Clinical Presentation and Surgical Management of Peptic Ulcer Perforation in a Tertiary Hospital in Mogadishu- Somalia: A 5 Years Retrospective Study

Background: Peptic ulcer perforation is a common surgical emergency condition worldwide, which is associated with signicant morbidity and mortality if early diagnosis and immediate surgical management was not carried out. Perforation occurs in roughly 5% of PUD patients during their lifetime. Methods: A 5 years Retrospective observational study on the clinical Presentation and Surgical Management of Peptic Ulcer Perforation in a Tertiary Hospital in Mogadishu- Somalia, department of General Surgery from January 2017 to December 2021. We included all patients undergoing operations with an intra-operative conrmed diagnosis of peptic ulcer perforation at the general surgery department. For operated patients, follow-up evaluation was performed in the outpatient department. Results: Fifty-one patients underwent an emergency operation for peptic ulcer perforation during the study period. The socio-demographic distribution of patients was 45(88.2%) males and 6 (11.8%) females, giving a male to female ratio of 7.5:1.


Background
Peptic ulcer perforation is a common surgical emergency condition worldwide, which is associated with signi cant morbidity and mortality if early diagnosis and immediate surgical management was not carried out. Perforation occurs in roughly 5% of PUD patients during their lifetime [1]. PUP is characterized by the classic triad of abrupt abdominal discomfort, tachycardia, and abdominal tenderness. "I hardly believe that anybody can fail in establishing a diagnosis," Edward Crisp mentioned in 1843 [2].
Young age group distribution is commonly seen in the developing world; which is mostly predisposed by smoking. While advanced age in developed countries, these patients tend to be elderly with multiple comorbidities and associated use of NSAIDs, Helicobacter pylori, physiological stress, corticosteroids and previous history of PUD are risks factors for PPU [3,4].
Mortality Risk was associated with age more than 60 years, shock (systolic pressure <90 mmHg) at presentation, and delay presentation, (more than 24 hours before surgery). Early diagnosis, prompt resuscitation, and urgent surgical intervention are essential to improve outcomes [5].
According to the diagnostic value of radiological investigation, 75% of patients with peptic ulcer perforation free air under diaphragm was detected on erect chest/ Abdominal X-ray.
In comparison to Computed tomography scan which reveals superior diagnostic accuracy of 98%. Besides, a CT scan can help to distinguish other mimicking differential diagnoses of the acute abdomen like acute pancreatitis that would not require surgical intervention, the utility of this CT scan is justi ed when the clinical presentation is not speci c to upper gastrointestinal pathology or malignancy is suspected and patients' hemodynamic is not deranged [6].
Exploratory laparotomy and omental patch repair remain the gold standard. Laparoscopic surgery should be preserved in the early presentation of disease and diminished associated complications. de nitive surgery is signi cantly associated with fatal outcomes in these patients, Gastrectomy is recommended in patients with a large or malignant ulcer [7].

Methods Study
Design and study area The patients were identi ed and extracted from hospital electronic medical records, fty-one patients operated on perforated Peptic Ulcer for Emergency Surgery were reviewed, where patient clinical information including patient demographic characteristics, diagnoses, investigative (laboratory and radiological) workup, performed surgical procedure, complications, hospital stay, pathology results, peritoneal uid culture and sensitivity, and mortality. were reviewed.
We included all patients undergoing operations with an intra-operative con rmed diagnosis of peptic ulcer perforation at the general surgery department.
Those who operated in another hospital and were later referred to our hospital and those who operated in the pediatric surgery department were excluded from the study.
For all operated patients, follow-up evaluation was performed in the outpatient department.

Data analysis
We used the Stata version 15 (StataCorp, College Station, TX) statistical program to perform statistical data analysis. Data were presented in proportions and frequency tables for categorical variables. To summarize the data for continuous variables, we utilized ranges, medians, and inter-quartile ranges (IQRs). We computed P-values for categorical variables using the odds ratio (OR) and its 95% con dence interval (CI). We determined the variables associated with the outcome using logistic regression, to adjust for confounding variables, we used multivariate logistic regression and direct standardization techniques. Signi cant was de ned as a P-value of 0.05 or less.

Results
Fifty-one patients underwent an emergency operation for peptic ulcer perforation during the study period. The socio-demographic distribution of patients was 45(88.2%) males and 6 (11.8%) females, giving a male to female ratio of 7.5:1.
According to the age group of the study population, they were ranged from 18 -70 years, with a mean age of 35.5±16.8 years. The peak frequency was in the third decade (20-30 years) The duration of symptoms ranged from 1 to 10 days with a mean duration of 3.8 ± 1.9 days, the median was 4 days.
A hospital stay of the patients was ranged minimum of 4 days to a maximum of 20 days; the mean average admission day was 8.7± 3.4 days.
The commonest presenting symptoms were sudden onset of severe epigastric pain in 42 (82.4%), abdominal tenderness in 41 (80.4%), abdominal distention in 36 (70.6%), and vomiting in 31(60.8) clinical signs of peritonitis was seen 38(74.5) and <90 mmHg systolic pressure was observed 15(29.4%) patients. (Table 1) The most common complication seen in these patients is pleural effusion which accounts for 29 (56.9%), second foremost complication noticed in this study was an acute renal failure which is about half 23 (45%) of the patients. surgical site infection was noted in nearly one-third 16 (31.4%) of the patients, only two patients encountered repair site leak. (Table 2) Two-third of the patients 34 (66.7%) was aged <40 years, There was a positive previous history of peptic dyspepsia disease in nearly half of the patients 25 (49%). 23 patients (45.1%) had a positive history of ingestion of painkillers including non-steroidal anti-in ammatory drugs (NSAIDS). 24 patients (47.1%) gave a history of cigarette smoking. (Table 3) Pleural effusion was signi cantly high in those patients with a delayed presentation in twenty out of twentynine patients with pleural effusion was seen in the patients that came beyond 72 hours of the onset of symptoms.(P-Value 0.013).
Patients who presented perforated peptic ulcer within 24 hours of initiation of symptoms were free from complications.
Graham omental repair was done nearly all the cases and only two cases of sealed perforation underwent peritoneal lavage. Two patient was reoperated because of the failed primary repair and 4 patients >5cm intraabdominal abscess image-guided percutaneous drainage was performed and the rest antibiotic therapy according to peritoneal uid culture and sensitivity results.
The total number of patients who performed Chest/ erect abdominal x-ray was 43 patients, among this air under diaphragm were detected 27(62.8%) patients. And 45 patients performed abdominal CT scan perforation signs was observed 44(97.7%). Benign tissue in ammation was come out in performed pathology samples.
Half 51% of Peritoneal uid culture no micro-organism growth was seen, Most common microorganism isolated was E. coli 22 % and Klebsiella 11%. other rare microorganisms (pseudomonas, Staphylococcus aureus, and Candida spp). (Figure 1). Table 5 Demonstrates predictors of complications according to bivariate and multivariate logistic regression analysis. In keeping in mind majority of our study population was Patients less than forty years of age, complications associated with this group were statistically signi cant (P 0.032).
Alongside this age group, also delayed presentation > 48 hours after onset of symptoms was linked to post operative complications and it is statistically signi cant (P0.005).

Discussion
The distribution of peptic ulcer perforation is common in the young age group in the third decades of life similar studies in Africa and around the globe demonstrated comparable results [8][9][10][11].
Our study demonstrated a male predominance of peptic ulcer disease, where the majority of the patients were 45(88.2%) males, giving a male to female ratio of 7.5:1. related to other studies where the male: female ratio ranged from 3.3:1and 4.5 in west Africa 5.5 in Ethiopia 9:1 in India, respectively [10,[12][13][14].
This study revealed enormous patients with delayed presentation of the disease, this linked most patients arrived from remote areas where proper facilities of health care and health education are not available and the patient might come to the hospital in an advanced stage of the disease, related studies agreed these ndings [15,16].
Long-term hospital stay was discovered as long as 20days which correlates late presentation of cases superimposed by consequence complications related to perforated peptic ulcer.
The comparable outcome was documented in various studies in the region and around the globe concluding that hospital stay and related complications of PPU including death increased in delayed(>24hours) presentation of the disease [17,18].
Positive previous history of peptic dyspepsia was observed in nearly half 25 (49%) of the patients with peptic ulcer, this might explain the inaccessibility of good health facilities and most of them may encounter nonprofessional health workers and traditional healers in many parts of the regions and patient will seek proper health care facility when condition get worse and patient develops severe abdominal pain and peritonism. This nding is common in developing countries as several reports stated [8,9,13].
The two Most common microorganism isolated was E. coli 22 % and Klebsiella 11%, comparable result was found in a study done in India [19].
Age less than forty years and delayed presentation was disease was found positive Predictors of complications with statistically signi cant according to bivariate and multivariate logistic regression analysis with p-value (0.032)( 0.005) respectively. In a similar study, Both factors were observed a positive association with postoperative complications in Tanzania.9 There was no signi cant association between complications and other above-examined factors.

Conclusion
Peptic ulcer Perforation is still a common surgical emergency problem in our country predominantly affecting young males and associated substantial morbidity and mortality in delayed disease presentation. Early diagnosis, immediate resuscitation, and urgent surgical intervention are warranted.
Simple primary repair with an omental patch is the most appropriate and effective surgical approach in the management of perforated peptic ulcer.
Implementation of endoscopic assessment in chronic and intractable dyspepsia will improve the early detection and management of non-complicated peptic ulcer disease.
We suggest further researches, preferable a multi-center study, to determine the epidemiology, associated risk factors, and prognostic factors of the disease in our context. And to conduct health awareness related to complications over-the-counter drugs self-medication and bad habit including smoking and to improve health-seeking behaviors of society. Ethical approval for the study was obtained from the Hospital Ethical Committee (MSTH/8136).

Consent for publication:
All of the patients whose radiological and intra-operative pictures were used gave written informed consent for their anonymized data to be published in the form of a case series.
Availability of data and materials: The data that support the ndings of this study are available in Mogadishu Somali Turkey, Recep Tayyip Erdogan Training and Research Hospital information system. Data are however allowed to the authors upon reasonable request and with permission of the education and research committee.
Competing interests: authors declare that they have no competing interests.
Funding: No funding received.
Authors' contributions: AMA, ANM participated in sequence alignment, study design, and data collection. AMA, YGM helped to draft the manuscript and data analysis. AMA, SIK participated in revising and data interpretation. All authors read and approved the nal manuscript.    .065

Tables
Combined 0(0.00) 1(100.00) Figure 1 Microorganism detected in culture uid analysis of peritoneal uid.  An axial abdominal CT shows free sub-diaphragmatic with air-uid levels under right hemidiaphragm (Yellow arrow), extensive free intraperitoneal uid (Blue arrow), and Left pleural effusion (Red arrow).