What is the management of gastric ulcer (peptic ulcer disease) perforation?

From the Guidelines

Management of gastric ulcer perforation requires immediate surgical intervention, preferably with a tailored approach based on the location and size of the ulcer, followed by supportive care and treatment of underlying causes. The primary steps are:

• Emergency surgery: Perform laparotomy or laparoscopic repair to close the perforation and wash out the peritoneal cavity, with consideration of resection with contextual operative frozen pathologic examination for large gastric ulcers suspicious of malignancy 1.
• Fluid resuscitation: Administer IV fluids to correct hypovolemia and electrolyte imbalances.
• Antibiotics: Start broad-spectrum antibiotics immediately, such as piperacillin-tazobactam 3.375g IV every 6 hours, or ceftriaxone 1g IV daily plus metronidazole 500mg IV every 8 hours, and continue for 3-5 days or until inflammatory markers normalize 1.
• Nasogastric decompression: Insert a nasogastric tube to decompress the stomach and reduce further leakage.
• Proton pump inhibitor (PPI) therapy: Administer high-dose IV PPI, such as pantoprazole 80mg IV bolus, followed by 8mg/hour continuous infusion for 72 hours, then transition to oral PPI therapy for 4-8 weeks.
• H. pylori eradication: If H. pylori positive, initiate triple therapy after oral intake resumes, with amoxicillin 1g orally twice daily, clarithromycin 500mg orally twice daily, and PPI (e.g., omeprazole 20mg) orally twice daily, for 14 days.
• Discontinue NSAIDs if applicable and address other risk factors.
• Gradually advance diet as tolerated, typically starting 24-48 hours post-surgery.

It is essential to note that the management of gastric ulcer perforation should be individualized based on the patient's condition, the size and location of the ulcer, and the presence of any complications, such as malignancy or peritonitis 1. The use of broad-spectrum antibiotics and PPI therapy is crucial in preventing sepsis and promoting ulcer healing, while H. pylori eradication addresses a major cause of ulcers 1. Close monitoring and supportive care are crucial in the immediate post-operative period to ensure recovery and prevent complications.

From the Research

Management of Gastric Ulcer Perforation

The management of gastric ulcer perforation, also known as peptic ulcer disease (PUD) perforation, involves immediate surgical intervention. The goal of treatment is to repair the perforation, control bleeding, and prevent further complications.

Surgical Approaches

• Primary closure and omental patch closure are common approaches for repair 2
• Omental patch may be most useful in large perforations with friable tissue 2
• Minimally invasive surgery is the preferred approach, with improved outcomes compared to open techniques 2, 3
• Laparoscopic repair is a feasible and safe procedure, especially in cases of short duration of ulcer perforation and good clinical condition 4

Techniques and Outcomes

• A one-row running suture (Lahodny) can be used to close the perforation, with good outcomes and no conversions to open surgery 4
• Omental patch repair is effective in managing perforated gastric ulcers, with a low rate of morbidity and mortality 5
• Simple closure with Graham patch, followed by ulcer excision and vagotomy with pyloroplasty, is also a viable option 6
• Peritoneal lavage and drainage are important components of the surgical management of perforated ulcers 6, 3

Complications and Morbidity

• Leak from the ulcer after repair is a potential complication, occurring in approximately 12% to 17% of cases 2
• Morbidity and mortality after releak are high, and complete healing of the leak may take time 2
• Overall morbidity and mortality rates for perforated PUD are significant, with rates of 50% and 30%, respectively 2