Perforated Peptic Ulcer

Perforated peptic ulcer is full thickness perforation of a gastric or duodenal ulcer with leakage of gastroduodenal contents into the peritoneal cavity.

Major causes include Helicobacter pylori, nonsteroidal anti inflammatory drugs and smoking.

Most perforations occur in the anterior duodenum or stomach. Posterior duodenal ulcers more commonly bleed because of proximity to the gastroduodenal artery.

Perforation produces chemical peritonitis followed rapidly by bacterial contamination and secondary intra abdominal infection.

Classically there is sudden severe epigastric pain that rapidly becomes generalised.

The patient often lies still because movement worsens peritoneal pain.

Important findings include:

• Board like abdominal rigidity
• Generalised percussion tenderness
• Tachycardia
• Reduced bowel sounds
• Progressive dehydration
• Sepsis or shock in delayed presentation

Older adults and immunosuppressed patients may have limited guarding despite significant contamination.

CT abdomen with IV contrast: preferred investigation in a stable patient; identify gastroduodenal perforation and quantify contamination.

An erect chest radiograph may demonstrate subdiaphragmatic free gas but a normal film does not exclude perforation.

Check full blood count, renal function, electrolytes, blood gas, lactate, coagulation and crossmatch according to severity.

Resuscitation and operative preparation should occur simultaneously.

Keep fasting.

Establish large bore IV access and use balanced crystalloid according to perfusion response. Correct potassium, magnesium and significant acid base disturbance.

Insert a urinary catheter in shock or major sepsis.

Nasogastric decompression is useful with substantial gastric distension or persistent vomiting.

Give:

Pantoprazole 40 mg IV every 12 hours.

Start antibiotics promptly.

A practical stable community acquired regimen is:

Ceftriaxone 2 g IV every 24 hours plus metronidazole 500 mg IV every 12 hours.

For septic shock or major contamination:

Piperacillin tazobactam 4.5 g IV every 8 hours by extended infusion, adjusted for renal function.

Nonoperative management

Routine conservative treatment of a free perforation is inappropriate.

A highly selected patient may undergo nonoperative management only when:

• Haemodynamics are stable
• There is no diffuse peritonitis or sepsis
• Imaging demonstrates a contained perforation
• Water soluble contrast assessment confirms that the perforation has sealed
• Continuous monitoring and immediate access to surgery are available

Clinical deterioration requires immediate source control.

Operative management

Stable patients are suitable for laparoscopic repair when expertise is available.

For a perforation below 2 cm, primary suture closure is generally sufficient. An omental patch can be added where the tissue is friable or the surgeon believes reinforcement is useful, but it is not mandatory for every small perforation.

For a gastric ulcer, inspect carefully for malignant features. Large, indurated or irregular ulcers require tissue diagnosis. Wedge resection or gastrectomy may be preferable when malignancy is strongly suspected and the patient is physiologically suitable.

For a large duodenal defect above approximately 2 cm, simple closure may be unsafe. Depending on location and tissue quality, options include reinforced repair, pyloric exclusion with gastrojejunostomy, antrectomy, Roux en Y duodenojejunostomy or another tailored reconstruction. Tube duodenostomy is reserved for exceptional destructive defects where safer reconstruction is impossible.

In septic shock, choose the shortest operation that reliably controls contamination. Complex acid reducing ulcer surgery should not be added routinely to emergency source control.

After adequate source control, continue antibiotics for approximately 4 days unless sepsis remains uncontrolled.

Ulcer eradication

Treat Helicobacter pylori after recovery when present.

A practical 14 day bismuth quadruple regimen is:

• Proton pump inhibitor standard dose orally twice daily
• Bismuth subsalicylate 524 mg orally four times daily
• Tetracycline 500 mg orally four times daily
• Metronidazole 500 mg orally three to four times daily

Stop nonsteroidal anti inflammatory drugs where possible. If long term treatment remains unavoidable, maintain appropriate gastroprotection.

Confirm Helicobacter pylori eradication after treatment.

Patients with a gastric ulcer require interval endoscopic reassessment, usually after healing, to ensure malignancy has not been missed. Persistent symptoms, recurrent pain, fever or postoperative ileus should trigger evaluation for repair failure or intra abdominal collection.