Original Article

Perforated Peptic Ulcer: Different Ethnic, Climatic

and Fasting Risk Factors for Morbidity in Al-Ain
Medical District, United Arab Emirates
Fawaz Chikh Torab, Mohamed Amer, Fikri M. Abu-Zidan and Frank James Branicki, Department of Surgery,
Faculty of Medicine & Health Sciences, UAE University, UAE.

AIM: To evaluate risk factors, morbidity and mortality rates of perforated peptic ulcer (PPU) and to investigate factors affecting postoperative complications of PPU.
BACKGROUND: The incidence of PPU has remained constant, simple closure with omental patch repair
being the mainstay of treatment.
PATIENTS AND METHODS: One hundred and nineteen patients admitted to Al-Ain Hospital with
PPU between January 2000 and March 2004 was studied retrospectively; two with deficient data were
excluded from the analysis. Logistic regression was used to define factors affecting postoperative
complications.
RESULTS: The mean age of patients was 35.3 years (range, 2065). 45.7% of patients were Bangladeshi,
and 85.3% originated from the Indian subcontinent. One patient, subsequently found to have a perforated gastric cancer, died. In 116 patients, 26 complications were recorded in 20 patients (17.2%).
Common risk factors for perforation were smoking, history of peptic ulcer disease (PUD) and use of
non-steroidal anti-inflammatory drugs (NSAIDs). A significantly increased risk of perforation was
evident during the daytime fasting month of Ramadan. An increase in the acute physiology and chronic
health evaluation (APACHE) II score (p = 0.047) and a reduced white blood cell count (0.04) were highly
significant for the prediction of postoperative complications.
CONCLUSION: Patients with dyspeptic symptoms and a history of previous PUD should be considered
for prophylactic treatment to prevent ulcer recurrence during prolonged daytime fasting in Ramadan,
especially during the winter time. [Asian J Surg 2009;32(2):95101]
Key Words: peptic ulcer, perforation

Introduction
Although morbidity from peptic ulcer disease (PUD)
is decreasing in the west, the incidence of perforated
ulcer remains relatively constant.1,2 Perforated ulcers are
decreasing in incidence in younger age patients and
are increasingly being observed in the elderly and in
women.1,2 Different risk factors for PUD and perforation

e.g. smoking,3 NSAID use, a previous history of PUD,

Helicobacter pylori infection4 and alcohol intake have different prevalence rates in differing communities and
affect the incidence of perforation in various ways with
additive effects of multiple factors.57 We observed in our
practice different epidemiological characteristics of peptic ulcer perforation other than those evident in western
societies.

Address correspondence and reprint requests to Professor Frank James Branicki, Department of Surgery, Faculty of
Medicine & Health Sciences, United Arab Emirates University, P.O. Box 17666, Al-Ain, United Arab Emirates.
E-mail: f.branicki@uaeu.ac.ae Date of acceptance: 5 December 2008
2009 Elsevier. All rights reserved.

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 TORAB et al

Following developments in the medical treatment of

PUD in the last two decades, surgical intervention is currently confined to the treatment of complicated disease,
namely, ulcer haemorrhage, perforation and obstruction.8
Simple closure or omental patch repair is the mainstay of
treatment of perforated peptic ulcer (PPU),911 definitive
surgery being rarely practised12 with dependence now
on medical therapy to complete the healing process and
prevent recurrence of the disease.10,1315
In this retrospective study we reviewed our PPU admissions during a 4-year period to identify risk factors in this
particular community, determine our morbidity and mortality rates and study factors affecting postoperative complications of PPU including Boey16 and APACHE II scores.17

Patients and methods

This is a retrospective study of the medical records of all
adult patients admitted to the Department of Surgery at
Al-Ain Hospital with the diagnosis of a perforated peptic
ulcer which was confirmed intraoperatively during the
period from 1 January 2000 to 31 March 2004. After
defining our objectives and reviewing the literature, we
designed a documentation sheet to collect data necessary
to complete the study. We obtained the approval of the
Research Ethics Committee and the Head of the
Department of Surgery and the Medical Records section
to undertake the study. The data were collected from
patients charts anonymously and documented.

Inclusion criteria
All patients > 18 years of age admitted during the period
of the study with operatively confirmed PPU.
Exclusion criteria
Patients with (a) association of bleeding and perforation,
(b) immunodeficiency arising from any cause apart from
diabetes mellitus, (c) vital data missing from the medical
records or (d) pregnancy.

Patients
Demographic data
One hundred and nineteen patients had been treated, two
of whom were excluded; in one case a lost medical record
could not be retrieved despite every effort being made and
in the other, operative notes were missing from the
patients file. In the remaining 117 patients there was one

96

postoperative death, thus the mortality rate was 1/117

(0.9%). This patient had a diagnosis of perforated gastric
cancer and was excluded from the statistics of the study as
the disease had different etiology and morbidity. Of the
other 116 patients, 114 were male (98.3%). The mean age of
patients was 35.3 years (range, 2065). No patient had
chronic cardiac, pulmonary or hepatic dysfunction. Renal
dysfunction was evident in two patients (1.7%), hypertension
occurred in three (2.6%), and four had diabetes mellitus
(3.4%). None had significant organ dysfunction or failure.

Management
All patients were treated, first by resuscitation, then
open laparotomy, peritoneal toilet and closure of the perforation employing an omental patch. Postoperatively,
intravenous antibiotics were used for 35 days. One
hundred and thirteen patients (97.4%) received postoperative oral eradication therapy with Amoxicillin 1 g twice
daily, Clarithromycin 500 mg twice daily for 12 weeks
plus Omeprazole (Losec) 20 mg twice daily for 10 days.
Intraoperative findings
Ulceration in the duodenal bulb was found in 107 of 116
patients (92.2%) there being only one ulcer in the second
part of the duodenum, six prepyloric ulcers and two gastric ulcers. The patient who died had a perforation in an
adenocarcinoma; the only case of malignant ulceration in
the study and this patient was excluded from our analysis. Ulcer size was only documented in 109 patients; in
seven patients it was not recorded. The mean diameter
was 5.2 mm (range, 120).
Postoperative course
The range of postoperative hospital stay was 326 days,
the mean SD being 7.6 3 days. The patient who stayed
26 days developed postoperative pleural effusion, pneumonia, liver abscess, and sepsis. He was treated by percutaneous drainage of the effusion and the abscess in
addition to antibiotic therapy. The patient who stayed
only 3 days left at his own request and against advice as
he planned to travel to his home country.
Postoperative morbidity
Postoperative complications including organ dysfunction
or failure were defined according to the published
definitions of Deithch et al.18 Twenty patients (17.2%)
developed postoperative complications. The most

ASIAN JOURNAL OF SURGERY VOL 32 NO 2 APRIL 2009

 PERFORATED PEPTIC ULCER

common were respiratory complications, which occurred

in 12 patients (10.3%). Cardiac complications occurred in
two patients (1.7%), intra-abdominal infection including
pelvic and right iliac fossa collections, and liver abscess
occurred in three patients (2.5%). Wound infection was
diagnosed in two patients (1.7%). Seven patients (6%)
experienced other complications. Morbidity encountered
in these patients included paralytic ileus (two), uremia
with convulsions (one), confusion with hallucination (one),
diarrhea (one), and a hypotensive episode with dehydration
(one). One patient had a postoperative acute abdomen
and was found to have gangrenous small bowel possibly
due to hypotension with non occlusion of mesenteric vessels on Angio computed tomography (CT). He underwent
small bowel resection and right hemicolectomy. Fifteen
patients each had a single complication, four patients
each had two complications and one patient had three
complications.

Follow up endoscopy
The plan of the study, and according to the policy of the
hospital, was to follow up all patients with PPU with
endoscopy, to exclude a persistent peptic ulcers. Patient
demographics are explained by the fact that most of our
patients are heavy manual workers on camp sites or construction sites based out of town, who may leave the country after having an operation. Only 25 patients came for
follow up endoscopy (21.6%). The remaining patients
failed to attend (78.4%). Of the 25 patients who underwent
upper gastrointestinal (GIT) endoscopy, five had persistent
ulcers, and one had a deformed duodenal bulb. We cannot
assume that most patients, who did not come for endoscopy, had no residual ulcer disease symptoms.

Statistical analysis
Univariate analysis to compare patients with and without
postoperative complications was performed using the
Mann-Whitney test for continuous or ordinal data and
Fishers exact test for categorical data. A multiple logistic

regression model was used to define factors related to

postoperative complications.19,20 The outcome variable of
the logistic model was whether the patient had postoperative complications or not and the factors which were
entered into the logistic model as covariates were factors
that had a p value of less than 0.05 in the univariate analysis. Different direct logistic models have been tried and
explored until the best model was found and presented.
Data were analyzed using the Statistical Package for the
Social Sciences (version 15, SPSS Inc., Chicago, IL, USA).
For all analyses, a p value < 0.05 was considered significant.

Results
Risk factors related to the incidence of the disease
Seasonal distribution of admissions
The number of patients with PPU admitted during the
winter months of November to February was four cases
per month. This was higher than the rate of 1.34 cases per
month in non winter months (Table 1). The number of
patients admitted during the fasting month of Ramadan
(27 patients) (Table 2) was significantly higher than the
Table 1. Frequency of admissions per month
Month of
admission

Total number
of admissions

Rate of admission
per month

January*
February*
March
April
May
June
July
August
September
October
November*
December*

16
16
5
8
7
5
3
5
4
6
17
24

3.2
3.2
1.25
2
1.75
1.25
0.75
1.25
1
1.5
4.25
6

*November to February are considered to be winter months.

Table 2. Individual Arabic (Ramadan) months of admissions

Ramadan month

Gregorian equivalent

No. of admissions

Ramadan 1,421 h
Ramadan 1,422 h
Ramadan 1,423 h
Ramadan 1,424 h

27/11/200025/12/2000
16/11/200114/12/2001
05/11/200203/12/2002
26/10/200324/11/2003

9
3
9
6

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 TORAB et al

expected number to be admitted in that month (10

patients) (p < 0.004, Fishers exact test; 27/116 compared
with 10/116). The highest admission rate occurred when
there was a coincidence of winter month and fasting days
(26 patients within 110 days, 7.1 cases/month) which was
higher compared with winter months alone (47 cases
within 431 days, 3.3 cases/month) or in non winter
months with non-fasting days (42 cases within 1,001 days,
3 cases/month).

Nationality distribution
The highest frequency rates were observed in Bangladeshi
nationals (45.7%), Pakistani patients (24.1%) and Indian
nationals (15.3%). Most patients (85.3%) emanated from
the Indian subcontinent. Although 12.1% were of Arab
origin, UAE nationals comprised only 1.7%.
Risk factors for perforation
Smoking and history of PUD were the most common factors, 42 patients in each category (36.2%), while NSAID

usage was less common, 13 patients (11.2%). Alcohol

intake was documented in three patients (2.6%).

Risk factors related to postoperative morbidity

Univariate analysis has shown four factors to be significantly different between the group with postoperative
complications and the group without (Table 3). These
were age (p = 0.02), white blood cell count (p = 0.03), Boey
Total Score (0.046), and APACHE II Score (p = 0.01).
Those who had complications had significantly longer
postoperative hospital stay (p < 0.0001, median range,
10 (526) days compared with 6 (312) days.
The multiple logistic model was highly significant
(p = 0.003). The results of this model are shown in Table 4.
An increase in the APACHE II Score (p = 0.047) and a
reduced white blood cell count (0.04) were highly significant to predict postoperative complications.
The Receiver Operator Curve (ROC) of the white
blood cell count has shown that a white blood cell count
of less than 4,000 109/L was the best cut off point for

Table 3. Univariate analysis comparing patients without postoperative complications and those with complications

Age
Gender (male:female)
Indian subcontinent nationality
Presence of risk factors
Fasting month
Temperature (C)
Systolic blood pressure (mmHg)
Heart rate (bpm)
Haematocrit (%)
White blood cell count (109/L)
Ulcer size (mm)
Delay of treatment (h)
APACHE II Score
Boey Total Score

No postoperative
complications (n = 96)

Postoperative
complications (n = 20)

p value

33 (2065)
94:2
83
63
22
37 (3638.5)
120 (90160)
82 (56120)
44.4 (2961.8)
14.26 (3.3932.7)
5 (120)
10 (462)
2 (015)
0 (02)

39 (2455)
20:0
16
12
5
37 (3639)
125 (86204)
82.5 (54160)
44.2 (3556)
11.48 (2.9425.1)
5 (210)
10 (672)
5 (012)
0 (02)

0.02
0.68
0.49
0.61
0.52
0.68
0.28
0.77
0.39
0.03
0.79
0.45
0.01
0.046

p = Mann-Whitney test or Fishers exact test as appropriate. Data are presented as numbers or median (range) as appropriate.

Table 4. Direct logistic regression model defining the factors affecting postoperative complications
Variable
Age
White blood cell count
Total APACHE Score

98

Estimate

Standard error

Wald test

p value

Odds ratio

0.035
0.1
0.18

0.03
0.05
0.09

1.16
4.3
3.95

0.28
0.038
0.047

1.04
0.9
1.2

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 PERFORATED PEPTIC ULCER

1.0

4,000 109/L

Sensitivity

0.8

0.6

0.4

0.2

0
0

0.2

0.4
0.6
1 specificity

0.8

1.0

Figure. Receiver Operator Curve of white blood cell count as

a predictor of postoperative complications. A white blood cell
count less than 4,000 109/L was the best cut off point for
predicting morbidity.

predicting morbidity. The ROC for APACHE II was not

useful in predicting morbidity as it was almost linear
without a plateau (Figure).

Discussion
The stimulus to this study was the hypothesis that
Ramadan daylight fasting is associated with a higher incidence of ulcer perforation than is seen in other non-fasting
months of the year. Table 1 shows that the incidence of
PPU is lowest in non-winter days with no fasting and is
increased with a relative risk of 2.62 for winter days with
no fasting, and this is even higher (5.67) in fasting days
during the winter.
The higher incidence in younger age groups and in
males in the UAE, is most probably attributable to a greater
number of younger age patients in the UAE and the fact
that most manual workers, the social group mainly at risk,
are male expatriates residing in the UAE without their
families. This observation was reported recently by a study
undertaken in a similar population.21
The most common risk factors for perforation in our
study were smoking and a history of PUD, in addition to
male gender and Bangladeshi nationality. Smoking more
than 15 cigarettes a day compared with never smoking
increased the risk of a perforated ulcer more than threefold.22 A high incidence in the male gender (88.8%) has

ASIAN JOURNAL OF SURGERY VOL 32 NO 2 APRIL 2009

been observed by other authors from the region.23 The

increased incidence in the Bangladeshi population may
serve to highlight some racial and dietary features which
merit further investigation. The percentage of Bangladeshi
patients who had PPU [53/116 (45.7%)] was significantly
higher than their percentage in our Trauma Registry at
Al-Ain Hospital [296/2,573 (11.5%)], which was similar to
their distribution in the real population (p < 0.00001,
Fishers exact test). This could be also related to different
risk factors for H. pylori infection in different ethnic
groups.3 It was shown that these risk factors have no
direct relationship to the likelihood of postoperative
complications. As most of our patients were young and
fit, chronic illness was very infrequent compared with the
literature.11,24
Two scoring systems; Boey Scores16 and APACHE II
Scores17 were examined for usefulness in predicting postoperative morbidity. Our logistic regression analysis has
shown that a reduced white blood cell count in the blood
and APACHE II scores significantly correlated with the
occurrence of complications. This is keeping with other
studies showing the usefulness of APACHE II Scores in
selecting patients for laparoscopic repair of PPU.25 Others
have reported coexisting medical illnesses, delayed treatment,21 and low albumin concentration to be independent
risk factors for mortality.24 Age, pulse rate at admission,
creatinine levels, delayed surgery, presence of shock, ASA
risk and definitive surgery were considered to be independent factors associated with prognosis in PPU.23,26
One study showed that having an age more than 65 years,
a haemoglobin level less than 10 g/dL, and hypotension
on admission were associated with poor outcome after
emergency gastrectomy irrespective of underlying gastric
pathology.27 The risk of developing a postoperative complication was found to be significantly influenced by
the presence of concomitant medical illness, abdominal
distension and a history suggestive of shock at the time
of admission.28
All of these perforations were treated in the same way
regardless of the ulcer location. Although no imaging
study was done to detect any leakage after repair, we did
not encounter any overt clinical leak, which might require
re-operation. Gastric ulcers were always biopsied, and we
had only one malignant gastric ulcer perforation (0.9%).
No test for H. pylori was routinely performed preoperatively. The policy of the hospital is to give empiric eradication for H. pylori to all patients with PPU. This policy

99

 TORAB et al

arose from a previous study conducted in the same hospital which had shown that more than 90% of patients
with perforated ulcer were found to be H. pylori positive.29
In our study all five patients who had postoperative recurrent ulcers had received postoperative oral eradication
therapy; one was not compliant with treatment whilst
the remaining four had received a full eradication regimen. Three of these had a history of PUD and one was
a smoker and drank alcohol. It is known that there is
increased risk of recurrent ulceration in patients with
PUD who have a low eradication rate of H. pylori infection
after surgical and antimicrobial treatment.30 This frequent manifestation of infection is mostly caused by persisting virulent strains of H. pylori.4 The importance of
smoking in association with H. pylori infection was
previously reported.3
Our zero mortality rate is much lower than that
reported in other studies from the region (3.9%),21 8.6%23
and 13.6%.26 This was also lower than rates reported
worldwide (930%).24 This may be attributed to an older
mean age and higher comorbidity in other reports.31,32

Conclusion
Patients with dyspeptic symptoms and/or a history of
PUD are at risk of peptic ulcer perforation associated with
prolonged daytime fasting periods in Ramadan, especially
during winter time. In order to obviate ulcer perforation
consideration needs to be given to vigilant promotion of
upper endoscopy and biopsy in symptomatic patients or,
perhaps, urea breath testing for active H. pylori infection
in those with a past history of ulcer disease. H. pylori
requires eradication therapy in symptomatic patients.
In addition, higher risk patients with dyspepsia and/or
a history of PUD in whom active H. pylori infection has
been excluded should be considered for prophylactic
acid suppression therapy before embarking on fasting
in Ramadan.

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