Perforations of the Upper Gastro-Intestinal Tract

Abstract: Material and methods: In all, 237 consecutive patients with a perforated peptic ulcer admitted from 1974-1992 and 125 consecutive patients with an oesophageal perforation admitted from 1970-2006 to Lund University hospital were studied retrospectively. Prognostic factors were evaluated using the Cox proportional hazards model. All cases of gastro-duodenal ulcer perforations diagnosed in Sweden from 1974 to 2002 were identified using the National Hospital Discharge Register and incidence figures were calculated. Information on sales of ASA/NSAID´s was obtained from the National Prescription Survey. Results and conclusions: Incidence of peptic-ulcer perforations has decreased in Sweden since the late 1980?s, after the introduction of the proton pump inhibitors (PPI), despite an increase in sales of NSAID/ASA of 28% during this period. The reason for this is probably multifactorial (cohort phenomena, smoking habits, Helicobacter pylori), but the increasing use of PPI might have protected the population from NSAID complications and thus contributed to the fall in incidence. In oesophageal perforations, a CAT scan or a contrast plain film investigation had the highest degree of true positive investigations. Regarding peptic ulcer perforations a plain film was the most widely used investigation and it was true positive in 75% of cases. In oesophageal perforations, pre-operative ASA-score was the only factor that significantly influenced outcome. Perforations in the thoracic part of the oesophagus had worse prognosis than perforations in the neck. Treatment with a covered stent with or without open drainage had the lowest mortality. Diversion by a pharyngostoma did not improve survival. In patients with a peptic ulcer perforation, age >75 years, significant co-morbidity, location in the stomach and > 24 hours from symptoms to operation, had a negative impact on outcome. Treatment with simple closure resulted in the lowest mortality.