The prognosis of the perforated acute duodenal ulcer.

The use of the terms 'acute' and 'chronic' when describing perforated duodenal ulcers has sometimes produced confusion. It is obviously incorrect to speak of an 'acute perforation' because all perforations are acute although some may be small and therefore leak slowly. On the other hand, it is established that both acute and chronic ulcers perforate, although it may appear to be of academic interest only to differentiate between them. However, Lowdon (1952) has shown that the duration of dyspepsia correlates with the histological findings, for in patients with a history of less than one month, 80% of the ulcers showed no signs of chronicity. Most authorities who have classified their patients in this way have concluded that patients with an acute ulcer fare better than those whose lesion is chronic (Illingworth, Scott, and Jamieson, 1946; Gilmour, 1953; Taylor and Warren, 1956). Indeed, Taylor has claimed that the mortality, complications, and disability following perforation are almost completely confined to the chronic ulcer group, and he therefore pays careful attention to the patient's previous history, and treats all those with perforation of an acute ulcer conservatively. However, a report on a recent series of perforated duodenal ulcers suggests that the prognosis of patients with an acute lesion is worse than for those with chronic ulcers (Hofkin, 1966). The series only comprised 57 patients of whom 13 had an acute ulcer. Eleven of them had a simple closure and all but one of these subsequently suffered further symptoms, eight coming to definitive surgery. The two other 'acute' patients had a definitive procedure initially and both of them required a further operation for recurrent ulceration. It seemed to us to be of more than passing interest to discover which of these two contrasting experiences was appropriate to our surgical practice, because whilst Taylor urges non-operative conservative treatment, Hofkin recommends immediate definitive surgery in the management of the acute duodenal perforation.