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Claim for major advance in treatment of perforated peptic ulcer seems premature

BMJ 1998; 316 doi: https://doi.org/10.1136/bmj.316.7134.860a (Published 14 March 1998) Cite this as: BMJ 1998;316:860
  1. Ian L P Beales, Lecturer in internal medicine and gastroenterology
  1. Department of Gastroenterology, West Norwich Hospital, Norwich NR2 3TU

    EDITOR—In their review of recent advances in general surgery Corvera and Kirkwood conclude that recognition of the importance of Helicobacter pylori in perforated peptic ulcer disease has led to a change in management strategy.1 They advocate a move away from acid-reductive surgery to simple closure with subsequent anti-H pylori treatment. While a reduction in the complexity of surgical intervention might be welcome, the published evidence does not support such a central role for medical anti-H pylori treatment in perforated peptic ulcer disease.

    Successful eradication of H pylori alters the natural course of chronic uncomplicated peptic ulcer disease,2 and recent controlled and uncontrolled studies have shown that clearance of the bacteria reduces the rate of rebleeding after an episode of peptic ulcer haemorrhage.3 The situation for perforated ulcers, however, is much less clear cut. Perforated ulcers may represent a specific subgroup of peptic ulcer disease, and anti-H pylori treatment may have a much less important role (if any). Reinbach et al found that perforated duodenal ulcer was not associated with H pylori infection: 47% of patients with perforated ulcer were seropositive for the bacteria, compared with 50% of matched hospital controls4; this is clearly lower than the 90-100% positivity in chronic uncomplicated duodenal ulceration. Additionally, the small study that Corvera and Kirkwood cite regarding omental patch repair was uncontrolled and contained no data on eradication of H pylori or long term follow up.5 Thus the authors' suggested management strategy has not been subjected to formal trial, and the epidemiological association between H pylori infection and perforated ulcer remains in doubt.

    Clinicians are unlikely to withhold anti-H pylori treatment in infected patients with perforated peptic ulcers. Follow up is advised after attempted eradication of H pylori from bleeding ulcers to ensure that the eradication has been effective, and it also seems necessary after perforation.3 This leaves the problem of what to do about those ulcers that were never infected. While the policy advocated by Corvera and Kirkwood may be both sensible and effective and may well be supported by future studies, it seems premature to base a claim regarding a major advance in the treatment of perforated peptic ulcer on such slim and contradictory evidence.

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