Predicting poor outcome in perforated peptic ulcer disease

Background: Despite modern medications for peptic ulcers, patients frequently require emergency surgery for complications of ulcer disease. Many of these patients have coexisting medical problems which not only predispose to perforated ulcer disease, but also influence the clinical outcome. This study reviews the outcome of a group of patients with perforated ulcer disease and examines the influence of a range of comorbidity factors on the outcome. Methods: A retrospective chart review of all cases of perforated peptic occurring over a period of 9 years. Results: One hundred and forty-nine perforated peptic ulcers in 147 patients were diagnosed between 1987 and 1996. Coexisting malignancy, use of immunosuppressives or corticosteroids, pre-operative shock and admission to intensive care were all significantly associated with reperforation by univariate analysis. However, logistic regression analysis indicated that none of these factors independently predicted reperforation which, therefore, occurs as a multifactorial event with all the above factors contributing. Death from perforated ulcer disease was related to pre-operative shock, malignancy, admission to intensive care and reperforation when examined by univariate analysis. Furthermore, logistic regression analysis showed that coexisting malignancy and reperforation were significant predictors of mortality. Conclusions: Perforated peptic ulcer disease remains a frequent clinical problem in patients with short dyspeptic histories, who may or may not have been using ulcerogenic medications. It is a significant cause of morbidity and mortality among an often aged and otherwise unwell group of patients. Patients with underlying malignant disease, who may be immunosuppressed with corticosteroids or cytotoxics, are at increased risk of dying from perforated ulcer disease. Reperforation of an ulcer, following simple closure or conservative treatment, is also highly predictive of increased mortality.