Peptic ulcer disease perforation

O Primary peritonitis develops in up to 25% of patients with alcoholic cirrhosis.3 Patients undergoing continuous ambulatory peritoneal dialysis (CAPD) average one episode of peritonitis every 2 years.4 Secondary peritonitis may be caused by perforation of a peptic ulcer traumatic perforation of the stomach, small or large bowel, uterus, or urinary bladder appendicitis pancreatitis diverticulitis bowel infarction inflammatory bowel disease cholecystitis operative contamination of the peritoneum or diseases of the female genital tract such as septic abortion, postoperative uterine infection, endometritis, or salpingitis. Appendicitis is one of the most common causes of intraabdominal infection. In 1998, 278,000 appendectomies were performed in the United States for suspected appendicitis.5... 

Gl effects - Do not use ketorolac in active peptic ulcer disease, recent Gl bleeding or perforation, a history of peptic ulcer disease, or Gl bleeding. 

Circunstantial evidence directly implicating dopamine in the pathogenesis of duodenal ulcer in man is the unusual incidence of peptic ulcer disease in dopamine-deficient disorders. From purely descriptive clinical and epidemiologic studies we know that patients with Parkinson s disease, before the introduction of dopamine therapy, had an excess of ulcer disease (72). One report even comments on the curiosity that after initiation of L-DOPA administration the ulcer symptoms have virtually disappeared (72 ). On the other hand, less clearly, schizophrenia which is associated with dopamine excess and/or receptor hyperactivity is accompanied by virtual lack, or decreased prevalence, of peptic ulcer (73-76). Schizophrenia associated with ulcer disease has been viewed as a reportable curiosity in medical literature (75). At present, possibly because of the widespread therapeutic application of neuroleptics, the lack of peptic ulcer disease in schizophrenics is less striking than in the past. On the other hand, we recently observed in our autopsy series perforated duodenal ulcers in two schizophrenic patients who had been on large doses of haloperidol therapy (Szabo, unpublished observation). Thus, even in man, dopamine may indeed be implicated in the pathogenesis of duodenal ulcer disease. 

Five cases of gastric perforation (rather than the more common duodenal perforation) have been reported in young male smokers of crack, all of whom had only brief histories of prodromal symptoms and none of whom had long-standing peptic ulcer disease (196). 

All NSAIDs have the potential to cause gastric and duodenal ulcers and bleeding through direct (topical) or indirect (systemic) mechanisms. Risk factors for NSAID-associated ulcers and ulcer complications (perforation, gastric outlet obstruction, GI bleeding) include increased age, comorbid medical conditions (e.g., cardiovascular disease), concomitant corticosteroid or anticoagulant therapy, and history of peptic ulcer disease or upper Gl bleeding. 

Patients with peptic ulcer disease who develop recurrent ulcer signs or symptoms of Cl bleeding or perforation should be referred to a specialist. Assess reasons for therapeutic failure, including noncompliance to the drug regimen, antibiotic resistance (HPeradication), heavy smoking, NSAID use, and the need for HP eradication in a patient on conventional antiulcer medications. 

Peptic ulcer disease is much less common in the pediatric population than in adulthood. The classification of peptic ulcers is based on the region of involvement (gastric versus duodenal ulcers) and on the presence or absence of a known etiology (primary or secondary due to an underlying disease). Primary peptic ulcers are associated with H. pylori infection. Gastric ulcers are mostly seen in neonates (with or without the development of gastric perforation) while duodenal ulcers are much more common after the neonatal period. 

Aspirin also places patients at risk for gastrointestinal bleeding, ulceration and perforation. Patients with a history of significant GI bleeding or peptic ulcer disease should not be prescribed aspirin. Patients who are already taking another type of NS AID should not take aspirin, as this increases the risk for upper GI bleeding even more. 

Peptic ulcer disease Bowel perforation Neuropsychiatric Euphoria Dysphoria Psychosis Insomnia... 

Relative active or latent peptic ulcer disease, recent intestinal anastomoses, nonspecific ulcerative colitis (increased risk of perforation), diabetes, adrenocortical insufficiency (may persist for months after discontinuing therapy), active or latent tuberculosis, cerebral malaria, chicken pox, meades, latent amebiasis or strongyloides infection, inactivated viral or bacterial vaccines where antibody response may not be induced, cirrhosis, congestive heart failure, renal failure or hypertension (increased risk of sodium retention, edema and potassium loss), hypokalemia or hypocalcemia, emotional instability or psychotic tendencies, hypothyroidism, growth retardation in infants and children. 

Although the first documented case of perforated peptic ulcer disease dates back more than 2,000 years to the western Han dynasty, the problem continues to confound physicians. In many instances, the first indication of a peptic ulcer may be the perforation itself, whereas in others, previous vague symptomatology suddenly culminates in acute perforation with peritonitis. The pathogenesis of the situation whereby an indolent or even chronic disease suddenly converts... 

Fultz PJ, Skucas J, Weiss SL (1991) CT in upper gastrointestinal perforation secondary to peptic ulcer disease. Gastrointes Radiol 17 5-8... 

Pancreatitis, any cause (P-AMY T) Pancreatic trauma (P-AMYT) Biliary tract disease (P-AMYT) - Intestinal obstruction (PtAMYT) Mesenteric infarction (P-Alv4Y(t Perforated peptic ulcer (P-AMYiT) Gastritis, duodenitis (P-AMY ) Ruptured aortic aneurysm Acute appendicitis Peritonitis Trauma... 

The most common sites of GI injmy are the gastric and duodenal mucosae." The incidence of gastric ulcers with NSAID use is approximately 11% to 13%, and that for duodenal ulcers is 7% to 10%. Serious GI complications associated with NSAIDs, including perforations, gastric outlet obstruction, and GI bleeding, occur in 1.5% to 4% of patients per year. NSAIDs are so widely used that these small percentages translate into substantial morbidity and mortality. " Moreover, the risk increases to 9% per year for patients with the risk factors of advanced age, history of peptic ulcer or GI bleeding, or cardiovascular disease. Consequently, about 16,500 deaths are associated annually with NSAID use in rheumatoid arthritis or OA patients. 

With intraabdominal contamination from the upper GI tract (perforation of a peptic ulcer or biliary tract disease), B. fragilis is an uncommon pathogen, and other agents therefore may be substituted for clindamycin or metronidazole. Alternatives include ampicUlin, penicillin, or first-generation cephalosporins. 

The complications of acid peptic disease usually represent the sequelae of long-standing or chronic ulceration. Occasionally, such events may occur in an acute setting, but in such circumstances, the acute presentation often represents administration of a drug such as an NSAID, aspirin, or alcohol or exposure to the stress of trauma or major surgery. For the most part, bleeding and perforation are the most dramatic and the most common, with penetration and obstruction being less frequent and far less acute in their presentations. 

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