What is the management for a patient with perforated peptic ulcer disease?

Management of Perforated Peptic Ulcer Disease

Surgical intervention is the standard treatment for perforated peptic ulcer disease, with immediate surgery recommended especially for patients with delayed presentation and those older than 70 years. 1

Initial Assessment and Resuscitation

• Evaluate vital signs, perform ABC (airway, breathing, circulation) assessment, and check for signs of peritonitis and sepsis 1
• Obtain laboratory tests including complete blood count, comprehensive metabolic panel, and lactate levels 1
• Request imaging studies including upright chest X-ray to detect free air under the diaphragm and CT scan with oral contrast to confirm diagnosis and assess for extravasation 2
• Initiate rapid resuscitation in unstable patients with the following targets:
  • Mean arterial pressure ≥ 65 mmHg
  • Urine output ≥ 0.5 ml/kg/h
  • Lactate normalization 1
• Perform microbiological cultures (blood and peritoneal fluid) before starting antibiotics 1

Surgical Management

• Perform surgery as soon as possible, particularly in patients with delayed presentation (>24 hours) and those older than 70 years 1
• Consider laparoscopic approach as the preferred surgical method in hemodynamically stable patients with minimal contamination 3, 4
• For small perforations (<2 cm):
  • Simple closure with omental patch (Graham patch) is the standard procedure 4
• For large perforations (≥2 cm):
  • Consider more complex repair techniques including resection depending on ulcer location and tissue viability 1
• For duodenal perforations:
  • Perform triple-loop suturing when dealing with gastroduodenal artery bleeding due to collateral blood supply 1
• For gastric perforations:
  • Consider resection or at least biopsy to rule out malignancy 1
• Consider damage control surgery in patients with hemorrhagic shock and severe physiological derangement 1

Non-Operative Management (NOM)

• NOM is not routinely recommended but may be considered in extremely selected cases 1
• Prerequisites for NOM include:
  • Radiologically confirmed sealed perforation (no contrast extravasation)
  • Absence of peritonitis or sepsis
  • Stable vital signs
  • Normal heart rate (<94 bpm)
  • Minimal pneumoperitoneum 1
• NOM components include:
  • Nil by mouth
  • Nasogastric tube decompression
  • Intravenous hydration
  • Proton pump inhibitor therapy
  • Intravenous antibiotics 1, 5
• Be prepared to convert to surgical management if clinical deterioration occurs within 12-24 hours 1

Antimicrobial Therapy

• Administer empiric antibiotics covering gastrointestinal flora in all patients with perforated peptic ulcer 1
• Target common pathogens including E. coli, Klebsiella, and other gram-negative organisms 2
• Continue antibiotics based on peritoneal fluid culture and sensitivity results 2

Post-Operative Management

• Monitor for complications including:
  • Leak from repair site (occurs in 12-17% of cases)
  • Intra-abdominal abscess formation
  • Wound infection 3
• Manage leaks based on severity:
  • Small contained leaks may be managed conservatively
  • Larger leaks or abscesses >5 cm may require image-guided drainage
  • Persistent leaks may require reoperation 2, 3

Helicobacter Pylori Testing and Management

• Test all patients with perforated peptic ulcer for H. pylori infection 1
• Eradicate H. pylori if detected to reduce ulcer recurrence and rebleeding 1

Common Pitfalls and Caveats

• Delayed surgery significantly increases mortality - each hour of delay is associated with 2.4% decreased probability of survival 1
• Patients >70 years old have higher mortality rates with both surgical and non-operative management 1
• Endoscopic treatments such as clipping, fibrin glue sealing, or stenting are not recommended for perforated peptic ulcers 1
• Mortality rates remain high (7.8-30%) despite advances in management 2, 3

Follow-up

• Perform endoscopy at 4-6 weeks after recovery to assess healing and rule out malignancy 1
• Provide education on risk factor modification (NSAIDs avoidance, smoking cessation) 2