Peptik Ülser Perforasyonu
Özet
Peptik ülser perforasyonu (PÜP), peptik ülser hastalığının en ciddi komplikasyonlarından biri olup, acil cerrahi müdahale gerektiren bir akut karın tablosuna yol açar. Mortalite oranları %10-30 arasında değişmekte olup, erken tanı ve tedavi prognozu doğrudan etkileyen en önemli faktörlerdir. Helicobacter pylori (H.pylori) enfeksiyonu ve non-steroid anti-inflamatuar ilaç (NSAİİ) kullanımı başlıca etiyolojik faktörlerdir. Klinik tablo, ani başlangıçlı şiddetli karın ağrısı ve peritonit bulguları ile karakterizedir. Tanıda kontrastlı batın bilgisayarlı tomografisi (BT) altın standart olup, pnömoperitoneum tespitinde yüksek duyarlılığa sahiptir. Acil serviste yönetim; hızlı resüsitasyon, hemodinamik stabilizasyon, geniş spektrumlu antibiyotik tedavisi ve acil cerrahi konsultasyonunu kapsar. Cerrahi müdahaledeki gecikme mortaliteyi artıran en önemli faktördür. Bu bölümde, PÜP’un epidemiyolojisi, etiyolojisi, patofizyolojisi, klinik bulguları, tanısı ve acil servis yönetimi güncel kanıtlar ışığında ele alınmaktadır.
Perforated peptic ulcer (PPU) is one of the most serious complications of peptic ulcer disease and causes an acute abdomen requiring emergency surgical intervention. Mortality rates range from 10% to 30%, with early diagnosis and treatment being the most important factors directly affecting prognosis. Helicobacter pylori(H.pylori) infection and non-steroidal anti-inflammatory drug (NSAID) use are the main etiological factors. The clinical presentation is characterized by sudden onset of severe abdominal pain and signs of peritonitis. Contrast-enhanced abdominal computed tomography (CT) is the gold standard for diagnosis, with high sensitivity for detecting pneumoperitoneum. Emergency department management includes rapid resuscitation,hemodynamic stabilization, broad-spectrum antibiotic therapy, and urgent surgical consultation. Delay in surgical intervention is the most important factor increasing mortality. This chapter discusses the epidemiology, etiology, pathophysiology, clinical findings, diagnosis, and emergency department management of PPU in light of current evidence.
Referanslar
Søreide K, Thorsen K, Harrison EM, Bingener J, Møller MH, Ohene Yeboah M, et al. Perforated peptic ulcer. Lancet. 2015;386(10000):1288 1298. doi:10.1016/S0140 6736(15)00276 7 (PubMed)
Chung KT, Shelat VG. Perforated peptic ulcer – an update. World Journal of Gastrointestinal Surgery. 2017;9(1):1 12. doi:10.4240/wjgs.v9.i1.1
Tarasconi A, Coccolini F, Biffl WL, Tomasoni M, Ansaloni L, Picetti E, et al. Perforated and bleeding peptic ulcer: WSES guidelines. World Journal of Emergency Surgery. 2020;15:3. doi:10.1186/s13017 019 0283 9
Malfertheiner P, Chan FK, McColl KE. Peptic ulcer disease. Lancet. 2009;374(9699):1449 1461. doi:10.1016/S0140 6736(09)60938 7
James Y Lau, Joseph Sung, Catherine Hill, Catherine Henderson, Colin W Howden, David C Metz. Systematic review of the epidemiology of complicated peptic ulcer disease: incidence, recurrence, risk factors and mortality. Digestion. 2011;84(2):102 113. doi:10.1159/000323958
Thorsen K, Søreide JA, Kvaløy JT, Glomsaker T, Søreide K. Epidemiology of perforated peptic ulcer: age and gender adjusted analysis of incidence and mortality. World Journal of Gastroenterology. 2013;19(3):347 354. doi:10.3748/wjg.v19.i3.347
Taş İ, Ülger BV, Önder A, Kapan M, Bozdağ Z. Risk factors influencing morbidity and mortality in perforated peptic ulcer disease. Ulusal Cerrahi Dergisi. 2014;31(1):20 25. doi:10.5152/UCD.2014.2705
Wang YR, Richter JE, Dempsey DT. Trends and outcomes of hospitalizations for peptic ulcer disease in the United States, 1993 to 2006. Annals of Surgery. 2010;251(1):51 58. doi:10.1097/SLA.0b013e3181b975b8
Salama NR, Hartung ML, Müller A. Life in the human stomach: persistence strategies of the bacterial pathogen Helicobacter pylori. Nature Reviews Microbiology. 2013;11(6):385 399. doi:10.1038/nrmicro3016
Drini M. Peptic ulcer disease and non steroidal anti inflammatory drugs. Australian Prescriber. 2017;40(3):91 93. doi:10.18773/austprescr.2017.037
Søreide K, Thorsen K, Søreide JA. Strategies to improve the outcome of emergency surgery for perforated peptic ulcer. British Journal of Surgery. 2014;101(1):e51 e64. doi:10.1002/bjs.9368
Svanes C. Trends in perforated peptic ulcer: incidence, etiology, treatment, and prognosis. World Journal of Surgery. 2000;24(3):277 283. doi:10.1007/s002689910045
Weledji EP. An overview of gastroduodenal perforation. Frontiers in Surgery. 2020;7:573901. doi:10.3389/fsurg.2020.573901
Lohsiriwat V, Prapasrivorakul S, Lohsiriwat D. Perforated peptic ulcer: clinical presentation, surgical outcomes, and the accuracy of the Boey scoring system in predicting postoperative morbidity and mortality. World Journal of Surgery. 2009;33(1):80 85. doi:10.1007/s00268 008 9796 9
Møller MH, Adamsen S, Thomsen RW, et al. Preoperative prognostic factors for mortality in patients with perforated peptic ulcer. Scandinavian Journal of Gastroenterology. 2010;45(6):655 662. doi:10.3109/00365521003623706
T J Crofts, K G Park, R J Steele, S S Chung, A K Li. A randomized trial of nonoperative treatment for perforated peptic ulcer. New England Journal of Medicine. 1989;320(15):970 973. doi:10.1056/NEJM198904133201504
Thorsen K, Søreide JA. Management of perforated peptic ulcer: a paradigm shift. World Journal of Gastrointestinal Surgery. 2014;6(10):189 191. doi:10.4240/wjgs.v6.i10.189
Roberto Grassi, Stefania Romano, Antonio Pinto, Luigia Romano. Gastro duodenal perforations: conventional plain film, US and CT findings in 166 consecutive patients. European Journal of Radiology. 2004;50(1):30 36. doi:10.1016/j.ejrad.2003.11.012
Kocer B, Surmeli S, Solak C, Unal B, Bozkurt B, Yildirim O, et al. Factors affecting mortality and morbidity in patients with perforated peptic ulcer. Journal of Gastroenterology and Hepatology. 2007;22(4):565 570. doi:10.1111/j.1440-1746.2006.04500.x
Møller MH, Adamsen S, Wøjdemann M, Møller AM. Perforated peptic ulcer: how to improve outcome? Scandinavian Journal of Gastroenterology. 2009;44(1):15 22. doi:10.1080/00365520802307997
Bertleff MJOE, Lange JF. Laparoscopic correction of perforated peptic ulcer: first choice? A review of literature. Surgical Endoscopy. 2010;24(6):1231 1239. doi:10.1007/s00464-009-0765-z
Buck D, Vester Andersen M, Møller MH. Surgical delay is a critical determinant of survival in perforated peptic ulcer. British Journal of Surgery. 2013;100(8):1045 1049. doi:10.1002/bjs.9175
Michael Imhof, Stefan Epstein, Christian Ohmann, Hans Dietrich Röher. Duration of survival after peptic ulcer perforation. World Journal of Surgery. 2008;32(3):408 412. doi:10.1007/s00268-007-9370-2
Sanabria A, Villegas MI, Morales Uribe CH. Laparoscopic repair for perforated peptic ulcer disease. Cochrane Database of Systematic Reviews. 2013;(2):CD004778. doi:10.1002/14651858.CD004778.pub3
Wing T Siu, Heng T Leong, Bonita K B Law, Chun H Chau, Anthony C N Li, Kai H Fung, et al. Laparoscopic repair for perforated peptic ulcer: a randomized controlled trial. Annals of Surgery. 2002;235(3):313 319. doi:10.1097/00000658-200203000-00001
Lunevicius R, Morkevicius M. Systematic review comparing laparoscopic and open repair for perforated peptic ulcer. British Journal of Surgery. 2005;92(10):1195 1207. doi:10.1002/bjs.5155
İlhan Taş, Burak Veli Ülger, Akın Önder, Murat Kapan, Zübeyir Bozdağ. Risk factors influencing morbidity and mortality in perforated peptic ulcer disease. Ulus Cerrahi Dergisi. 2014;31(1):20 25. doi:10.5152/UCD.2014.2705
Carlos Nogueira, António Sérgio Silva, Jorge Nunes Santos, António Gomes Silva, Joaquim Ferreira, Eduarda Matos, et al. Perforated peptic ulcer: main factors of morbidity and mortality. World Journal of Surgery. 2003;27(7):782 787. doi:10.1007/s00268-003-6645-0
Gisbert JP, Pajares JM. Helicobacter pylori infection and perforated peptic ulcer: prevalence of the infection and role of antimicrobial treatment. Helicobacter. 2003;8(3):159 167. doi:10.1046/j.1523-5378.2003.00139.x
Lanas A, Carrera Lasfuentes P, Arguedas Y, García S, Bujanda L, Calvet X, et al. Risk of upper and lower gastrointestinal bleeding in patients taking nonsteroidal anti-inflammatory drugs, antiplatelet agents, or anticoagulants. Clinical Gastroenterology and Hepatology. 2015;13(5):906 912. doi:10.1016/j.cgh.2014.11.007
Referanslar
Søreide K, Thorsen K, Harrison EM, Bingener J, Møller MH, Ohene Yeboah M, et al. Perforated peptic ulcer. Lancet. 2015;386(10000):1288 1298. doi:10.1016/S0140 6736(15)00276 7 (PubMed)
Chung KT, Shelat VG. Perforated peptic ulcer – an update. World Journal of Gastrointestinal Surgery. 2017;9(1):1 12. doi:10.4240/wjgs.v9.i1.1
Tarasconi A, Coccolini F, Biffl WL, Tomasoni M, Ansaloni L, Picetti E, et al. Perforated and bleeding peptic ulcer: WSES guidelines. World Journal of Emergency Surgery. 2020;15:3. doi:10.1186/s13017 019 0283 9
Malfertheiner P, Chan FK, McColl KE. Peptic ulcer disease. Lancet. 2009;374(9699):1449 1461. doi:10.1016/S0140 6736(09)60938 7
James Y Lau, Joseph Sung, Catherine Hill, Catherine Henderson, Colin W Howden, David C Metz. Systematic review of the epidemiology of complicated peptic ulcer disease: incidence, recurrence, risk factors and mortality. Digestion. 2011;84(2):102 113. doi:10.1159/000323958
Thorsen K, Søreide JA, Kvaløy JT, Glomsaker T, Søreide K. Epidemiology of perforated peptic ulcer: age and gender adjusted analysis of incidence and mortality. World Journal of Gastroenterology. 2013;19(3):347 354. doi:10.3748/wjg.v19.i3.347
Taş İ, Ülger BV, Önder A, Kapan M, Bozdağ Z. Risk factors influencing morbidity and mortality in perforated peptic ulcer disease. Ulusal Cerrahi Dergisi. 2014;31(1):20 25. doi:10.5152/UCD.2014.2705
Wang YR, Richter JE, Dempsey DT. Trends and outcomes of hospitalizations for peptic ulcer disease in the United States, 1993 to 2006. Annals of Surgery. 2010;251(1):51 58. doi:10.1097/SLA.0b013e3181b975b8
Salama NR, Hartung ML, Müller A. Life in the human stomach: persistence strategies of the bacterial pathogen Helicobacter pylori. Nature Reviews Microbiology. 2013;11(6):385 399. doi:10.1038/nrmicro3016
Drini M. Peptic ulcer disease and non steroidal anti inflammatory drugs. Australian Prescriber. 2017;40(3):91 93. doi:10.18773/austprescr.2017.037
Søreide K, Thorsen K, Søreide JA. Strategies to improve the outcome of emergency surgery for perforated peptic ulcer. British Journal of Surgery. 2014;101(1):e51 e64. doi:10.1002/bjs.9368
Svanes C. Trends in perforated peptic ulcer: incidence, etiology, treatment, and prognosis. World Journal of Surgery. 2000;24(3):277 283. doi:10.1007/s002689910045
Weledji EP. An overview of gastroduodenal perforation. Frontiers in Surgery. 2020;7:573901. doi:10.3389/fsurg.2020.573901
Lohsiriwat V, Prapasrivorakul S, Lohsiriwat D. Perforated peptic ulcer: clinical presentation, surgical outcomes, and the accuracy of the Boey scoring system in predicting postoperative morbidity and mortality. World Journal of Surgery. 2009;33(1):80 85. doi:10.1007/s00268 008 9796 9
Møller MH, Adamsen S, Thomsen RW, et al. Preoperative prognostic factors for mortality in patients with perforated peptic ulcer. Scandinavian Journal of Gastroenterology. 2010;45(6):655 662. doi:10.3109/00365521003623706
T J Crofts, K G Park, R J Steele, S S Chung, A K Li. A randomized trial of nonoperative treatment for perforated peptic ulcer. New England Journal of Medicine. 1989;320(15):970 973. doi:10.1056/NEJM198904133201504
Thorsen K, Søreide JA. Management of perforated peptic ulcer: a paradigm shift. World Journal of Gastrointestinal Surgery. 2014;6(10):189 191. doi:10.4240/wjgs.v6.i10.189
Roberto Grassi, Stefania Romano, Antonio Pinto, Luigia Romano. Gastro duodenal perforations: conventional plain film, US and CT findings in 166 consecutive patients. European Journal of Radiology. 2004;50(1):30 36. doi:10.1016/j.ejrad.2003.11.012
Kocer B, Surmeli S, Solak C, Unal B, Bozkurt B, Yildirim O, et al. Factors affecting mortality and morbidity in patients with perforated peptic ulcer. Journal of Gastroenterology and Hepatology. 2007;22(4):565 570. doi:10.1111/j.1440-1746.2006.04500.x
Møller MH, Adamsen S, Wøjdemann M, Møller AM. Perforated peptic ulcer: how to improve outcome? Scandinavian Journal of Gastroenterology. 2009;44(1):15 22. doi:10.1080/00365520802307997
Bertleff MJOE, Lange JF. Laparoscopic correction of perforated peptic ulcer: first choice? A review of literature. Surgical Endoscopy. 2010;24(6):1231 1239. doi:10.1007/s00464-009-0765-z
Buck D, Vester Andersen M, Møller MH. Surgical delay is a critical determinant of survival in perforated peptic ulcer. British Journal of Surgery. 2013;100(8):1045 1049. doi:10.1002/bjs.9175
Michael Imhof, Stefan Epstein, Christian Ohmann, Hans Dietrich Röher. Duration of survival after peptic ulcer perforation. World Journal of Surgery. 2008;32(3):408 412. doi:10.1007/s00268-007-9370-2
Sanabria A, Villegas MI, Morales Uribe CH. Laparoscopic repair for perforated peptic ulcer disease. Cochrane Database of Systematic Reviews. 2013;(2):CD004778. doi:10.1002/14651858.CD004778.pub3
Wing T Siu, Heng T Leong, Bonita K B Law, Chun H Chau, Anthony C N Li, Kai H Fung, et al. Laparoscopic repair for perforated peptic ulcer: a randomized controlled trial. Annals of Surgery. 2002;235(3):313 319. doi:10.1097/00000658-200203000-00001
Lunevicius R, Morkevicius M. Systematic review comparing laparoscopic and open repair for perforated peptic ulcer. British Journal of Surgery. 2005;92(10):1195 1207. doi:10.1002/bjs.5155
İlhan Taş, Burak Veli Ülger, Akın Önder, Murat Kapan, Zübeyir Bozdağ. Risk factors influencing morbidity and mortality in perforated peptic ulcer disease. Ulus Cerrahi Dergisi. 2014;31(1):20 25. doi:10.5152/UCD.2014.2705
Carlos Nogueira, António Sérgio Silva, Jorge Nunes Santos, António Gomes Silva, Joaquim Ferreira, Eduarda Matos, et al. Perforated peptic ulcer: main factors of morbidity and mortality. World Journal of Surgery. 2003;27(7):782 787. doi:10.1007/s00268-003-6645-0
Gisbert JP, Pajares JM. Helicobacter pylori infection and perforated peptic ulcer: prevalence of the infection and role of antimicrobial treatment. Helicobacter. 2003;8(3):159 167. doi:10.1046/j.1523-5378.2003.00139.x
Lanas A, Carrera Lasfuentes P, Arguedas Y, García S, Bujanda L, Calvet X, et al. Risk of upper and lower gastrointestinal bleeding in patients taking nonsteroidal anti-inflammatory drugs, antiplatelet agents, or anticoagulants. Clinical Gastroenterology and Hepatology. 2015;13(5):906 912. doi:10.1016/j.cgh.2014.11.007
