From the Guidelines
Non-operative management is the recommended approach for sealed-off perforated peptic ulcer disease (PPUD), as it avoids the morbidity associated with surgery, provided the patient is stable and there are no signs of peritonitis or sepsis. This approach is based on the most recent guidelines, which suggest that non-operative management (NOM) could be considered in extremely selected cases where perforation has sealed, as confirmed on water-soluble contrast study 1. The management includes hospital admission, nasogastric tube placement, intravenous fluids, and broad-spectrum antibiotics for 3-5 days. Proton pump inhibitors (PPIs) like omeprazole should be administered, and patients should be kept nil by mouth initially, with diet gradually reintroduced as symptoms improve.
Key considerations in the management of sealed-off PPUD include:
- Close clinical monitoring, including vital signs, abdominal examination, and laboratory markers of inflammation
- Immediate surgical intervention if clinical deterioration occurs
- Testing for Helicobacter pylori and eradication therapy if positive
- A 14-day regimen of two antibiotics plus a PPI for eradication therapy, as recommended by recent guidelines 1. The rationale for NOM is that, in the case of small perforations, the ulcer seals by omental adhesions and can then heal, and the peritonitis does not need operation, as supported by studies such as Croft et al. in 1989 and Songne et al. in 2004, cited in 1.
The most important factors regarding the feasibility of NOM for perforated peptic ulcer are normal vital signs in a stable patient and whether the ulcer itself has sealed, as confirmed by a water-soluble contrast study 1. If there is a free leak of contrast, surgery is needed, but NOM could be considered if no contrast extravasation is present and the patient does not have signs of peritonitis or sepsis.
From the Research
Management of Sealed-Off Perforated Peptic Ulcer Disease (PPUD)
The management of sealed-off PPUD involves a range of approaches, including:
- Conservative management: This approach can be considered in selected cases where the patient is stable and there are no signs of generalized peritonitis 2.
- Surgical management: This is the standard treatment for PPUD and involves exploratory laparotomy and omental patch repair or simple closure of the perforation 3, 4, 5.
- Minimally invasive surgery: This approach is preferred for PPUD, with improved outcomes compared to open techniques 3.
- Medical management: This includes the use of medications such as histamine H2-receptor antagonists, proton pump inhibitors, and mucosal protective drugs to manage the underlying peptic ulcer disease 6.
Factors Influencing Management
The management of sealed-off PPUD is influenced by several factors, including:
- Patient stability: Patients who are vitally stable and have no signs of generalized peritonitis may be considered for conservative management 2.
- Perforation size and location: The size and location of the perforation can influence the choice of surgical approach, with omental patch repair being more suitable for large perforations with friable tissue 3.
- Presence of complications: The presence of complications such as leak or abscess may require additional interventions, such as radiologic or endoscopic intervention, or repeat surgery 3.
Outcomes
The outcomes of sealed-off PPUD management can vary, with:
- Morbidity and mortality rates: These rates can be high, especially in cases where there are complications or delayed treatment 3, 4, 5.
- Success of conservative management: Conservative management can be successful in selected cases, but requires close monitoring and a low threshold for surgical intervention 2.
- Effectiveness of surgical management: Surgical management can be effective in treating PPUD, but requires careful patient selection and technique 3, 4, 5.