CHAPTER ONE

INTRODUCTION

1.1 Background to the Study

Perforated peptic ulcer is a surgical emergency and is associated with short-term mortality in up to 30% of patients and morbidity in up to 50%.1 Worldwide variations in demography, socioeconomic status, Helicobacter pylori prevalence, and prescription drugs make investigation into risk factors for perforated peptic ulcer diffi cult. Perforated peptic ulcer presents as an acute abdominal condition, with localised or generalised peritonitis and a high risk for development of sepsis and death. Early diagnosis is essential, but clinical signs can be obscured in elderly people or immunocompromised patients, thus delaying diagnosis. Imaging has an important role in diagnosis, as does early resuscitation, including administration of antibiotics. Appropriate risk assessment and selection of therapeutic alternatives becomes important to address the risk for morbidity and mortality. In this review, we present an update on the present understanding and management of perforated peptic ulcer (Lancet,2015).

The management of peptic ulcer disease and its complications remain a challenge. In addition, non‑steroidal anti‑inflammatory drugs (NSAIDs), low-dose aspirin, smoking, excessive alcohol use, emotional stress and psychosocial factors are increasingly important causes of ulcers and their complications even in H. pylori-negative patients. Other rare causes of peptic ulcer disease in the absence of H. pylori, NSAIDs, and aspirin also exist(Prabhu;Shivani,2014).

Epidemiological studies reveal a very strong association between H. pylori infection and peptic ulcer disease. More than half the world’s population has a chronic H. pylori infection of the gastroduodenal mucosa, yet only 5-10% develops ulcers. Factors that determine whether the infection will produce the disease depends on the pattern of histological changes, gastritis induced changes in homeostasis of gastric hormones and acid secretion, gastric metaplasia in the duodenum, interaction of H. pylori with the mucosal barrier, immunopathogenesis, ulcerogenic strains, and genetic factors (Prabhu; Shivani,2014).

Management of peptic acid disease varies from using H2 receptor antagonist, proton pump inhibitors (PPI) to triple chemotherapy and sequential regimen for H. pylori. Similarly treating perforation varies from a conservative non-operative approach to a surgical approach. Various prognosticating factors to predict mortality and morbidity have been used for scoring these patients of which Boey’s scoring system still forms a reliable system. Some scoring systems take only pre-operative criteria into account whereas others include pre-operative, intra operative and laboratory findings to score the patients (Prabhu; Shivani,2014).

The first clinical description of a perforated peptic ulcer was made in 1670 in princess Henrietta of England (Milosavljevic,2011). Since then several notable people have succumbed to this illness over the years. The presentation may be dramatic with pain of sudden onset often severe and radiating to the back with rapidly supervening features of peritonitis in about two-thirds of patients (Hirschowitz,2005). In this classical presentation the patient may recall the exact time of perforation, often in the early hours of the morning. Pain may sometimes be insidious in onset and sometimes mimic an acute appendicitis (Bewes,1999) when perforation is small and contents leak slowly into the right iliac fossa through the right paracolic gutter. In elderly patients, or immunocompromised patients, the signs of perforation may be insidious or equivocal (Fakhry,2003).

The diagnosis is made with a high index of suspicion with the main differential being an acute exacerbation in a patient with known peptic ulcer disease (Saverio,2014). The presence of air under the diaphragm in an erect chest radiograph often clinches the diagnosis. This sign, present in up to 75% (Mehboob,2000) of erect chest radiographs, is dependent on size of perforation and interval before presentation. The use of an erect lateral chest radiograph can improve detection of pneumoperitoneum to 98% (Woodring,1995). Currently, the use of computerized tomographic scan is the gold standard for detection of perforation (Baker,1995). With ultrasonography, though easily accessible, and useful when radiation burden is critical (Coppolino;Gatta;Grezia,2013), detection of pneumoperitoneum is difficult even for the skilled sonographer(Seitz;Reising,1982).

1.2 Statement of Problem

Peptic ulcer perforation is a life-threatening complication of peptic ulcer disease occurring in about 2–14% of cases of peptic ulcer disease (Bertleff; Lange,2010). This perforation is either located in the lesser curvature of the stomach or on the anterior surface of the duodenum (Williams,2013) resulting in a spillage of gastric contents into the peritoneal cavity. Perforation is one of the commonest causes of emergency hospitalization and surgery in peptic ulcer disease (Wang,2010).

Perforations of the stomach and duodenum are common in surgical practice and do occur as a complication of peptic ulcer disease (PUD), abuse of non steroidal anti inflammatory drugs (NSAIDS) and gastric cancer (Svaness,2000). Despite the widespread use of anti secretory agents and Helicobacter Pylori eradication therapy, the incidence has remained relatively unchanged (Oribor;Naaeder;Clegg,2009). Perforations due to peptic ulcer is a serious complication which affects an average 2-10% of peptic ulcer patients (Testini;Portincasa;,2003) and having an overall mortality of 10% (Rajesh;Sarathchandra,2003) , although some authors report ranges between 1.3 and 20% (Hermansson,1999) .Being a life threatening complication of PUD, it needs special attention with prompt resuscitation and appropriate surgical management if morbidity and mortality are to be avoided (Elnagib;Mahadi,2013). This study seeks to determine the knowledge and perception of perforated ulcer patients in surgery Out Patients University of Benin Teaching Hospital.

Today, much advancements at preventing Perforated ulcers has been documented in the developed nations with the advent of sophisticated equipments such as alternating pressure mattresses/overlays, air fluid beds, low-air-loss beds and devices such as water-filled mattresses, air filled mat-tresses and gel-filled mattresses/overlays among others (Adejumo and Ingwu, 2010). Despite these innovative concepts and technology, Perforated ulcers still remains recalcitrant and prevalent among hospitalized and high dependent patients (Chacon et al., 2010; Gunningberg and Stotts, 2008 and Grey et al., 2006). A developing nation like Nigeria seems disadvantaged in combating the challenge of Perforated ulcers due to lack of facilities and trained personnel (Adejumo and Ingwu, 2010).

1.3 Aim and Objectives of the Study

The main aim of the study is to assess the KNOWLEDGE AND PERCEPTION OF PERFORATED ULCER PATIENTS IN SURGERY OUT PATIENTS (SOP), University of Benin Teaching Hospital.

The specific objectives are:

1.    To assess the Knowledge and perception of perforated ulcer in Sugery Out Patient (SOP).

2.    To determine the number of Surgery Out Patient (SOP) with perforated ulcer in Medical, Neurosurgical and Orthopaedic wards, UBTH.

3.    To identify the stages of perforated ulcers among Surgery Out Patient (SOP)  with the condition in medical, neurosurgical and orthopaedic wards, UBTH.

4.    To determine the nurses awareness and its application on stage-based treatment of perforated ulcer in medical, neurosurgical and orthopaedic wards, UBTH.

1.4  Research Question

1.To assess the Knowledge and perception of perforated ulcer in Sugery Out Patient (SOP).

2.To determine the number of Surgery Out Patient (SOP) with perforated ulcer in Medical, Neurosurgical and Orthopaedic wards, UBTH.

3.To identify the stages of perforated ulcers among Surgery Out Patient (SOP)  with the condition in medical, neurosurgical and orthopaedic wards, UBTH.

4.To determine the nurses awareness and its application on stage-based treatment of perforated ulcer in medical, neurosurgical and orthopaedic wards, UBTH.

1.5 Significance of the Study

This study will provide nurses and the management of University of Benin Teaching Hospital with the necessary awareness about the cases and severity of perforated ulcers seen among bed-redden patients as well as the efficiency of the care given by the care providers. By this, the management will be able to reestablish the importance of improving perforated ulcer risk assessment and prevention through the implementation of guideline recommendations and new treatment and prevention protocols of perforated ulcer as an addition to the basic health care practice that is commonly provided for the Surgery Out Patients (SOP) and others at risk for perforated ulcer development.

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