Materials and Methods:
Between 1995 and 2001, the author operated seven patients who presented with perforated duodenal ulcer 72 hours after perforation. They were initially diagnosed as gastritis in upcountry health units. The highlights of the cases and the appropriate surgical option are presented:
Case 1:
A 32-year-old policeman was referred from an upcountry clinic because of severe abdominal pain due to suspected poisoned food. The referral note described the patient as a teetotaler, conscientious worker who is attached to the CID section of Uganda police. He spends the whole day investigating all sorts of crimes in his area. He rarely, if ever, takes meals during the day except on that unfortunate day when he took a local dish from a local restaurant for his lunch. He had never fallen sick before.
Later in the evening when he returned home from work,
he developed severe abdominal pain. The pain was localized in the upper
abdomen and radiating to the back. He didn’t vomit but rather had
severe nausea. Because the family believed that he had been poisoned
because of the nature of his work, they tried all sorts of emetics from
a traditional healer. Because the patient seemed to improve, the family
decided to continue with the treatment but he was unable to go to work.
After three days, the pain came back and this time more severe and involving the whole abdomen. He developed a temperature and the abdomen became distended. He started vomiting. It is at this stage that the family decided to take him to a clinic upcountry where the attending doctor referred him to my surgical clinic.
On examination, he was in hypovolaemic shock, dyspnoeaic, frightened, dehydrated, febrile and anaemic. He had moderately distended abdomen and generalized abdominal pain. The abdomen was silent and rebound tenderness was remarkable. There was no back pain. Peritonitis secondary to acute pancreatitis was suspected.
He was admitted for resuscitation and exploration. At operation, generalized peritonitis with purulent effusion secondary to perforated duodenal ulcer was found. Pancreas was normal. Peritoneal toilet was done and the perforation closed with an added omental patch. He was discharged after eight days. He is back on duty at his station.
Case 2:
A 36-year-old businessman was traveling from upcountry to Kampala for his business transactions. He was known to be alcoholic and indeed he had taken a lot of it the night before traveling. While traveling from home to Kampala, he developed severe abdominal pain. His colleagues took him to the nearest hospital where he was treated. The working diagnosis was acute gastritis from heavy alcohol consumption. When he seemed to improve, he was allowed to continue with his journey. He decided to rest at home taking the drugs from that hospital. After two days on conservative management, he came to the surgical clinic because there was no improvement.
From the history, it was discovered that he was a known alcoholic who had consumed a lot of it the night before travel. He was known to develop severe hangover after heavy bout of drinking. He used to take panadol and plenty of vegetables for his lunch to be able to continue drinking in the evening. There was no peptic ulcer history.
On examination, he looked sick, exhausted, afebrile but in good nutritional status. The lower abdomen was soft but there was rigidity in the epigastrium. Percussion note showed fluid in the peritoneum. At auscultation, the abdomen was silent and plain abdominal x-ray showed gas under the diaphragm. Haemogram and serum electrolytes were normal. A diagnosis of duodenal ulcer was made.
He was admitted for operation. At operation, a perforated duodenal ulcer, which had been sealed off by omentum was found. Truncal vagotomy and drainage were done. Post-operative period was uneventful. He is back on his business.
Case 3:
A 38- year old man was seen in the surgical clinic because
of severe abdominal pain for three days. He was able to recall
the time when the pain started. He associated the pain with “ adulterated”alcoholic
drink taken the previous night. Pain had persisted despite all
kinds of medications from friends and family. There was no ulcer
history.
On examination, he was in moderate hypovolaemic shock. He was afebrile with normal haemoglobination. Auscultation was normal but with guarding in the upper abdomen. There was rebound tenderness. A plain abdominal x-ray showed gas under the diaphragm.
He was admitted for operation. At operation, a perforated duodenal ulcer was found. There was no peritonitis. The omentum had sealed off the perforation. The perforation was closed and an omental patch added. He made uneventful recovery. He was discharged after five days.
Case 4:
This was a 30-year-old causal worker. Apparently, he spent all his earnings on a potent local gin known as crude waragi. His friends knew him as Mr. D. D. O (Daily Drinking Officer). One night during the drinking spree, he was involved in a scuffle. The following morning, he failed to wake up to go to work and neighbors thought that it was the usual hangover made worse by the scuffles. He was taken to the nearest clinic where a diagnosis of gastritis was made and magnesium trisilicate and panadol were given. For three days, he was on this medication from that clinic. Friends were buying him all sorts of other medications and food to treat the gastritis.
When he deteriorated, he was referred to a surgical clinic where a diagnosis of peritonitis was made. There was no significant medical history and he denied peptic ulcer history. He was admitted for emergency operation. At operation, diffuse peritonitis from a perforated anterior duodenal ulcer was found. Peritoneal toilet and closure of the perforation with an added omental patch were done. He died on the third postoperative day from septicaemia.
Case 5
A 38-year-old female nurse was referred to the surgical clinic from upcountry because of backache and abdominal pain, which had increased in frequency and intensity within the previous 72 hours. The significant points in the referral note were that within the last two years she had been on treatment for thoracolumbar pain of insidious onset. She had been put on Diclofenac sodium 50 mgs tds. She was on and off the drug because she was on self-medication.
In the clinic there was no history of peptic ulcer disease
and therefore no such diagnosis had ever been made. On examination,
she was in pain but in good nutritional status. The abdomen
was rigid with rebound tenderness. Haemogram and serum electrolytes
were normal. Barium meal investigation showed “features
suggesting duodenal diverticulum and duodenal ulcer. Ulceration
and perforation in the diverticulum are not excluded.”
She was admitted for surgery and at operation there was indeed a perforated duodenal ulcer. Partial gastrectomy and gastrojejunostomy were done. Postoperative period was uneventful.
Case 6
This is a 45- year old shopkeeper who was taken to an upcountry clinic because of sudden onset of epigastric pain, which had started the previous night. He had vomited and the vomits contained blood. The severe attack started late at night after a Baptismal party for his daughter. Initial management in the clinic was for gastritis from heavy alcohol consumption. After about three days, he was referred to the surgical clinic. There was no history of peptic ulceration according to the referral note.
On examination, he was a sick man, febrile and in shock. There was guarding with mild rebound tenderness more marked on the right side of abdomen. After thorough examination and investigations, a diagnosis of perforated duodenal ulcer was made. He was admitted for operation.
At operation, a perforated duodenal ulcer with peritonitis was found. After peritoneal toilet, the perforation was closed and augmented with an omental patch. He was put on antibiotics and analgesics. On the fourth postoperative day, he developed a burst abdomen, which was repaired. Thereafter, he made a steady recovery.
Case 7:
This was a 39-year-old Secretary known to be saved. This meant that she does not take alcohol and goes for prayer meetings more often than an average Christian. She was however known to enjoy partying. She was referred to the surgical clinic because of severe abdominal pain, and general weakness.
From the history, it was revealed that she was a single mother with three children. The father of the chil-dren had abandoned her and yet her income was not adequate to cater for the family. She had no history of peptic ulceration. Attempts to get another man were futile and she resorted to prayers.
On examination, she was dehydrated, febrile and anaemic. Haemogram was normal. She had moderately distended abdomen and generalized abdominal pain. The abdomen was silent and rebound tenderness was remarkable. Auscultation was normal with generalized guarding. There was no rebound tenderness. A plain abdominal x-ray showed gas under the diaphragm.
Diagnosis of a perforated duodenal ulcer was made. She was admitted for operation. At operation, a perforated duodenal ulcer was found. It was closed and an omental patch added. The patient made uneventful recovery. She is back in her office on her job.
DISCUSSION
Peptic ulcer disease is becoming more common in developing countries in general and Uganda in particular. There is a higher prevalence of Helicopter pylori infection. Although the actual route of transmission is unknown, oral-oral or faecal-oral transmission is suspected. The contamination of drinking water may play a role8.
Man is the only known reservoir. It is now believed that half of the
world’s population is colonized with H. pylori, and that infection with these bacteria probably happens in childhood. However, why ulcers eventually develop in only some of these people remains unknown.
It has been suggested that environmental factors may play a part. Some studies have shown that the risk factors for ulcer from H. pylori infection include lower socio-economic group in a crowded and unsanitary living environment black or Hispanic and aged 60 or older.4 Changes in life style leading to cigarette smoking, anxiety, stress, excess coffee and alcohol drinking and family history of ulcer disease are other risks.
There is variation in management of peptic ulcer disease. Patients in rural areas are not getting same medical services as their counterparts in urban areas. Specialist clinics are in the city, while general practitioners manage rural medical units.
Recent natural disasters such as the AIDS pandemic in the region are also becoming significant aetiological factors in peptic ulcer diseases. There is a significant presence of HIV patients among our patients coming for endoscopy.
In the general U.S. population the sero prevalence of IgG antibodies to H. pylori is 30-40%, with the rate of seroconversion estimated at 0.5% per year. What appears to be the increasing frequency of seropositivity in older adults in developed countries is mostly due to the cohort effect, with the prevalence of antibody in adults actually reflecting acquisition of disease earlier in life.
Better diagnostic tools particularly fibreoptic endoscopy has helped to make early diagnosis of dyspepsia. Many medical centers offer adequate treatment of non-ulcer dyspepsia; they have the tools and patients have the ability to afford the drugs.
Changes in smoking habits may be contributory. It is in
the developed countries where “No Smoking”zones are enforced.
There is decreased physical work with adequate exercises.
The significant factors in the pathogenesis of perforated duodenal ulcer in this series include 7:
- Acute gastric distention immediately after heavy meals and heavy consumption of alcohol.
- Trauma to the “silent”chronic duodenal ulcer
again from heavy fried foods.
- Psychological stimuli may accelerate perforation in susceptible patients due to stress and strain and worries.