A perforated peptic ulcer (PPU) is a common and life-threatening surgical emergency that happens when a stomach or duodenal ulcer breaks through the peritoneal cavity. It is one of the most dangerous problems that can happen with peptic ulcer disease (PUD) and is still a major source of illness and death around the world, especially in underdeveloped countries where people often wait too long to see a doctor and don't have easy access to medical treatment [1, 2]. The incidence of PPU has diminished in industrialized countries owing to enhanced H. pylori eradication therapy, the extensive application of proton pump inhibitors (PPIs), and increased knowledge of risk factors. Nonetheless, it continues to represent a substantial burden in resource-limited contexts. Research indicates that 5–10% of individuals with peptic ulcer disease ultimately experience perforation, with a death rate varying from 6% to 30%, contingent upon the timing of presentation, comorbidities, and the severity of sepsis [3, 4]. The pathophysiology entails the erosion of the stomach or duodenal wall due to acid-peptic action, frequently aggravated by variables such as Helicobacter pylori infection, nonsteroidal anti-inflammatory medication (NSAID) usage, smoking, alcohol intake, and stress-induced mucosal injury. If not treated right away, chemical and bacterial peritonitis, rapid fluid loss, and septic shock can happen when the stomach or duodenum leaks into the peritoneal cavity [5, 6]. Even though diagnostic imaging, anesthetic, surgical procedures, and postoperative care have all gotten better, people still die from PPU a lot. The result is contingent upon various parameters, including age, comorbidities (such as diabetes, renal impairment, or cardiovascular disease), the interval between perforation and surgical intervention, hemodynamic status at admission, and the size of the perforation. There are now many grading systems, such the Boey score and APACHE II, that can help doctors figure out how likely someone is to get better and how to best treat them [7, 8]. It is very important to find the things that predict bad outcomes in people with PPU so that we can sort patients by risk, respond quickly, and make the best use of our resources. Comprehending these factors can assist clinicians in diminishing morbidity, mortality, and postoperative complications. Consequently, the current prospective study was conducted to assess the clinical presentation, intraoperative findings, postoperative outcomes, and prognostic factors affecting morbidity and mortality in patients receiving surgery for perforated peptic ulcer [9, 10].

This prospective observational study was conducted in the Department of General Surgery, Dr. Patnam Mahender Reddy Institute of Medical Sciences (PIMS), Chevella, Rangareddy, Telangana between July 2024 to June 2025. A total of 70 consecutive patients presenting with perforated peptic ulcer (PPU) who underwent surgical management were included in the study. Ethical clearance was obtained from the Institutional Ethics Committee, and informed written consent was obtained from all participants prior to inclusion. Inclusion Criteria:  Patients aged 18 years and above.  Patients diagnosed with perforated peptic ulcer confirmed intraoperatively.  Patients who underwent emergency surgical repair for the perforation. Exclusion Criteria:  Patients with perforation due to malignancy or traumatic perforation.  Patients with previous gastric surgery or recurrent perforations.  Patients who were unfit for surgery or refused surgical intervention.  Patients with concurrent perforation from other hollow viscus  Patients lost to follow-up or who died before surgical intervention. Statistical analysis: We used SPSS version 25.0 to do the statistical analysis. Continuous variables were represented as mean ± standard deviation (SD) and compared using the Student’s t-test; categorical variables were evaluated using the Chi-square test. A p-value of less than 0.05 was seen as statistically significant.

The study comprised 70 patients who had perforated peptic ulcers and were treated with surgery. The observations and results were examined in relation to demographic characteristics, clinical presentation, surgical findings, postoperative complications, and prognostic factors affecting the outcome. Table 1 shows that most of the patients were men (82.9%), and their average age was 47.2 ± 13.9 years. The majority of patients were aged between 31 and 50 years. Diabetes, high blood pressure, or chronic kidney disease were present in 31.4% of cases. Most of the patients (65.7%) lived in rural areas. Table 1: Distribution of Patients According to Demographic Characteristics Parameter Category Number of Patients Percentage (%) Age (years) <30 10 14.3 31–50 28 40.0 >50 32 45.7 Gender Male 58 82.9 Female 12 17.1 Residence Rural 46 65.7 Urban 24 34.3 Comorbidities Present 22 31.4 Absent 48 68.6 Table 2: Clinical Presentation and Risk Factors Clinical Parameter Category Number of Patients Percentage (%) Duration of symptoms before admission <24 hours 33 47.1 24–48 hours 25 35.7 >48 hours 12 17.2 Shock at admission (SBP < 90 mmHg) Present 14 20.0 Absent 56 80.0 Smoking Yes 40 57.1 No 30 42.9 NSAID use Yes 22 31.4 No 48 68.6 Table 2 shows that 52.9% of patients came in after 24 hours of having symptoms. Twenty percent of patients were shocked when they were admitted, and smoking was a common risk factor (57.1%). Almost one-third (31.4%) of the patients said they used NSAIDs. Table 3: Operative Findings Parameter Category Number of Patients Percentage (%) Site of perforation Duodenum 52 74.3 Gastric antrum 18 25.7 Size of perforation <0.5 cm 28 40.0 0.5–1 cm 30 42.9 >1 cm 12 17.1 Peritoneal contamination Mild 18 25.7 Moderate 34 48.6 Severe 18 25.7 Table 3 shows that the duodenum (74.3%) was the most prevalent place for perforation, followed by the gastric antrum (25.7%). Most of the perforations were between 0.5 and 1 cm, and in almost three-fourths of the cases, the peritoneum was moderately to severely contaminated. Table 4 shows that 28 patients (40%) had problems after surgery. Infections of the wound were the most common problem (20%), followed by problems with breathing (10%). The total number of deaths was 12.9% (9 individuals). Table 4: Postoperative Complications Complication Number of Patients Percentage (%) Wound infection 14 20.0 Respiratory complications (pneumonia, atelectasis) 7 10.0 Intra-abdominal abscess 4 5.7 Septicemia 3 4.3 Burst abdomen 2 2.9 Mortality 9 12.9

Perforated peptic ulcer (PPU) remains a life-threatening surgical emergency associated with considerable morbidity and mortality, although breakthroughs in diagnostic imaging, anesthetic, and perioperative care. The current prospective study involving 70 patients sought to evaluate the clinical presentation, operational findings, postoperative outcomes, and prognostic variables affecting mortality and morbidity in individuals with PPU [11-13]. In this study, 82.9% of the patients were male, and 17.1% were female, indicating a significant male predominance. This discovery aligns with the findings of Nuhu et al. (2009) and Søreide et al. (2013), which indicated a male predominance attributed to increased exposure to risk factors, including smoking, alcohol use, and NSAID usage. The average age of presentation was 47.2 years, akin to findings by Jain et al. (2010) and Vaidya et al. (2012), suggesting that PPU is more prevalent among middle-aged persons. However, older patients (over 60 years) had greater death rates because they waited too long to see a doctor and had more than one health problem [14-16]. In this study, smoking (57.1%) and NSAID use (31.4%) were common risk variables linked to PPU. These findings corroborate the studies by Testini et al. (2002) and Søreide et al. (2013), which highlighted the significance of these parameters in mucosal injury and ulcer perforation. The delayed presentation (>24 hours) in 52.9% of patients was significantly associated with heightened postoperative morbidity and death (p = 0.008). Late presentation was frequently ascribed to inadequate early medical access, misdiagnosis, or self-medication—challenges particularly pronounced in rural demographics [17, 18]. The duodenum (74.3%) was the most frequent site of perforation, followed by the gastric antrum (25.7%). This aligns with the findings of Svanes (2000) and Malhotra et al. (2004), who also noted a prevalence of duodenal perforations. The average size of the hole was between 0.5 and 1 cm, and holes that were bigger than 1 cm were linked to significant contamination and bad results [18]. In this study, the total complication rate was 40%. The most common complications were wound infections (20%) and respiratory problems (10%). These numbers are similar to those reported by Kocer et al. (2007), who documented problems after surgery in 35–45% of patients. The mortality rate of 12.9% in this study corresponds with the previously reported range of 10–20%, as indicated by Boey et al. (1982) and Søreide et al. (2013) [18, 19]. In the previous study, among the prognostic indicators, age over 60 years, shock upon admission, concomitant conditions (e.g., diabetes, renal disease), delayed surgery (over 24 hours), and a high Boey score (2 or above) were all substantially linked to death (p < 0.05). The Boey score, which takes into account three important factors—preoperative shock, significant medical sickness, and delay in surgery—was a good way to predict the result of this trial. Mortality rates rose in direct correlation with the Boey score, aligning with findings from Boey et al. (1982) and Rajesh et al. (2013) [21, 22]. In the previous study, survivors stayed in the hospital for an average of 10.6 days, while non-survivors stayed for an average of 16.2 days, mostly because of postoperative sepsis and multi-organ failure. These results show how important it is to recognize and act quickly. The findings underscore that prompt surgical intervention, vigorous resuscitation, and vigilant postoperative surveillance can markedly diminish mortality rates [22, 23]. In the previous study, multiple investigations have confirmed that the interval between perforation and surgery is the most significant prognostic factor. Svanes (2000) found that fatality rates rise dramatically when surgery is postponed beyond 24 hours following perforation. Likewise, the current investigation identified a statistically significant correlation between delayed presentation and unfavorable outcomes. Laparoscopic repair has become a less intrusive choice for minor perforations in stable patients in the last few years. Nonetheless, in resource-constrained emergency environments, open repair via Graham’s omental patch continues to be the conventional method, as demonstrated in this study [23, 24].

The current prospective analysis involving 70 patients with perforated peptic ulcer underscores that this illness remains a prevalent and critical surgical emergency linked to considerable morbidity and mortality. This study identified advanced age, comorbidities, admission shock, delayed surgical intervention (exceeding 24 hours), and a high Boey score (≥2) as significant predictors of postoperative complications and mortality. The duodenum was recognized as the predominant site of perforation, with a death rate of 12.9%, consistent with earlier published studies. To sum up, cutting down on diagnostic delays, improving perioperative care, and dealing with risk factors that can be changed, such smoking and taking NSAIDs, will greatly lessen the burden of perforated peptic ulcer. Strengthening emergency surgical facilities, particularly in rural areas, and enhancing community awareness are essential measures to reduce the morbidity and death linked to this potentially preventable illness. Funding None Conflict of Interest: None

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