Peptic ulcer disease (PUD) results from an imbalance

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1 Print ISSN: Online ISSN: DOI: /SUR/2016/32 Original Article Clinicopathological Study of Peptic Perforation was Carried Out in 150 Cases Admitted in Surgical Wards of Sanjay Gandhi Memorial Hospital Associated with Shyam Shah Medical College, Rewa (Madhya Pradesh) Swaroop Brajendra 1, Ahirwar Sandeep Kumar 2, Singh Brijesh 3, Yedalwar Vinod 4 1 Senior Resident, Department of Trauma and Neurosurgery, Gajara Raja Medical College, Gwalior, Madhya Pradesh, India, 2 Senior Resident, Department of Surgery, Sanjay Gandhi Memorial Hospital Associated Shyam Shah Medical College, Rewa, Madhya Pradesh, India, 3 Assistant Professor, Department of Surgery, Sanjay Gandhi Memorial Hospital Associated Shyam Shah Medical College, Rewa, Madhya Pradesh, India, 4 Associate Professor, Department of Surgery, Sanjay Gandhi Memorial Hospital Associated Shyam Shah Medical College, Rewa, Madhya Pradesh, India Abstract Background: Peptic ulcer disease (PUD) is a common disorder that affects millions of individuals each year. PUD has a major impact on our health-care system by accounting for roughly 10% of medical costs for digestive diseases. Overall, peptic ulcer mortality and hospitalization rates have declined for the past two decades, but complications such as peptic ulcer perforation and bleeding remain a substantial health-care problem. Materials and Methods: It was a prospective 1-year study conducted in all cases of peptic perforation admitted in surgical wards during the study period August 2013-July On admission, every patient was interrogated about name, age, sex, address, occupation, religion, and residence. All patients suspected of peptic perforation with symptoms of the sudden onset of epigastric pain in abdomen, distention of abdomen, constipation, and vomiting were admitted to surgery ward from the outpatient department or transferred from other wards. Their findings were recorded in a pro forma and master chart. The information obtained was tabulated and analyzed. Results: Incidence of peptic perforation was 1.65% of all surgical admissions. It was 6.63% of total case of acute abdomen and 50.17% of total case of perforation peritonitis. A maximum number of peptic perforation cases was found in age group years (24.67%). Conclusion: Perforation of the peptic ulcer is due to the persistence of causative factors of peptic ulceration with a decrease in mucosal resistance due to injudicious use of corticosteroids, decreased immunity, malnutrition, delay in hospitalization due to initial treatment by homemade medicines and abdominal massage further complicates the perforation in this region. Peptic perforation is diagnosed on clinical grounds and abdominal X-ray easily, yet due to delayed hospitalization and time consumed in resuscitation of the patient affects the outcome of standard surgical procedure. Keywords: Clinicopathological study, Peptic perforation, Surgical ward INTRODUCTION Peptic ulcer disease (PUD) results from an imbalance of acid secretion and a mucosal defense that resist Access this article online Month of Submission : Month of Peer Review : Month of Acceptance : Month of Publishing : acid digestion. Moreover, studies have confirmed the strong association between gastric antral infection with Helicobacter pylori and peptic ulceration. More than 90% of patients with PUD are infected with H. pylori, and eradication of this infection not only heals most uncomplicated ulcers but also significantly decreases the likelihood of recurrent ulceration. Most PUD not associated with H. pylori is secondary to the use of Nonsteroidal anti-inflammatory drugs (NSAIDs). Steroid use, cigarette smoking, rapid gastric emptying, and defective duodenal acid defense mechanisms also contribute to the Corresponding Author: Dr. Brajendra Swaroop, C/O Chetramnishad, Street In Front of House No. 1, Ashok Colony, Morar, Gwalior , Madhya Pradesh, India. Phone no: , drbrajendraswaroopgrmc@gmail.com IJSS Journal of Surgery July-August 2016 Volume 2 Issue 4 21

2 pathophysiology of PUD. The patients with high gastrin levels (e.g., those with Zollinger Ellison syndrome) are at increased risk of developing PUD and subsequent perforations. Although the frequency of ulcer disease in general has declined, the number of patients affected by bleeding and perforation has not changed significantly. Classical symptoms of peptic perforation are pain in abdomen, distension of abdomen, not passing flatus and motion, vomiting with or without fever. The classical signs include tenderness, guarding, rigidity, distention of abdomen, and obliteration of liver dullness. The presence of a large amount of gas under the dome of diaphragm is suggestive of peptic perforation in an X-ray abdomen taken in standing position. X-ray chest and ultrasonography may be required to demonstrate small amount of gas and collection of fluids in the pockets. Primary resuscitation of the patient followed by exploratory laparotomy is a well-accepted approach for the management of peptic perforation. MATERIALS AND METHODS This is a prospective study, entitled clinicopathological study of peptic perforation was carried out in 150 cases admitted in surgical wards of Sanjay Gandhi Memorial Hospital associated with Shyam Shah Medical College, Rewa, Madhya Pradesh, India during the period from 1 st August 2013 to 31 th July Inclusion Criteria All cases of peptic perforation admitted in surgical wards during the study period. All patients suspected of peptic perforation with symptoms of the sudden onset of epigastric pain in abdomen, distention of abdomen, constipation, and vomiting were admitted to surgery ward from the outpatient department or transferred from other wards. On admission, every patient was interrogated for a detailed history of age, sex, residence, occupation, and socio-economic status. Complaints of pain in abdomen, distention of abdomen, fever, constipation, vomiting, etc. recorded with duration. A history of similar complaints in the past, history of analgesics or steroids use, tobacco chewing, smoking, and alcohol recorded. History of hypertension, diabetes, chronic obstructive pulmonary disease, tuberculosis, history of previous operation, and treatment recorded. On admission, after recording history and preliminary examination, IV cannula was placed, blood sample collected, resuscitation started and correction of dehydration with ringer lactate and normal saline. Blood sample was sent for routine investigations such as complete blood count, blood grouping, liver function test, renal function test, and serum electrolytes. Ryle s tube insertion and Foley s urinary catheterization (for measuring urine output and collecting sample for urine R/M) was done. Antibiotics started and close observation of all bedside parameters (such as pulse rate, blood pressure, respiratory rate, urine output, urine output, bowel sounds and tenderness and guarding) was done. After stabilizing the patient, they were shifted for X-rays and/or ultrasonography where required. A statistical analysis of various epidemiological parameters was performed with SPSS software. The ethical clearance was obtained from institutional Ethical Committee. RESULTS (TABLES 1-23) 1. Incidence of peptic perforation was 1.65% of all surgical admissions. It was 6.63% of total case of acute abdomen and 50.17% of total case of perforation peritonitis. 2. Maximum numbers of peptic perforation cases were found in the age group years (24.67%). Table 1: Month wise distribution of cases of peptic perforation peritonitis Months of admitted Total cases of acute abdomen Total cases of perforation Total % Out of total admitted % Out of acute abdomen August September October November December January February March April May June July Total % Out of total number of perforation 22 IJSS Journal of Surgery July-August 2016 Volume 2 Issue 4

3 Table 2: Distribution of cases according to age group Age group (in years) <10 1 (0.67) (5.33) (14.0) (19.33) (19.33) (24.67) (12.67) (4.0) Table 8: Distribution of cases according to addiction history Addiction history Tobacco+smoking 52 (34.66) Tobacco chewing 41 (27.33) Tobacco+alcohol 10 (6.67) Tobacco+alcohol+smoking 10 (6.67) Smoking+alcohol 7 (4.67) Smoking 0 (0.0) Alcohol 4 (2.66) No addiction 26 (17.33) Table 3: Distribution of cases according to sex Sex Male 136 (90.67) Female 14 (9.33) Table 4: Distribution of cases according to residence Residence Rural 120 (80.0) Urban 30 (20.0) Table 5: Distribution of cases according to occupation Occupation Laborer 72 (48.0) Farmer 43 (28.67) Housewife 11 (7.33) Government/private servant 11 (7.33) Businessmen 7 (4.67) Student 5 (3.33) Dependent (Infant) 1 (0.67) Table 6: Distribution of cases according to socio economic status Socio economic status Low 103 (68.67) Middle 45 (30.0) Upper 2 (1.33) Table 7: Distribution of cases according to past history (n=150) Past history Analgesic abuse 112 (74.66) Similar complaints (dyspepsia) 67 (44.66) 3. Peptic perforation was common in male than female and male to female ratio was 9.7:1. Table 9: Distribution of cases according to presenting complaints (n=150) Presenting complaints Pain in abdomen 150 (100.0) Not passing flatus and motion 131 (87.33) Abdominal distension 121 (80.67) Fever 67 (44.67) Vomiting 63 (42.00) Table 10: Distribution of cases according to finding on general examination (n=150) General examination Dehydration 125 (83.33) Pallor 102 (68.00) Tachycardia 95 (63.33) Hypotension 85 (56.66) Table 11: Distribution of cases according to physical signs (n=150) Physical signs Tenderness 150 (100.0) Generalized 124 (82.67) Localized 26 (17.33) Guarding/rigidity 135 (90.0) Distension 121 (80.67) Obliterated liver dullness 112 (74.67) Bowel sounds Absent 113 (75.33) Present/sluggish 37 (24.67) P/R examination anterior 58 (38.67) bulging/bogginess 4. Peptic perforation was more common in rural population (80%) than in urban (20.0%). 5. Peptic perforation was more prevalent in laborers (48.0%) and farmers (28.67%). 6. Incidence of peptic perforation was maximum in the month of March. IJSS Journal of Surgery July-August 2016 Volume 2 Issue 4 23

4 Table 12: Distribution of cases according to blood group Blood group O 64 (42.67) B 51 (34.00) A 27 (18.00) AB 8 (05.33) Table 13: Distribution of cases according to hemoglobin (g%) Hemoglobin (g%) <9 9 (6.0) (56.0) >11 57 (38.0) 7. In this study, 74.66% cases of peptic perforation presented with past history of analgesic abuse followed by past history of similar complaints in 44.66% of cases. 8. Most common addiction in patients of peptic perforation was of tobacco with smoking (34.66%). Total 82.67% patients had one or more addiction. 9. Most common presenting complaints was pain in abdomen (100%) followed by constipation (87.33%), abdominal distension (80.67%), fever (44.67%) and vomiting 42.0%). 10. Dehydration (83.33%), pallor (68.0%), tachycardia (63.33%), and hypotension (56.66%) were the most common findings on general examination. 11. On per abdomen examination, abdominal tenderness was the most common finding (100%) Followed by guarding/rigidity 90%, distension (80.67%), absent bowel sound (75.33%) and obliterated liver dullness 74.67%. 12. Overall incidence of peptic perforation was more common in O blood group (42.67%) followed by blood group B (34.0%), blood group A (18.0%) and least in AB blood group (5.33%). 13. Anemia was the commonest hematological findings, present in 62% of patients. 14. Gas under diaphragm was the most common radiological finding (92.0%). 15. In the present series, 140 (93.33%) patients were treated by exploratory laparotomy including 19 (13.57%) patients who were treated initially by peritoneal drainage under local anesthesia and 10 (6.67%) patients by conservative treatment. 16. In present series, 140 (93.33%) patients underwent surgery out of which omentopexy was done in 73 cases (52.14%), simple closure (S.C.) with omentopexy was done in 62 cases (44.29%), S.C./ omentopexy with gastrojejunostomy was done in Table 14: Distribution of cases according to radiological findings Radiological findings Total cases of peptic perforation Gas under diaphragm 138 (92) Without fluid level 127 (84.67) with fluid level 11 (7.33) No gas under diaphragm 12 (8.0) Table 15: Distribution of cases according to Various Modes of Treatment Mode of treatment of cases Conservative 10 (6.67) Operative (initially IPD followed by operation) 140 (19) (13.57) Omentopexy 73 (52.14) Simple closure with omentopexy 62 (44.29) 3 (2.14) with gastrojejunostomy 2 (1.43) with feeding jejunostomy IPD: Impulsive personality disorder 3 (2.14%) cases and S.C./omentopexy with feeding jejunostomy was done in 2 (1.43%) cases. 17. On exploratory laparotomy, escape of gas was present in 88.57% of cases. Nature of peritoneal fluid was bilious in 74.29% of cases and adhesion was present in 35.71% of cases. 18. Most common site of peptic perforation was anterior wall of the 1 st part of duodenum (60.71%) followed by prepyloric region of stomach (32.86%) and only in 6.43% of cases on lesser curvature of stomach. 19. The size of perforation was less than or equal to 1cm in majority (84.29%) of cases followed by more than 1-2 cm in 14.29%. 20. The most common post-operative general complication was pulmonary infection with toxemia which was present in 24.29% of cases whereas commonest local complication was wound infection (28.57%). 21. Post-operative commonest complication i.e. pulmonary infection with toxemia was most common in patients who underwent S.C./ omentopexy with feeding jejunostomy (100.0%), whereas the highest incidence of wound infection (commonest local infection) was present in patients in whom S.C./omentopexy with gastrojejunostomy was done (66.67%). 22. Other local complication like wound gaping present (50.0%) in patients of feeding jejunostomy and burst abdomen (9.68%) were most common in patients of S.C. with omentopexy. 24 IJSS Journal of Surgery July-August 2016 Volume 2 Issue 4

5 Table 16: Distribution of cases according to intra operative finding Intra operative finding Total, N (%) n=140 Male (n=126) Female (n=14) Escape of gas 124 (88.57) 110 (87.3) 14 (100) Site of perforation 1 st part of duodenum (anterior wall) 85 (60.71) 74 (58.7) 11 (78.6) Prepyloric region 46 (32.86) 44 (34.9) 2 (14.3) Lesser curvature of stomach 9 (06.43) 8 (6.35) 1 (7.14) Size of perforation (cm) Up to (84.29) 107 (84.9) 11 (78.6) > (14.29) 19 (15.1) 1 (7.14) More than 2 2 (01.43) 0 (0.0) 2 (14.3) Peritoneal fluids Bilious 104 (74.29) 93 (73.8) 11 (78.6) Bilious+pus mixed 27 (19.29) 24 (19.0) 3 (21.4) Pus 9 (06.43) 9 (7.14) 0 (0) Adhesion 50 (35.71) 46 (36.5) 4 (28.6) Table 17: Distribution of cases according to post operative complication in various types of operation Post operative complication Omentopexy (n=73) Simple closure omentopexy (n=62) N (%) Feeding Jejuno stomy (n=2) Gastrojeju nostomy (n=3) Local Wound infection (40) 18 (24.66) 19 (30.65) 1 (50.0) 2 (66.67) Wound gap (16) 7 (9.59) 8 (12.90) 1 (50.0) 0 (0.0) Burst abdomen (7) 1 (1.37) 6 (9.68) 0 (0.0) 0 (0.0) Fistula (1) 0 (0.0) 0 (0.0) 0 (0.0) 1 (33.33) General Pulmonary+Toxemia (34) 12 (16.44) 18 (29.03) 2 (100) 2 (66.67) Pulmonary (19) 12 (16.44) 7 (11.29) 0 (0.0) 0 (0.0) Toxemia (5) 2 (2.74) 3 (4.84) 0 (0.0) 0 (0.0) Table 18: Distribution of cases according to mode of treatment (n=150) Mode of treatment Number of case Average hospital stay (in days) Conservative Operative with feeding jejunostomy Simple closure omentopexy with gastrojejunostomy IPD followed by operation Omentopexy with simple closure Omentopexy IPD: Impulsive personality disorder 23. Average hospital stay was 9.8 days in patients treated by conservatively and days in operated group. Hospital stay was maximum in patients of S.C./omentopexy with feeding jejunostomy 30 days. 24. Average hospital stay was days in patients initially treated by peritoneal drainage followed by exploratory laparotomy. 25. Overall mortality was 18.0% of total cases. It was zero in patients with conservative treatment and 19.3% in operated patients. In patients of impulsive personality disorder (IPD) followed by definitive surgery, mortality was 31.58%. Mortality was highest 28.0% in age group of years. There was no statistical significance (P = 0.121) in the mortality in relation to the various age groups. 26. Mortality was maximum 50.0% in cases treated by S.C./omentopexy with feeding jejunostomy followed by 27.4% in patients treated by S.C. with omentopexy. 27. Perforation of less than 1 cm of size had a least mortality of 13.33% and more in patients with size of perforation 1-2 cm 27.08% and 100.0% in more than 2 cm of size of perforation. This was statistically significant (P = 0.002). 28. In present series, omentopexy was superior to other surgical procedures in terms of morbidity and mortality. The most common general complication, i.e., pulmonary infection with toxemia was least (16.44%) in patients of omentopexy and most common local complication, i.e., wound infection IJSS Journal of Surgery July-August 2016 Volume 2 Issue 4 25

6 Table 19: Mortality in relation to age group Age group (in years) of cases was also lowest (24.66%) in patient of omentopexy. Mortality was lowest in omentopexy group which was 12.3%. Furthermore, average hospital stay was lowest in patient of omentopexy, i.e., days. DISCUSSION Mortality < (0) (24.0) (12.12) (28.0) Total (18.0) P=0.121, χ 2 = P is statistically not significant Table 20: Relation of size of perforation with mortality Size of peptic perforation (cm) Number of patients (%) Mortality <1 90 (64.29) 12 (13.33) (34.29) 13 (27.08) >2 2 (1.43) 2 (100.0) Total (19.3) P=0.002, χ 2 = P is statistically significant Table 21: Distribution of cases according to mortality in various types of operation Types of operations of cases Total deaths N (%) 2 01 (50.0) with Feeding Jejunostomy Omentopexy+simple closure (27.4) Omentopexy 73 9 (12.3) 3 0 (0.0) with gastro jejunostomy Total (19.3) In the present series, incidence of peptic perforation was 1.65% out of total admission. This is similar to that of Sahu (2008) and Dakubo (2009). According to Christensen (1987), the incidence of perforated peptic ulcer is approximately 7-10 cases per 1,00,000 population per year. The present analysis of 150 cases in relation to various month of the year showed that maximum incidence of perforation occurred in the month of March. Al-Marsoumi 2 (2013) in his study found that perforation was maximum during the months of winter (December, January, and February). This might be due to higher rates of NSAIDs ingestion in these months (i.e., winter) for joint pain and common cold. In the present series, mean age is 47 years which is similar to the mean age of 49 years reported by Kirkpatrick et al. (1980). In the present series, Table 22: Distribution of cases according to mortality in various types of operation in patients when intraperitoneal drainage was not done Types of operations of cases Total deaths N (%) 2 1 (50) with Feeding Jejunostomy Omentopexy+simple closure (25.5) Omentopexy 66 7 (10.6) 2 0 (0.0) with gastro jejunostomy Total (17.36) Table 23: Mortality in relation to the patients with intraperitoneal drainage followed by various surgical procedures Types of operation of cases of IPD Mortality of IPD patients Simple closure with 11 4 (36.36) omentopexy Omentopexy 7 2 (28.57) Simple closure with 1 0 (0) omentopexy with feeding jejunostomy Total 19 6 (31.58) IPD: Impulsive personality disorder peptic perforation was more in males with male to female ratio of 9.7:1. This is similar to that of Patil (2012) study. In the present series, gastric (including prepyloric) and duodenal perforation was more in males with male to female ratio of 17:1 and 6.7:1, respectively. In present series, most of the patients of peptic perforation belong to rural areas (80%). This can be explained on the basis that patients of the rural area are of low socioeconomic group and they did not get opportunity for the treatment of their illness either in proper time or they fail to receive the full course of treatment. In present series, 48.0% cases of peptic perforation occurred in laborers followed by 28.67% in farmers, 7.33% cases each were housewives and serviceman group and 4.67% were businessman. This is mostly due to their low socioeconomic status (68.67%), great mental stress, misuse of analgesics for relief of pain generated due to any cause and poor medical facilities. In addition, infection with H. pylori is found to be more prevalent in persons belonging to low socio-economic status. Sondashi 4 (2011) suggested that stress is directly linked to occupation and is thus a known cause of PUD. In his study, self-employed patients accounted for 40%, business people were 28.6%. In the present study, a very significant number (74.66%) of patients of peptic perforation had a past history of analgesic abuse which is a well-known risk factor and 44.66% of patients had a history of dyspepsia. 26 IJSS Journal of Surgery July-August 2016 Volume 2 Issue 4

7 History of diabetes mellitus was present in 9 patients and history of previous surgery was present in 2 patients. Dakubo 2 (2009) reported that previous history of dyspepsia or peptic ulcer symptoms was absent in 120 out of 264 patients. 28 patients had experienced dyspepsia for less than 3 months before the perforation. 116 patients suffered dyspepsia for more than 3 months. In the present series, 34.66% of patients of peptic perforation were addicted to tobacco chewing + smoking followed by 27.33% to tobacco chewing, 6.67% to tobacco chewing + alcohol, 6.67% to tobacco chewing + smoking + alcohol, and 4.67% to smoking + alcohol. Alcohol, tobacco and excessive smoking have been blamed as accessory cause of peptic ulcer. The influence of alcohol and tobacco in predisposing to perforation has been emphasized by author Parmar 3 (2012) and Al-Marsoumi 2 (2013). The cardinal symptoms of perforation peritonitis in the present series were sudden onset of severe epigastric pain (100%) followed by not passing flatus and motion (87.33%), distention of abdomen (80.67%), fever (44.67%), and vomiting in 42% of patients. Chalya 6 (2011) found that most common presenting symptoms were sudden onset of severe epigastric pain in 97.6% patients, abdominal distention in 76.2% and vomiting in 36.9% patients which is similar to that found in the present series. In present series, a maximum number of cases of peptic perforation belongs to blood group O (42.67%) followed by blood group B (34.0%), blood group A (18.0%) and blood group AB (5.33%). While other authors like Sharma et al. 9 from India 2006 found that PPU with blood group O (55%) was most common followed by B (22%) and Kumar et al reported 50.0% patients of peptic perforation of blood group O. It was done in all the cases, 56% of these were having hemoglobin (Hb) between 9 and 11 g%, 38% were >11 g% and 6% were having <9 g%. As most of the patients attending our hospitals are from rural area and belong to lower socio-economic status, 62% of them had Hb below 11 g% due to malnutrition. While another author Sahu 7 (2008) found that majority (63.6%) of patients had Hb 9-11 g% followed by Hb>11 g% in 23.6% and Hb<9 g% in 12.7% cases. In present series, 92.0% cases of peptic perforation showed gas under diaphragm including gas under diaphragm with fluid level; this is similar to that of Chalya et al. 6 (2011) 94% and Sahu 7 (2008) 80% studies. In present series, 10 out of 150 cases (6.67%) of peptic perforation were treated conservatively none of them expired making mortality zero. It is similar to that of Sahu (2008). In present series, mortality in patients of IPD followed by operation 4% which is higher than that reported by Manoj (2004) that is 1.6% and less than that reported by Sahu 7 that is 7.8%. In present series, conservative treatment was given in 6.67% patients and an exploratory laparotomy was performed in 93.33% patients. Intraperitoneal drainage followed by operation was performed in 13.57% patients. In operative group, 52.14% patients underwent omentopexy followed by 44.29% patients underwent S.C. with omentopexy, S.C./omentopexy with gastrojejunostomy was performed in 2.14% cases and S.C./omentopexy with feeding jejunostomy was performed in 1.43% cases. Operative procedures were chosen on the basis of perforation size, peritoneal contamination and fragility of gut. Sahu 7 (2008) reported that 7.6% cases of peptic perforation were treated conservatively and exploratory laparotomy was performed in 92.4% cases. Intraperitoneal drainage followed by operation was performed in 12.73% patients. In operative group, 41.82% patients underwent S.C. with omentopexy followed by 37.27% patients underwent omentopexy. In present series, release of gas on opening abdomen was present in 88.57% cases. In 100% operated cases of peptic perforation, single number of perforation was present. In 60.71% of cases of peptic perforation, the site of perforation was in the anterior wall of 1 st part of duodenum and in 32.86% of cases the site of perforation was prepyloric region of stomach. Only in 9 (6.43%) case of peptic perforation, perforation was present at lesser curvature of stomach. The size of perforation was less than or equal to 1 cm in diameter in 84.29% of cases, and the size of perforation was between more than 1-2 cm in 14.29% of cases. In 35.71% of cases, adhesion was present around perforation site. The quality of intraperitoneal fluid was bilious in 74.29% of cases, bilious and pus mixed in 19.29% cases, and frank pus in 6.43% of cases. Gupta et al. 8 (2005) found that a total of 40 patients were identified to have duodenal ulcer perforations more than 1 cm in size, thus accounting for nearly 25% of all duodenal ulcer perforations operated during the study period. These patients had a significantly higher incidence of leak, morbidity, and mortality when compared to those with smaller perforations. Post-operative complications are divided into general and local complications. In present series, pulmonary infection with septicemia was the most common general complication found in 24.29% of cases followed by IJSS Journal of Surgery July-August 2016 Volume 2 Issue 4 27

8 pulmonary infection alone in 13.57%. A similar rate of complications was reported by Sahu 7 (2008) who recorded pulmonary infection to be the most common general complication found in 31.0% of cases. The most common local complication was wound infection (28.57%) followed by wound gaping (11.43%) and burst abdomen (5.0%). A similar finding was reported by Sahu 7 (2008) that wound infection in 37.2% of cases was recorded. The pulmonary complication could be due to delayed mobilization, whereas poor nutrition and anemia may be factors responsible for wound infection, wound gaping, and fistula. In present series average stay in hospital in the conservative treatment group was 9.8 days and in operative group it was days. Sondashi 4 (2011) reported that most patients had long post-operative hospital stay for more than 10 days (51.4%) indicating the high morbidity associated with the disease. Mortality was maximum (28%) in the age group years. There was no statistical significance (P = 0.121) in the mortality in relation to the various age groups. Mortality was more in patients if they had a perforation size more than 1 cm in size. This was statistically significant (P = 0.002) and indicates that size of perforation has a significant effect on mortality. This is similar to the findings by Gupta et al. (2005) who reported the similar significance. In present study, overall mortality was 18.0%. It was 19.29% in operative group of patients while it was zero in patients who had undergone conservative treatment. It was similar in the conservative group to that of Sahu (2008) and Nusree 10 (2005) studies. CONCLUSION The mortality was significantly less in the group of patients in whom only omentopexy was done (12.3%) in contrast to patients in whom S.C. followed by omentopexy was done (27.4%) (P = 0.046). The incidence of peptic ulcer and acid peptic disorder is on increase. It is estimated that about 50% of the world population is infected by H. pylori organism and it is the most important factor responsible for peptic ulcer. The competition in life, stress and social and economic burden are important environmental factors which contribute to the causation of peptic ulcers. NSAIDS, spicy food, smoking, alcohol and tobacco complicate the whole issue. Perforation of the peptic ulcer is due to the persistence of causative factors of peptic ulceration with a decrease in mucosal resistance due to injudicious use of corticosteroids, decreased immunity, malnutrition, delay in hospitalization due to initial treatment by homemade medicines and abdominal massage further complicates the perforation in this region. Peptic perforation is diagnosed on clinical grounds and abdominal X-ray easily, yet due to delayed hospitalization and time consumed in resuscitation of the patient affects the outcome of the standard surgical procedure. In the present series, it was observed that IPD helps to improve the general condition of patients in which clinical parameters are poor and vitals unstable. The procedure gives time to resuscitate the patient and make them fit for a standard surgical procedure. It was also observed that omentopexy gives better results as compared to other procedures. REFERENCES 1. Al-Marsoumi AM, Jabbo NS. Risk factors in perforated peptic ulcer disease: Incidence and relation to morbidity and mortality. Mustansiriya Med J 2013;12: Dakubo JC, Naaeder SB, Clegg-Lamptey JN. Gastroduodenal peptic ulcer perforation East African Medical Journal Vol. 86 No. 3 March Parmar H, Prajapati M, Shah R. Recent trends in peptic perforation. Int J Med Sci Public Health 2013;2: DOI: /ijmsph Sondashi KJ, Odimba BF, Kelly P. A cross-sectional study on factors associated with perforated peptic ulcer disease in adults presenting to UTH, Lusaka. Med J Zambia 2011;38: Pawan Kumar V. Koliwad, Clinicopathological Study of Duodenal Ulcer Perforation and its Management. Karnataka, Bangalore: R.G.U.H.S.; Chalya P, Mabula JB, Koy M, Mchembe MD, Jaka HM, Kabangila R, et al. Clinical profile and outcome of surgical treatment of perforated peptic ulcers in Northwestern Tanzania: A tertiary hospital experience, World J Emerg Surg 2011;6: Diwakar S. Clinico-Pathological Study of Peptic Perforation and Evaluation of Various Modes of Treatment, Thesis for M.S. (Gen. Surg.) Submitted to APS University Rewa (M.P.), May-June; Gupta S, Kaushik R, Sharma R, Attri A. The management of large perforations of duodenal ulcers. BMC Surg 2005;5: Sharma SS, Mamtani MR, Sharma MS, Kulkarni H. A prospective cohort study of postoperative complications in the management of perforated peptic ulcer. BMC Surg 2006;6: Nusree R. Conservative management of perforated peptic ulcer. Thai J Surg 2005;26:5-8. How to cite this article: Brajendra S, Kumar AS, Brijesh S, Vinod Y. Clinicopathological Study of Peptic Perforation was Carried Out in 150 Cases Admitted in Surgical Wards of Sanjay Gandhi Memorial Hospital Associated with Shyam Shah Medical College, Rewa (Madhya Pradesh). IJSS Journal of Surgery 2016;2(4): Source of Support: Nil, Conflict of Interest: None declared. 28 IJSS Journal of Surgery July-August 2016 Volume 2 Issue 4