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| Year : 1986 | Volume
: 32
| Issue : 2 | Page : 82-4 |
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Nasogastric air insufflation in early diagnosis of perforated peptic ulcer.
AS Upadhye, AN Dalvi, HT Nair
Correspondence Address:
A S Upadhye
How to cite this article:
Upadhye A S, Dalvi A N, Nair H T. Nasogastric air insufflation in early diagnosis of perforated peptic ulcer. J Postgrad Med 1986;32:82-4
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How to cite this URL:
Upadhye A S, Dalvi A N, Nair H T. Nasogastric air insufflation in early diagnosis of perforated peptic ulcer. J Postgrad Med [serial online] 1986 [cited 2023 Sep 23 ];32:82-4
Available from: https://www.jpgmonline.com/text.asp?1986/32/2/82/5351 |
Full Text
INTRODUCTION
Perforation forms a common mode of presentation of Peptic ulcer disease. Overall mortality and morbidity in perforated peptic ulcer were closely related with the time interval between perforation and operation.[8] Principal cause of in-hospital delay being misdiagnosis,[2] efforts to confirm an earlier diagnosis of perforation should lead to earlier operation and improved survival.
After review of literature, a study was carried out by insufflation of air via nasogastric tube to demonstrate pneumoperitoneum in cases of suspected peptic ulcer perforation who failed to reveal free gas under the dome of diaphragm in initial radiographs.
MATERIAL AND METHODS
Patients presenting with symptoms and signs of acute upper abdominal catastrophy at Dr. R. N. Cooper Hospital and K.E.M. Hospital, Bombay, were subjected to upright antero-posterior abdominal and chest radiograph. Out of total 86 such patients, who were ultimately diagnosed as perforation of peptic ulcer, 57 demonstrated free gas under diaphragm and 29 failed to show the same. Out of these 29, 19 patients were subjected to four quadrant abdominal paracentesis. Out of these 19, 6 showed pus on aspiration and 13 (Group I) had a dry tap.
All the patients in Group I were subjected to nasogastric air insufflation. About 300-400 ml of air were insufflated through a nasogastric tube into the stomach. Vent of the tube was occluded and patient was subjected to upright antero-posterior chest and abdominal radiograph.
Group II consisted of remaining 10 patients who revealed no pneumoperitoneum on initial radiographs and only revealed it when they were subjected to repeat radiographs after 5-6 hours. The mean time interval between presentation and operative intervention as well as outcome of management were compared in both the groups.
RESULTS
Both the groups were comparable in terms of age, sex and site of perforation, interval between time of onset of symptoms and time of presentation and mode of operative management. [Table 1] summarises the results of the study. Group I patients were surgically intervened within 4-6 hours whereas Group 11 patients had delay of about 8-10 hours before they were taken up for surgery. Surgical treatment of both the groups comprised mainly simple closure and occasionally truncal vagotomy with drainage. However, the overall morbidity and mortality were more in Group II.
DISCUSSION
Acute disease in abdomen has always been an intriguing part of a surgeon's practice. Many laboratory and radiological investigations prove helpful in arriving at a diagnosis of conditions that may cause acute abdominal pathology.
The diagnosis of perforation of peptic ulcer is easy in patients having history suggestive of ulcer disease, presenting with sudden epigastric pain and abdominal rigidity. In certain patients, however, either no such history can be elicited or the examination findings are equivocal. In such patients, finding of pneumoperitoneum in upright antero-posterior chest radiograph forms the most important indication for surgery. About 60-70% of patients with perforated peptic ulcer reveal presence of free gas under the dome of diaphragm. This suggests that rest of the patients are either operated due to other findings requiring operation (e.g. aspiration of pus in abdominal paracentesis), or experience delay in operative treatment. Time delay between onset of symptoms and surgery is a consistent determinant of outcome.[2], [8]
In patients with equivocal findings, other investigations to rule out differential diagnosis of acute upper abdominal distress should also be considered. However, diagnosis of perforated peptic ulcer should be kept in mind. In 1981, Coleman and Denham[3] advocated repeated X-rays few hours after initial non-diagnostic X-rays. However, our study indicates that delay encountered in this method results in increase in mortality and morbidity.
Dye study to find out perforation was suggested by Kane et al[7] employing water soluble contrast. Foley et al[5] substituted barium sulfate as contrast material, after demonstrating that small tears in the stomach and duodenum could be missed with water soluble contrast.
Use of gastric insufflation to diagnose gastric perforation was described by DeBakey[4] in 1940. Baker and Beahrs[1] reported perforations in six patients using same technique. Henelt et al[6] also recommended the same method to diagnose perforations. He reported no complications following this technique. Taylor[9] in support of conservative treatment raised an objection that fibrin seal may be broken by air insufflation. However, since the treatment pattern followed in our institution for perforated peptic ulcer is only surgical, we believe that no contraindication to nasogastric air insufflation exists. Throughout the period of our study, insufflation of stomach with air had been routinely practised in patients suspected to have perforated peptic ulcer with equivocal findings and non-diagnostic radiograph. We did not find a single case with negative findings on penumogastrography to have perforated peptic ulcer. Moreover, the time-delay between presentation and surgery was considerably shortened. The morbidity and mortality were notably less due to early surgical intervention. We thus recommend nasogastric insufflation as procedure to be done in cases suspected to have perforated peptic ulcer with equivocal findings and non-diagnostic plain abdominal radiography.
References
| 1 | Baker, N.H. and Beahrs, O.H.: Pneumogastrograms in the diagnosis of acute abdominal disease. Ann. Surg., 153: 587588, 1961. |
| 2 | Cohen, M.M.: Treatment and mortality of perforated peptic ulcer: a survey of 852 cases. Can. Med. Assoc. J., 105: 263. 269, 1971. |
| 3 | Coleman, J.A. and Denham, M.J.: Perforation of the peptic ulceration in the elderly. Age Ageing, 9: 257-261, 1980. |
| 4 | DeBakey, M.: Acute perforated gastro, duodenal perforation; a statistical analysis and review of the literature, Surgery, 8: 852-884, 1940. |
| 5 | Foley, M.I., Ghahremani, G.G. and Rogers, L.F.: Reappraisal of constrast media used to detect upper gastrointestinal perforations. Comparision of ionic water-soluble media with barium sulfate. Radiology, 144: 231-237, 1982. |
| 6 | Henelt, E.R., Smith, S.E. and Dodds, M.E.: Pneumogastrography in perforated gastroduodenal ulcers. Amer. J. Surg., 106: 491-493, 1963. |
| 7 | Kane, E., Fried, G., McSherry, C.K.: Perforated peptic ulcer in the elderly. J. Amer. Geriatr. Soc. 29: 224-227, 1981. |
| 8 | Mattingly, S.S. and Griffen, W.O. Jr.: Factors influencing morbidity and mortality in perforated ulcer. Amer. Surgeon, 46: 61-66, 1980. |
| 9 | Taylor, H. :The Guest Lecture: Non surgical treatment of perforated peptic ulcers. Gastroenterology, 33: 353-368, 1957. |
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