Management of perforated duodenal ulcer in a resource poor environment.

BACKGROUND

The majority of literature on the management of perforated duodenal ulcer comes from the west. However, this is not necessarily appropriate in the developing world where perforated ulcers occur in younger patients, there is a strong association with cigarette smoking, and presentation is often delayed.

OBJECTIVE

An attempt to guide management of perforated duodenal ulcer in the developing world using the best evidence available.

DATA SOURCES: Review of the literature on perforated ulcers and retrospective chart review of cases from a rural African hospital.

STUDY SELECTION: Relevant studies from the western and developing world literature.

DATA EXTRACTION: Med-line search.

DATA SYNTHESIS: Assessment of relevance to clinical management of perforated duodenal ulcers in the developing world.

CONCLUSIONS

Due to recognition of Helicobacter pylori (HP) as a causative agent in duodenal ulcer disease many western surgeons are questioning the need for definitive ulcer surgery in the acute management of perforated duodenal ulceration. This philosophy may not be appropriate in the developing world due to poor HP eradication rates, conditions fostering re-infection with HP, problems with patient compliance in taking medications, and difficulties with follow-up. It is suggested that selected patients, without preoperative risk factors, are offered definitive surgery but those at any risk of postoperative mortality be treated with conservative surgery and treatment for HP. These patients will have to be followed closely to check ulcer healing. Attention will also need to be paid to stopping smoking.