|Ahead of print publication
An assessment of peptic ulcer perforation score: A predictor of mortality following peptic ulcer perforation from a rural tertiary care setting
Taraka Krishna Nulukurthi1, Balaji Karnasula1, L V Simhachalam Kutikuppala1, R Hemanth Kumar Chowdary2, Jyothi Swaroop Chintala3
1 Department of General Surgery, Konaseema Institute of Medical Sciences and Research Foundation, Amalapuram, Andhra Pradesh, India
2 Department of Vascular Surgery, MS Ramaiah Memorial Hospital, Bengaluru, Karnataka, India
3 Department of General Surgery, Dr. NTR University of Health Sciences, Vijayawada, Andhra Pradesh, India
|Date of Submission||28-Oct-2022|
|Date of Acceptance||07-Dec-2022|
|Date of Web Publication||03-Feb-2023|
L V Simhachalam Kutikuppala,
Konaseema Institute of Medical Sciences and Research Foundation, Amalapuram - 533 201, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Background and Aim: Peptic ulcers (PUs) result from the increased aggressive or decreased protective elements in the stomach or duodenum, which can gradually cause mucosal damage and ulceration. The risk of death as a consequence of PU disease is highest in perforation. Therefore, early identification of patients with perforated PUs (PPUs) who are more likely to experience negative outcomes after surgery is crucial for making the right treatment decisions. Hence, this study uses the peptic ulcer perforation (PULP) score to predict mortality within 30 days of surgery and risk stratifies patients undergoing surgical therapy for PPUs. Materials and Methods: The patients presenting to a tertiary care setting with symptoms of hollow viscous perforation and intraoperative evidence suggestive of PPU were included in this prospective study between November 2016 and October 2020. After taking necessary ethical permissions from the institution, a total of 120 PPU patients were made part of this study. Results: In total, 120 patients were involved in the study including 94 men and 26 women. One hundred and ten patients were in the low-risk group, and 10 were in the high-risk group. In the postoperative period, eight patients from the high-risk group passed away, compared to two deaths in the low-risk group. Conclusion: The prognostic markers employed in the PULP score are simple to use and straightforward to be identified before surgery. The PULP score can help with the quick and accurate identification of high-risk patients, which can help with risk stratification and triaging of PPU patients.
Keywords: Peptic ulcer disease, peptic ulcer perforation, perforation, systemic inflammatory response syndrome
|How to cite this URL:|
Nulukurthi TK, Karnasula B, Kutikuppala L V, Chowdary R H, Chintala JS. An assessment of peptic ulcer perforation score: A predictor of mortality following peptic ulcer perforation from a rural tertiary care setting. Arch Med Health Sci [Epub ahead of print] [cited 2023 Mar 29]. Available from: https://www.amhsjournal.org/preprintarticle.asp?id=369092
| Introduction|| |
Peptic ulcers (PUs) are a result of the body's increased aggressive or decreased protective elements, which can gradually cause mucosal damage and ulceration. The mucosal epithelium's secretion of bicarbonate, the columnar epithelium's synthesis of mucus (goblet cells), growth hormones, blood flow for cell renewal, and the presence of endogenous prostaglandins are among the elements that can prevent mucosal injury. PUs are thought to develop as a result of damaging factors such as excessive hydrochloric acid secretion, alcohol consumption, smoking, excessive pepsin release, bile reflux from the duodenum, excessive use of nonsteroidal anti-inflammatory drugs (NSAIDs), ischemia, hypoxia, and Helicobacter pylori (H. pylori) infection.,,
Between 5% and 15% of people are believed to have PU disease globally, with a lifetime incidence of about 10%. With the development of H2 receptor antagonists and proton-pump inhibitors (PPIs), the prevalence of elective surgery for PU illness has reduced, even if its consequences, including bleeding and perforation, have remained uniformly persistent.,,,, The use of PPIs, H2 receptor antagonists, misoprostol, sucralfate, and H. pylori eradication therapy is still the mainstay treatment for PU disease. Complications include bleeding, blockage, perforation, intractability, or nonhealing would be reasons for surgical intervention in PU disease.,
Peptic ulcer perforation (PULP) is still a medical condition that requires urgent surgical intervention. The risk of death from an ulcer disease consequence is highest in perforation. For this reason, it is critical to identify patients with perforated PUs (PPUs) who are at a high risk of suffering complications after surgery. Preoperative respiratory and circulatory stabilization timing and extent, postoperative admission to a high dependency unit, the level and extent of monitoring, and inclusion in particular perioperative care protocols are just a few examples of how accurate and early identification of such patients can help with risk stratification and triage.,,
The PPU is associated with significant mortality and morbidity, with death proportions of 25%–30% documented in population-based studies. Numerous clinical prediction rules have been proposed for prognostic prediction and further research purposes, including the theory score, the "American Society of Anesthesiologists (ASA) score," the "Acute Physiology and Chronic Health Evaluation (APACHE) II score," and the "sepsis score," in response to the large number of prognostic factors for morbidity and mortality following PPU that have been reported. From a comparison analysis, it was found that these ratings did a poor job of predicting death among patients with PPUs.,,,, In patients who undergo PPU surgery, the PULP score can be a considerably more reliable indicator of 30-day mortality than the Boey score or the ASA score. Before surgery, it is simple to identify the prognostic markers that make up the PULP score. In addition, the PULP score can help in the early and accurate identification of PPU patients who are at high risk, aiding in risk stratification and triage., The purpose of this study is to use the PULP score to predict mortality within 30 days of surgery and to risk stratify patients undergoing surgical therapy for PPUs.
| Materials and Methods|| |
Between November 2016 and October 2020, 120 patients who presented to KIMS Hospital, Amalapuram with symptoms of hollow viscous perforation and intraoperative evidence suggestive of PPU were included in a prospective observational study through purposive sampling technique. The patients were recruited before the surgery with the diagnosis of PU disease and plan of surgical management. After taking necessary ethical committee permissions from the institution with a reference number KIMS/2016/019, the study included all individuals who were older than 18 years of age who had hollow viscous perforation features together with intraoperative findings indicative of PPU and were willing to provide written informed consent for the investigation. Patients whose histology results indicated that they had malignant ulcers, hollow viscous perforation instances that had been treated conservatively, or patients who had passed away before surgery, were not included in the study. The suspected PULP patients had a thorough medical history recorded, including information on their age, sex, past use of steroids or NSAIDs, smoking, alcohol consumption, any ongoing malignancies, and other concomitant disorders. The diagnosis was made based on clinical findings and was confirmed by tests such as an erect and supine plain X-ray of the abdomen and a contrast-enhanced computed tomography abdomen. The patient had urgent resuscitation using nasogastric aspiration, intravenous fluids, antibiotics, analgesics, and urine output monitoring. Patients with perforations in their PUs were operated on as soon as it was practical to use Graham's omental patch closure. A biopsy was taken from the ulcer's margins to rule out malignancy. After doing a medical history, physical examination, standard preoperative examinations, radiological imaging, and using the patient's specific ASA score, patients were given points based on the PULP scoring system. Patients were divided into high-risk and low-risk groups based on their PULP scores, and in the immediate postoperative period, continuous bedside monitoring of vital signs was performed on each patient daily. Low-risk patients are those with a mortality risk of <25% (a score of ≤7), and high-risk patients are those with a mortality risk of more than 25% (a score of >7). Patients were checked for complications such as wound infection, wound dehiscence, pleural effusion, septicemia, respiratory infections, renal failure, etc., everyday. Prompt symptomatic treatment consisting of antibiotics, fluid supplementation, wound care, and other preventive measures were provided to the patients depending on their need. Patients were released from the hospital after fully recovering with advice regarding a proper diet, antacid medications, and giving up alcohol and/or smoking, among other things. After a month, all patients were invited for reevaluating the PULP score, and those who did not turn up to the hospital were contacted by phone.
This data was gathered using a thorough structured pro forma. Tables, charts, and graphs were used to discuss the findings and compare them to published literature that was at the time.
| Results|| |
One of the most frequent surgical emergencies requiring immediate surgical care is a PPU. In our study, which was carried out at our hospital between November 2016 and October 2020, we included a total of 120 patients. The majority of the patients (68/110) were in the 41–60 age range, with 42 being in the 41–50, and 26 being in the 51–60 brackets. One hundred and ten patients fall into the low-risk group, and 10 patients fall into the high-risk group, according to the risk classification. In the low-risk group, there were 8/110 older patients (>65 years), whereas there were 8/10 in the high-risk group. Males are 4:1 more likely than females to experience perforation than females. There were 94 male patients and 26 female patients out of the total 120 cases [Table 1]. [Table 2] displays the distribution of patients by ASA score, with the majority of them falling into ASA II and III. There were 46 members of ASA III and 41 members of ASA II. In contrast to the high-risk group, where 8 out of every 10 cases (80%) experienced shock at admission, just 14 out of 110 patients (12.72%) in the low-risk group did. Only 6 of the 110 patients in the low-risk group and 8 of the 10 individuals in the high-risk group had higher blood creatinine levels. Out of 120 cases, we found that 46 (38%) cases had duodenal perforation and 74 (62%) cases had perforation in the gastric-prepyloric region. In both the gastric and duodenal kinds of perforation, the gender distribution showed a male majority. Male patients made up 28/46 (60.8%) of those with duodenal perforation and 66/74 (89.2%) of those with gastric perforation. Using 7 as the cut-off point, the PULP score was calculated for each patient; 110 patients fell into the low-risk category, whereas 10 patients fell into the high-risk category. The duodenal ulcer types were more prevalent in the low-risk group, whereas gastro-prepyloric ulcer types were more prevalent in the high-risk categories. Patients in the high-risk group had a higher mean age (70.02 years) than those in the low-risk group (47.34 years). The mean PULP score varied greatly across the low-risk and high-risk groups, from 2.4 to a substantially higher 10.2 [Figure 1]. Ten (8.33%) individuals passed away during the course of our investigation. Two deaths were noted in the low-risk group, whereas eight instances fell into the high-risk category. When we analyzed the mortality group, we discovered that four PULP score components stood out as being very important: high serum creatinine, shock on admission, high ASA score, and delay at presentation.
|Figure 1: The mean PULP score among the low-risk and high-risk groups. PULP: Peptic ulcer perforation|
Click here to view
| Discussion|| |
Even though ulcer disease is one of the most common and serious gastrointestinal disorders, its incidence and hospitalization rates have been declining for a while. A significant fall in elective surgical therapy for chronic disease has also reduced the role of surgical intervention in the management of ulcer disease. Despite this, the proportion of patients who need emergency surgery for issues including bleeding and perforation has not changed. PPU is associated with significant mortality and morbidity, with death proportions of 25%–30% recorded in population-based studies.
Although PPU can occur at any age, we found that the youngest patient in our study was 18 years old and the oldest was 91 years. Perforations of PUs are frequent in the third and fourth decades of life. In a study by Kocer et al. and a study by Dakubo et al., the average age of PPU patients was 43 years old and 41 years old, respectively. Recent research from Møller et al. and Thorsen et al. revealed older age group patients as being the most frequently affected age groups (median age, 71 and 67 years, respectively).
Our research is consistent with that of Kocer et al. and Dakubo et al. In our study, the mean age of patients with PULP was 49.25 years old. The findings of our study are consistent with research done in India by Testini et al. and Dakubo et al. Males made up 78.3% of the study population in our study, whereas females made up 21.7% of the study population. Mortality after delayed surgery was found to be 9.8% in a study by Testini et al., 20% in a study by Kocer et al., and 11.8% in a study by Dakubo et al., according to these studies [Table 3]. Mortality among patients who were in shock at the time of admission was 55.6% in a study by Testini et al., 68.8% in a study by Kocer et al., and 20.6% in a study by Dakubo et al. in 2009. In our investigation, 10 patients passed away altogether. Twenty-two patients were in shock at the time of admission, and eight of them had surgery 24 h following the onset of symptoms. In our study, the mortality rate for patients who underwent surgery within 24 h after the beginning of symptoms was 23.5%, and it reached 45.5% for patients who were in shock when they were admitted. Due to the fact that 8 out of 10 patients who died had surgery performed within 24 h of the onset of their symptoms and that all 10 of them were in shock at the time of admission, the timing of the surgery and shock at the time of admission had a major impact on postoperative mortality. In the postoperative phase, delayed surgery exacerbated bacterial peritonitis, produced septicemic shock, and altered renal parameters in 8 out of 10 patients who died. In the Kocer et al.'s study from 2007, each point increase in the ASA score resulted in a 4.5-fold increase in patient mortality. In our study, 10 patients passed away, of whom three had an ASA grade IV and seven had an ASA grade V. As a result, the ASA grade is regarded as a key indicator of postoperative mortality. This aids us in communicating the risk to the patient's caregivers.
|Table 3: American Society of Anesthesiologists grade affecting mortality in patients with perforated peptic ulcer|
Click here to view
| Conclusion|| |
Peptic ulcer disease (PPU) has historically high rates of morbidity and death and is a potentially fatal condition. All of the scoring methods had certain limitations, even though none of them were perfect. The Boey score and the ASA score, which are the most frequently used in the current research to predict outcomes for PPU patients, both had varying degrees of accuracy and appeared to be simple to adapt in clinical practice. While the Boey and ASA scores are outperformed by the PULP score. A thorough preoperative evaluation of the patient's severity grade, early detection of the systemic inflammatory response syndrome, and prompt goal-directed therapy, which includes perioperative and postoperative care, can be critical in achieving the best outcome. About one in seven patients with PPU develop symptoms of sepsis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
David MM, Seth BK, Sabiston Text Book of Surgery. 20th
ed. Philadelphia: Elsevier Saunders; 2016. p. 1197-211.
Arveen S, Jagdish S, Kadambari D. Perforated peptic ulcer in South India: An institutional perspective. World J Surg 2009;33:1600-4.
Gujar N, Awati J, Mudhol S, Contractor S, Choudhari R, Sushila G. Immediate results of omentopexy in perforated duodenal ulcer: A study of 186 cases. Al Ameen J Med Sci 2012;5:29-38.
Singh R, Kumar N, Bhattacharya A, Vajifdar H. Preoperative predictors of mortality in adult patients with perforation peritonitis. Indian J Crit Care Med 2011;15:157-63.
] [Full text]
Buck DL, Vester-Andersen M, Møller MH. Accuracy of clinical prediction rules in peptic ulcer perforation: An observational study. Scand J Gastroenterol 2012;47:28-35.
Siu WT, Chau CH, Law BK, Tang CN, Ha PY, Li MK. Routine use of laparoscopic repair for perforated peptic ulcer. Br J Surg 2004;91:481-4.
Thorsen K, Søreide JA, Søreide K. Scoring systems for outcome prediction in patients with perforated peptic ulcer. Scand J Trauma Resusc Emerg Med 2013;21:25.
McColl KE. Clinical practice. Helicobacter pylori infection. N Engl J Med 2010;362:1597-604.
Bedoui S, Kupz A, Wijburg OL, Walduck AK, Rescigno M, Strugnell RA. Different bacterial pathogens, different strategies, yet the aim is the same: evasion of intestinal dendritic cell recognition. J Immunol 2010;184:2237-42.
Lu Y, Loffroy R, Lau JY, Barkun A. Multidisciplinary management strategies for acute non-variceal upper gastrointestinal bleeding. Br J Surg 2014;101:e34-50.
Søreide K, Thorsen K, Søreide JA. Strategies to improve the outcome of emergency surgery for perforated peptic ulcer. Br J Surg 2014;101:e51-64.
Bae S, Shim KN, Kim N, Kang JM, Kim DS, Kim KM, et al.
Incidence and short-term mortality from perforated peptic ulcer in Korea: A population-based study. J Epidemiol 2012;22:508-16.
Hanumanthappa MB, Gopinathan S, Guruprasad RD, Neil D. A non-operative treatment of perforated peptic ulcer. J Clin Diagn Res 2012;6:696-9.
Moller MH, Adamsen S, Thomsen RW, Moller AM. The PULP trial group. Multicentre trial of a perioperative proto col to reduce mortality in patients with peptic ulcer perforation. Br J Surg 2011;98:802-10.
Møller MH, Adamsen S, Thomsen RW, Møller AM. Preoperative prognostic factors for mortality in peptic ulcer perforation: A systematic review. Scand J Gastroenterol 2010;45:785-805.
Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, et al.
Surviving sepsis campaign: International guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008;36:296-327.
Wang CY, Lin YS, Tzao C, Lee HC, Huang MH, Hsu WH, et al.
Comparison of Charlson comorbidity index and Kaplan-Feinstein index in patients with stage I lung cancer after surgical resection. Eur J Cardiothorac Surg 2007;32:877-81.
Taha AS, Angerson WJ, Prasad R, McCloskey C, Gilmour D, Morran CG. Clinical trial: the incidence and early mortality after peptic ulcer perforation, and the use of low-dose aspirin and nonsteroidal anti-inflammatory drugs. Aliment Pharmacol Ther 2008;28:878-85.
Koç M, Yoldaş O, Kiliç YA, Göçmen E, Ertan T, Dizen H, et al.
Comparison and validation of scoring systems in a cohort of patients treated for perforated peptic ulcer. Langenbecks Arch Surg 2007;392:581-5.
Egberts JH, Summa B, Schulz U, Schafmayer C, Hinz S, Tepel J. Impact of preoperative physiological risk profile on postoperative morbidity and mortality after emergency operation of complicated peptic ulcer disease. World J Surg 2007;31:1449-57.
Kumar P, Rodrigues GS. Comparison of POSSUM and P-POSSUM for risk-adjusted audit of patients undergoing emergency laparotomy. Ulus Travma Acil Cerrahi Derg 2009;15:19-22.
Sharma SS, Mamtani MR, Sharma MS, Kulkarni H. A prospective cohort study of postoperative complications in the management of perforated peptic ulcer. BMC Surg 2006;6:8.
Kocer B, Surmeli S, Solak C, Unal B, Bozkurt B, Yildirim O, et al.
Factors affecting mortality and morbidity in patients with peptic ulcer perforation. J Gastroenterol Hepatol 2007;22:565-70.
Dakubo JC, Naaeder SB, Clegg-Lamptey JN. Gastro-duodenal peptic ulcer perforation. East Afr Med J 2009;86:100-9.
Møller MH, Engebjerg MC, Adamsen S, Bendix J, Thomsen RW. The Peptic Ulcer Perforation (PULP) score: A predictor of mortality following peptic ulcer perforation. A cohort study. Acta Anaesthesiol Scand 2012;56:655-62.
Thorsen K, Glomsaker TB, von Meer A, Søreide K, Søreide JA. Trends in diagnosis and surgical management of patients with perforated peptic ulcer. J Gastrointest Surg 2011;15:1329-35.
Testini M, Portincasa P, Piccinni G, Lissidini G, Pellegrini F, Greco L. Significant factors associated with fatal outcome in emergency open surgery for perforated peptic ulcer. World J Gastroenterol 2003;9:2338-40.
[Table 1], [Table 2], [Table 3]