Diagnosis and treatment of perforated or bleeding peptic ulcers: 2013 WSES position paper
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WORLD JOURNAL OF EMERGENCY SURGERY
REVIEW
Open Access
Diagnosis and treatment of perforated or bleeding peptic ulcers: 2013 WSES position paper Salomone Di Saverio1*†, Marco Bassi7†, Nazareno Smerieri1,6, Michele Masetti1, Francesco Ferrara7, Carlo Fabbri7, Luca Ansaloni3, Stefania Ghersi7, Matteo Serenari1, Federico Coccolini3, Noel Naidoo4, Massimo Sartelli5, Gregorio Tugnoli1, Fausto Catena2, Vincenzo Cennamo7 and Elio Jovine1 Diagnosis and treatment of perforated peptic ulcer (Dr. S. Di Saverio MD) Introduction
Every year peptic ulcer disease (PUD) affects 4 milion people around the world [1]. Complications are encountered in 10%-20% of these patients and 2%-14% of the ulcers will perforate [2,3]. Perforated peptic ulcer (PPU) is relatively rare, but life-threatening with the mortality varying from 10% to 40% [2,4-6]. More than half of the cases are female and they are usually older and have more comorbidities than their male counterparts [6]. Main etiologic factors include use of non-steroidal antiinflammatory drugs (NSAIDs), steroids, smoking, Helicobacter pylori and a diet high in salt [3,7]. All these factors have in common that they affect acid secretion in the gastric mucosa. Defining the exact etiological factor in any given patient may often be difficult, as more than one risk factor may be present and they tend to interact [8]. While previous reports have shown a seasonal variation in the incidence of PPU, others have failed to find such a pattern [9-11]. Other causes of gastroduodenal perforation are traumatic, neoplastic, foreign body or corrosive ingestion, and those that occur as a result of a diagnostic or therapeutic intervention (iatrogenic). Traumatic injury to the stomach and duodenum causing perforation is rare, comprising only 5.3% of all blunt hollow viscus organ injuries, but is associated with a complication rate of 27% to 28% [12]. Perforations from malignancy can result from obstruction and increased luminal pressure, or from successful treatment and response to chemotherapy and involution of a previously transmural tumor [13]. Foreign bodies, ingested either intentionally or accidentally can cause
* Correspondence: [email protected] † Equal contributors 1 Emergency and General Surgery Dept, Maggiore Hospital– Bologna Local Health District, Bologna, Italy Full list of author information is available at the end of the article
perforations, either through direct injury or as a result of luminal obstruction [14,15] (Table 1). Iatrogenic injury is an increasing cause of gastroduodenal perforation. The increasing use of esophagoduodenoscopy for diagnosis and therapy is associated with an increase in procedure-related perforations [16]. Gastroduodenal perforation has also been reported as a complication of a variety of abdominal procedures including Inferior Vena Cava filter placement [17,18], ERCP [19,20], and biliary stents [21]. Outcomes
When PPU are diagnosed expeditiously and promptly treated, outcomes are excellent. Mortality ranges from 6% to 14% in recent studies [22-24]. Poor o
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