Abstract

     Aim: To evaluate the probable risk factors for perforation of duodenal ulcer, highlighting any prevalent one in the occurrence of perforation in Mosul - Iraq .

   Design: Retrospective study. Patients: The study was performed on 62 patients with perforated duodenal ulcer attending the emergency departments of the three major hospitals in Mosul over a four year period (Oct. 1998 - Oct. 2002). A number of probable risk factors for perforation of the duodenal ulcer were studied. Asymptomatic patients who perforated were studied as a separate group.

    Results: Sixty two patients with duodenal ulcer perforation were studied, 58 male and 4 female (male to female ratio 14.5:1) about 60% of patients were within their 4th and 5th decade of age. Patients residing in the rural areas had a higher incidence of perforation (58%) than those living in the urban areas (42%) but this difference is not statistically significant. Thirty seven patients (60%) were asymptomatic before they developed the perforation. Thirty three patients (53% of the total number) developed the perforation during Ramadan fasting months (four out of the total 48 months), 21% of them were asymptomatic before perforation. Seventy percent of the cases were smokers. Stress played a significant rule in the occurrence of perforation in 78% of cases.

   Conclusions: Stress and fasting played a major rule as a risk factor in the occurrence of duodenal ulcer perforation. A high incidence of perforation occurs during the months of Ramadan fasting, especially those without or on irregular treatment. The incidence of asymptomatic patients who were fasting and under stress, who then perforated was high.

Introduction

     Despite the wide spread use of gastric antisecretory agents and eradication therapy, the incidence of perforation of duodenal ulcer remains more or less the same (5 - 10%). The association of various probable risk factors such as smoking, alcohol, inadequate dietary intake, ABO blood group and non-steroidal anti-inflammatory drugs has been studied widely (1-4).

    However, there has been a considerable change in the epidemiology of perforated duodenal ulcer over the last decade. Previously, most patients were middle aged, but with time, there has been a steady increase in the age of patients suffering this complication. It has been mentioned that the majority of patients have a preceding history suggestive of chronic duodenal ulcer, but about one third of patients have no history of ulcer or dyspepsia or one which extends to only a week or two(5). By far the most common site of perforation is the anterior ulcer(8). The surgical intervention of simple closure of the perforation with or without an omental patch is the accepted procedure, the role of laparoscopic closure is gaining popularity since its initial reports in 1987(4,9,10).

     Modern antiulcer therapy like the proton pump inhibitors with the antihelicobacter agents, has decreased the recurrence rate after simple closure of the perforation from 40% to 4%(6,9) The effects of stress, fasting and smoking in the establishment of duodenal ulcer and the development of its perforation must not be ignored. Patients: The study was carried out in the emergency departments of the three major hospitals in Mosul City - Iraq, two teaching hospitals (Al Zahrawi Hospital, and Al Salam General Hospital), and Al Zahrawi Private Hospital.    

Patients

Patients with a diagnosis of perforated duodenal ulcer were included in the study over a four-year period (Oct. 1998 - Nov. 2002). The age, sex, and residence were studied. Patients known to have a history of duodenal ulcer were divided into three groups (on regular treatment, on irregular treatment and those on no treatment). Patients who were asymptoamtic till perforation are a separate group.

The risk factors studied included:

 1. Fasting (1,12)
 2. Stress (15)
 3. Smoking (14,17,18)
 4. Family history of duodenal ulcer (14)
 5.Intake of Non Steroidal Anti inflammatory Drugs (NSAID`s) (1,3,4)
 6. Alcohol Intake (14,18)

Results

      During the study period, 62 patients proved to have perforated duodenal ulcer, 58 male and 4 female, the age and sex distribution is shown in Table 1. Perforated DU is more common in the age group 30 - 50 years. Thirty six patients (58%) were from rural areas and 26 (42%) were residing in urban areas.

The number of patients who were asymptomatic prior to perforation was thirty seven (62%) (twenty one of these patients perforated during the months of Ramadan fasting). Twenty five patients (40%) had a history of duodenal ulcer or dyspepsia. Of these, ten were on no treatment, nine on irregular treatment and six on regular therapy. The number of patients having the observed risk factors are shown in Table 2. Thirty three patients (53.2%) had their perforation during the Ramadan fasting months while twenty nine (46.8%) perforated during the rest of the study period (44 months), these numbers include all patients either symptomatic or asymptomatic.

 Out of the thirty three patients perforated during the Ramadan fasting, twenty one (63.6%) were asymptomatic and twelve (27.4%) were known to have duodenal ulcer, seven of them were on no treatment and five on irregular therapy. Twenty nine patients perforated during the 44 months of non fasting period. Sixteen of them were asymptomatic and thirteen symptomatic, five of them were on no treatment and eight on regular therapy.

    On comparing the number of perforations per month of fasting to the number of perforation per one month of non fasting, i.e. 33/4 in comparison with 29/44, the results will be statistically highly significant p < 0.01 (z = 3.89) indicating that fasting is a highly significant risk factor for perforation. Forty seven patients (75.8%) gave a significant history of different events of stress (worry from the war situation in the country. Loss of a close relative, economic difficulties with the economic block, work or family problems complicated during the war). The patient distribution was more or less even during the study period. Forty three patients (69.4%) were heavy smokers.

    This factor was in common during the years (Ramadan fasting and non fasting months) as patients used to smoke heavily during the nights of Ramadan as well. Seventeen patients (27%) who perforated were also Alcoholics, were distributed evenly during the study period. Twenty patients (32.2%) who perforated gave a history of taking (NSAID) for chronic painful conditions. Twenty one patients (34%) reported a family history of duodenal ulcer. The remaining patients had no idea about such a disease in the family. Of the total number of 62, thirty six patients (58%) were from rural areas and twenty six patients (42%) were from the urban areas.

Discussion

      In spite of overall decline in the incidence of peptic ulcer disease, the incidence of perforated duodenal ulcer has not been reduced in western countries. This may be due to the increased use of non steroidal anti-inflammatory drugs over the last twenty years(1,3,4). This was not the case in our study as only 32.2% of patients who presented with perforated duodenal ulcer gave a history of using non steroidal anti inflammatory drugs. Our results indicate that perforation of a duodenal ulcer is more common in males in agreement with other studies(10,11). This sex difference is attributed probably to the psychological and smoking habits in this society as the male predominance recently declining. In the western countries with the changing pattern of smoking and increased stress in the working women(12). The peak age for ulcer prevalence is different among different studies, and in different populations and time. In one study, ulcers were more frequent in the fourth decade and rare in subjects under the age of twenty(13). In our study, duodenal ulcer perforation occurred in 36 cases out of the total number 62 (58%) in the age between 30 and 59 and less frequent after the age of 60.

    There were no significant differences in this study in terms of perforation between people living in rural and urban areas. This is probably due to the migration between the two communities during the last twenty years due to the social changes in the country. The presence of first degree relatives with duodenal ulcer increases the risk to develop ulcer disease and its complications. This familial aggregation of ulcer is mutlifactorial, sharing psychological stress, food habits, in addition to the same genetic factors(14). This could also apply in our society to explain similar results. As smoking and coffee intake is known to have a number of adverse effects on mucosal aggressive and protection factors(1,20), a strong association is found in this study between cigarette smoking and prevalence of peptic ulcer perforation, especially in men, however, this is not in agreement with the negative studies of cigarette smoking in relation to duodenal ulcer by Eastwood(17).

    In our study, fasting played an important role in duodenal ulcer perforation. This may be explained in that missing one of the important three daily meals, during fasting, with prolonged un-neutralization of gastric acidity, especially in smokers during the nights of Ramadan, can he increase gastric acidity and decrease the defensive mechanisms of gastric mucosa causing ulcer and then perforation(16, 18). The high incidence of duodenal ulcer perforation in patients under stress cannot be ignored in our society.

     It seems that stress is a significant factor. This might reflect the effects of the war situation with the long lasting economic blockade in this country and its lethal sequelae. Sixty percent of our patients were asymptomatic i.e. have no history of duodenal ulcer during the period preceding the perforation. This is not in agreement with other reports(5) where only about one third of their patients who present with perforation were asymptomatic. This high incidence of perforation without preceding history is explained on the fact that all the Iraqis over that period were under stress especially those who were fasting Ramadhan. Fasting, stress and smoking are the leading risk factors in the study have their serious effect on patients with duodenal ulcer as a precipitating factors for the development of the serious complication of perforation.

    The religion of Islam has allowed ill people, including those with duodenal ulcer, not to fast Ramadhan. On the other hand, smoking is strictly prohibited by Islamic rules. Also, it is a religion that promotes peace and non-violence. All our results approve the Islamic regulations, the advice is that patients having duodenal ulcer or dyspepsia not to fast (even during Ramadhan), not to smoke and to avoid stress and violence.

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