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UP remains the most frequently indicated means of urgent surgery in the case of complex ulcerous disease. According to the specialized literature, UP prevents the evolution of the ulcerous disease in 2-10% of the cases and determines a global mortality of 3-14%, in the case of the aged it exceeds 30%.
The peak of the occurrence of the perforation is considered to be between 41-50 but recent publications draw the attention to the increase of the occurrence of perforated ulcer in the case of teenagers. Let alone the increased occurrence at the aged, many times with the suspicion of neoplasic perforations.
UP may be the source of peritonitis, when the bacteria spread by means of gastrointestinal perforation. The peritonitis may initially be chemical and subsequently septic, developing germs. Depending on the level of the inflammation the peritonitis may be local or general. Among the group of patients the mortality rate was of 21% 97 patients) the cause of death being mostly the multi-organic suppurative and generalized insufficiency that appears after the installation of the peritonitis. All 7 patents were operated on more that 24 hours since the beginning of the symptoms.
There is evidence, taking into account anamnesis of the group of patients, that 32% were constantly consuming AINS 2-6 years before the UP observation at the doctor's recommendation; 6% were sporadically consuming AINS without a doctor's recommendation.
Generally in the case of the perforated post-medicinal ulcer the diagnosis is difficult to be determined due to the simultaneous perforation-bleeding syndrome. The pneumoperitoneum's resistance has a certain diagnosis value for any rough abdominal syndrome that may have appeared during the corticotherapy.
Among the group of patients who have been monitored I have encountered 25 cases of perforation also by means of anti-inflammatory medication, 4 cases by treatment that provided medication using cortisone induced for a long period of time in the case of a rheumatic disease and 21 cases with AINS. The last ones represent 9,41% of all the UP cases.
In the case of 6 subjects of over 60 from a total of 21 under AINS cure, the consumption represented a factor of risk for the duodenal ulcerous perforation. The specialized literature and our observations have both reached the conclusion that AINS may determine or exacerbate the ulcer, the bleeding or the perforation.
The corticotherapy used on a large scale caused the increase of accidents in the case of this cure of which the most serious are the perforated ulcers recorded as early as 1951 by Gray and Holander (table 3)
The distribution of the AINS consumers according the localization of the ulcer
Type of ulcer %
a) duodenal ulcer 61,90%
b0 gastric ulcer 38,10%
Among the monitored group I have encountered 112 perforated hidden ulcers having an atypical symptomatology at the moment of hospitalization; suppurative peritonitis in the case of 23 patients and chemical peritonitis in the case of 28 patients.
Among those, only 1/3 admitted to have suffered from ulcer, mostly women, with an extended corticotherapy of 12,5 mg a day. Besider the UP the patients indicated co-morbid conditions.
The distribution of pathological records in the monitored group
Liverwort cirrhosis 20%
Ulcers caused by stress 15%
The characteristics of perforated ulcers in the group of patients are highlighted in the table below:
The perforated ulcers in the group of patients (the characteristics)
The laparoscopic intervention was performed especially on young patients between 20-40 years with a recent perforation; as for the rest, the open surgery was employed, because the patients were aged people having serious associated diseases with latent beginning and risk of shock.
Among the monitored group 98 post-surgical complications have been recorded.
- post-surgical obstructions 14
- post-surgical fistulae 29
- intra-peritoneal residual abscesses 9
- diffusing peritonitis 11
-pulmonary thromboembolism 24
- broncho-pneumonia 11
UGDP is a surgical emergency although the therapy of the ulcerous disease has made progress. The death took place when the patients called on specialized aid more than 24 hours since the beginning and the complications were recorded in the same category of patients.
UGDP is also a consequence of the abusive AINS consumption causing problems by to co-morbid associated conditions because the patients are generally between 50-60 years old.
Nowadays, it is unanimously accepted that the suture of the ulcer, the washing of the peritoneal cavity and the complete anti-ulcerous therapy represent the standard cure for UP.