterally is usually added to reduce both acid secretion and gastric juice volume.

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Safety of Non-surgical Treatment of Duodenal Ulcer Perforation 7 Patients & Methods: Study design: Observational longitudinal Duration of study: 1998-2006 Study population: 960 Duodenal ulcer perforation cases

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Safety of Non-surgical Treatment of Duodenal Ulcer Perforation 8 Inclusion criteria: Duodenal ulcer perforations who are decided for non-surgical treatment on a clinical ground, that is history of NSAID/steroid intake stable haemodynamic status localized/ minimum abdominal pain localized tenderness and/or rigidity no or minimum gas shadow under the dome(s) of the diaphragm has been included in this study.

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Safety of Non-surgical Treatment of Duodenal Ulcer Perforation 9 Exclusion criteria: Gastric perforation Traumatic perforation Appendix perforation Typhoid / Tubercular perforations. Cost-effectiveness: Sonography for this study group is free of cost from Radiology & Imaging department of Dhaka Medical College Hospital.

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Safety of Non-surgical Treatment of Duodenal Ulcer Perforation 10 The patients were grouped into three grades– Grade-1 : obviously favorable for conservative treatment, Grade-2 : borderline, Grade-3 : non-favorable for conservative treatment . Grade 1 & 2 patients were closely observed every 2 hourly for 12 hours, migration of any parameter to Grade-3 were subjected to surgical intervention if not otherwise unfit. Methods: We fixed a definitive criteria for continuing non surgical treatment reviewing different literatures.

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Safety of Non-surgical Treatment of Duodenal Ulcer Perforation 11 Parameters score-1 score-2 score-3 Age young middle *elderly History of DU long history present *no history History of NSAID long history present *no history Vital parameters normal changed *marked changed Tenderness mild moderate *severe Rigidity mild moderate *severe Bowel sound bowel moved present *absent Gas shadow leaking moderate *massive gas& fluid level Grade-1: score 7 to 10 Grade-2: score 11- 14 Grade-3: score >15 Presence of 2 or more “ * “ marked parameters are clearly fall into outfit for conservative treatment

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Safety of Non-surgical Treatment of Duodenal Ulcer Perforation 12 Results: Successful Non-operative treatment: 200(20.83%) Male: 171 (85.50%) Female: 29(14.50%) Ratio: 5.89:1

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Safety of Non-surgical Treatment of Duodenal Ulcer Perforation 13 Total cases Age range: 15-85 years Age distribution (n =960): 10-19 = 33 (3.43%) 20-29 = 237 (24.68%) 30-39 = 242 (25.20%) 40-49 = 243 (25.31) 50-59 = 83 (8.64%) 60-69 = 79 (8.22%) 70-79 = 40 (4.16%) > 80 = 03 (0.31%) Conservative cases Age range: 15-85 years Age distribution (n =200): 10-19 = 05 (02.50%) 20-29 = 68 (34.00%) 30-39 = 60 (30.00%) 40-49 = 55(27.50%) 50-59 = 05(2.50%) 60-69 = 04(02.00%) 70-79 = 02(02.00%) > 80 = 01(0.50%) Age Incidence

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Safety of Non-surgical Treatment of Duodenal Ulcer Perforation 14 History of NSAIDs intake (n=200) NSAIDs intake Number of patients Percentage Positive 148 74 Negative 52 26 Patient profile. Profile Number of patients Percentage Sudden severe pain in epigastrium 200 100 Obliteration of liver dullness 192 96 Absent Bowel sound 200 100

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Safety of Non-surgical Treatment of Duodenal Ulcer Perforation 15 Abdominal X-ray findings Plan X-ray findings Number of patients Percentage Free gas shadow present 184 92 Free gas shadow absent 16 08 Paralytic ileus present 192 96 Paralytic ileus absent 08 04

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Safety of Non-surgical Treatment of Duodenal Ulcer Perforation 16 Duration of hospital stay (n=200) Duration (Days) Number of patients Percentage 4 day 92 92 5 day 64 08 6 day 40 96 7 day 2 04 8 day 2 92

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Safety of Non-surgical Treatment of Duodenal Ulcer Perforation 17 we added Ultrasonography in this study for last 50 cases, because of -

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Safety of Non-surgical Treatment of Duodenal Ulcer Perforation 18 The use of abdominal sonography in suspected perforated duodenal ulcer may help increase the diagnostic accuracy and may reduce the need for surgery. Evidence of intra-peritoneal free fluid and/or reduced intestinal peristalsis at sonographic examination considered as indirect signs of gastro-duodenal perforation. US can demonstrate free air on the liver and a "fish-eye sign" when the anterior or lateral wall become perforated Ultra-sonographic measurements of intra-abdominal fluid in spaces like Sub-pherenic. Sub-hepatic, pelvic spaces etc. can guide for deciding non-surgical treatment of duodenal ulcer perforations.

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Safety of Non-surgical Treatment of Duodenal Ulcer Perforation 19 Peritoneal collection detected by 1 st Ultrasonography (n=50). Amount Number of patients Percentage < 100 ml 7 14 100-200 ml 41 82 > 200 ml 2 4

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Safety of Non-surgical Treatment of Duodenal Ulcer Perforation 20 Frequency of detection peritoneal fluid by Ultrasonography Number of Sono. Number of patients Percentage 1 st Sono (1 st day) 50 100 2 nd Sono (3 rd day) 4 8 3 rd Sono (5 th day) 3 6 Frequency of Ultrasonography needed (n=50). Frequency Number of patients Percentage 2 times 47 94 More than 2 times 3 6

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Safety of Non-surgical Treatment of Duodenal Ulcer Perforation 21 Outcome (n=50) Outcome Number of patients Percentage Successful 47 94 Sub-phrenic abscess 02 04 Pelvic abscess 01 02

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Safety of Non-surgical Treatment of Duodenal Ulcer Perforation 22 Discussion: This study was done to find out, how safe the non-surgical treatment is. Patients were sent for abdominal sonography when their vital parameters were found stable. In 1st sono mostly 100-200 ml fluids were found in different peritoneal spaces in both supine and sitting posture.

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Safety of Non-surgical Treatment of Duodenal Ulcer Perforation 23 Patients who were responded very well to non-surgical therapy (n=47) were found nothing collected in the peritoneal cavity in 2nd sono. Their ileus resolved on 3rd-4th day. They were mostly discharged 4th -5th day following their admission.

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Safety of Non-surgical Treatment of Duodenal Ulcer Perforation 24 Upper G.I. Endoscopy was not advised immediately because it may disrupt the spontaneous sealing. During discharge routine Endoscopy was advised within a week to determine possible other pathology.

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Safety of Non-surgical Treatment of Duodenal Ulcer Perforation 25 6% patients developed few complications in this last 50 cases which is much lower than 33%(SMN ISLAM et al. Journal of surgical sciences 2006; 10(2);46-60). 1patient developed pelvic abscess , sonographic amount was 230ml. He underwent drainage per rectally. Per-rectal ultrasound can be used for safe drainage. 2 patients developed sub- diaphragmatic abscess . These patients were treated by sono guided percutaneous drainage using a “Epidural set” needle.

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Safety of Non-surgical Treatment of Duodenal Ulcer Perforation 26 Conclusion This study demonstrates that up to 20% of duodenal ulcer perforation can be managed non-surgically and help of Ultrasonography can lower much of the complications. Ultrasonography can contribute in diagnosis, deciding modality of treatment as well as therapeutic aspects of duodenal ulcer perforations. This experience highlights up to 200ml initial fluid collection can be managed by non-surgical means successfully in a general hospital. we do however stress the labour intensive methods and close clinical monitoring that is required to avoid overenthusiastic morbid sequelae.

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Safety of Non-surgical Treatment of Duodenal Ulcer Perforation 27 Thank you

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