Perforated Peptic Ulcer

Definition

peptic ulcer penetrates through the entire thickness of gastric or duodenal wall
leading to leakage of gastric or duodenal content into peritoneal cavity
resulting peritonitis

Risk Factors

H. pylori
NSAIDs
Zollinger-Ellison syndrome

Pathophysiology

Classification

History Taking

epigastric pain - sudden, severe, sharp
persistent pain
gradually extends involving whole abdomen
aggravated by movement and respiration

Physical Examination

General: tachycardia, afebrile, patient looks obviously in pain, lying completely still
Inspection: abdominal muscles can be seen to be tightly contracted
Palpation: right hypochondriac & epigastric tenderness & guarding
rebound tenderness & board-like rigidity in peritonitis
Percussion: usually painful, liver dullness may be diminished or absent if there is large amount of air in the peritoneal cavity
Auscultation: bowel sounds disappear once generalized peritonitis is established

Investigations

Imaging

1. Erect Abdominal X-ray:

Detects free air under the diaphragm

2. CT Abdomen:

More sensitive for detecting perforation and can identify subtle leaks.

Lab

Bloodwork & Crossmatching:

FBC, U&E, serum amylase (to differentiate from pancreatitis), ABG, and coagulation profile.
Crossmatch at least 2–4 units of blood in case of hemorrhagic shock.

Management

1. Resuscitation

Airway & Breathing:
- Ensure adequate oxygenation and monitor for respiratory distress due to peritonitis.
Circulation:
- Two large-bore IV cannulas (14G or 16G).
- Begin aggressive fluid resuscitation with crystalloid fluids (e.g., Ringer’s lactate or normal saline).
- Monitor urine output with a catheter (target: >0.5 mL/kg/hr).
Nasogastric Tube (NGT) Decompression:
- Decompression to prevent further peritoneal contamination.
Pain Control:
- IV opioid analgesia (e.g., morphine, fentanyl).
IV Broad-Spectrum Antibiotics:
- piperacillin-tazobactam or ceftriaxone + metronidazole

2. Surgical Management

Indications for Surgery:

Generalized peritonitis
Hemodynamic instability
Persistent or worsening symptoms despite conservative management
Large perforation (>1 cm)

Principle of Surgery:

thorough peritoneal toilet and closure of the perforation

Surgical Options:

1. Simple Closure with Omental Patch (Graham’s Patch)

Most common technique for duodenal perforations.
Closure of the perforation with interrupted absorbable sutures, reinforced with a vascularized omental patch.
Extensive peritoneal lavage with warm saline is crucial.

2. Primary Repair with Biopsy (for Gastric Ulcers)

Gastric ulcers must be biopsied to exclude malignancy.
If malignancy is suspected, partial gastrectomy (Billroth I/II) may be needed.

3. Laparoscopic Approach

Increasingly used in stable patients.
Offers faster recovery and less postoperative pain.

Postoperative:

stomach is kept empty postoperatively by nasogastric suction
gastric antisecretory agents are commenced to promote healing in the residual ulcer

Complications

Reference