From the Guidelines
The mortality rate of a perforated duodenal ulcer is approximately 23.5% as reported in the most recent and highest quality study 1. This rate is significantly higher than that of bleeding peptic ulcers, which has a reported 30-day mortality of 8.6% 1. The high mortality rate associated with perforated duodenal ulcers underscores the importance of prompt recognition and treatment.
Factors Influencing Mortality
Several factors can influence the mortality rate of a perforated duodenal ulcer, including:
- Patient age, with elderly patients facing higher mortality rates
- Presence of comorbidities, such as cardiovascular or pulmonary disease
- Time to treatment, with delayed diagnosis and treatment increasing mortality risk
- Access to healthcare resources, which can impact the quality and timeliness of care
Treatment Approach
Immediate surgical intervention is the standard treatment approach for perforated duodenal ulcers 1. This typically involves laparoscopic or open repair with an omental patch (Graham patch), combined with broad-spectrum antibiotics. Post-operative management should include:
- Helicobacter pylori eradication therapy if the bacterium is present
- Proton pump inhibitors for at least 8 weeks to allow complete healing and prevent recurrence Non-operative management may be considered in extremely selected cases where the perforation has sealed, as confirmed by a water-soluble contrast study 1. However, this approach is not routinely recommended and should be reserved for patients with minimal symptoms and no signs of peritonitis or sepsis.
From the Research
Mortality Rate of Perforated Duodenal Ulcer
The mortality rate of a perforated duodenal ulcer varies depending on several factors, including the patient's pre-operative risk, age, and the presence of co-morbidities.
- According to a study published in the Irish journal of medical science 2, the mortality rate was 54.5% for patients with an ASA-score of IV/V who underwent operative management, and 52.9% for those who received conservative management.
- A review published in the World journal of gastrointestinal surgery 3 reported a mortality rate ranging from 1.3% to 20% for perforated peptic ulcers, with a 30-day mortality rate reaching 20% and a 90-day mortality rate of up to 30%.
- A retrospective cross-sectional study published in Surgery research and practice 4 found a mortality rate of 38% among patients with duodenal perforation, with a higher mortality rate seen in patients with preoperative organ failure, postoperative leak, and longer duration from onset of symptoms to surgery.
- A prospective validation of predictive factors published in the Annals of surgery 5 reported a mortality rate that increased progressively with increasing numbers of risk factors, ranging from 0% to 100% in patients with none to all three risk factors.
- A prospective randomized study published in Surgical endoscopy 6 compared surgery with stent treatment for perforated duodenal ulcers and found no significant difference in complications between the two groups, although the sample size was limited.
Factors Affecting Mortality Rate
Several factors can affect the mortality rate of a perforated duodenal ulcer, including:
- Pre-operative risk, as measured by the ASA score 2
- Age, with older patients tend to have a higher mortality rate 3, 6
- Presence of co-morbidities, such as major medical illness, preoperative shock, and longstanding perforation 5
- Duration from onset of symptoms to surgery, with longer durations associated with higher mortality rates 4
- Presence of postoperative complications, such as leak or re-exploration 4