What is the management and treatment for a ruptured gastric ulcer?

Management of Ruptured Gastric Ulcer

Immediate surgical exploration is mandatory for unstable patients with peritonitis, with the surgical approach determined by hemodynamic status, perforation size, and ulcer location. 1

Initial Stabilization and Assessment

Hemodynamic status is the critical determinant of surgical strategy. 1 Patients presenting with acute abdomen require:

• Aggressive fluid resuscitation and correction of electrolyte imbalances while preparing for surgery 2
• CT scan as the preferred imaging modality (more sensitive than plain radiographs, which miss 15% of perforations) 2, 3
• Immediate broad-spectrum antibiotics covering gram-negative, gram-positive, and anaerobic organisms 2
• Laboratory evaluation including white blood cell count and C-reactive protein 2

Surgical Approach Based on Hemodynamic Status

Hemodynamically Stable Patients

For stable patients with perforations <1 cm, laparoscopic primary repair with omental patch is the preferred approach due to decreased operative time, blood loss, and hospital stay. 1, 2

• Mandatory biopsy of the ulcer edge must be obtained to exclude malignancy, as 10-16% of gastric perforations are caused by gastric carcinoma. 1
• Simple closure without omental patch may be considered in highly selected cases with similar outcomes 1
• The classic Graham patch repair (omental patch reinforcement) remains the standard treatment 1, 4

Hemodynamically Unstable Patients

Damage control surgery with abbreviated laparotomy is recommended for patients in septic shock with severe physiological derangement. 5, 1

• Avoid complex definitive procedures (such as Whipple or extensive resections) in patients with severe sepsis and peritonitis 5, 1
• Focus on controlling contamination and stabilizing the patient 1
• Consider open abdomen technique with planned re-laparotomies every 36-48 hours until peritonitis resolves 2
• Pyloric exclusion with gastric decompression and external biliary diversion via T-tube may be the safest option for complex cases 5

Management Based on Perforation Size and Location

Small Perforations (<1 cm)

• Primary suture with omental patch is standard 1
• Laparoscopic approach preferred when expertise available 1, 3

Large Perforations (≥2 cm)

Gastric location is easier to treat than duodenal, and gastric resection with reconstruction should be the surgical choice for perforated gastric ulcers larger than 2 cm. 5

• For large gastric ulcers with suspicion of malignancy, resection with intraoperative frozen section examination is recommended 1
• For large duodenal ulcers, only the first portion can be safely resected without risking bile duct or pancreatic head injury 5
• Antrectomy plus or minus D1-D2 resection with diversion is the classic intervention if the ampullary region is not involved 5
• Alternative techniques for large duodenal defects include jejunal serosal patch, Roux-en-Y duodenojejunostomy, or pyloric exclusion 5
• Leak rates up to 12% have been reported with omental patch closure of large ulcers 5

Critical Intraoperative Considerations

• Thoroughly assess the proximity of the defect to the common bile duct and ampulla of Vater 5
• Intraoperative cholangiography may be necessary to verify common bile duct anatomy 5
• Consider gastrostomy tube placement proximal to perforation if significant postoperative ileus is anticipated 2
• Duodenostomy should be used only as a last resort in giant ulcers with severe inflammation when duodenal mobilization is impossible and the patient is in severe septic shock 5

Postoperative Management

• Serial clinical and imaging monitoring every 3-6 hours in the immediate postoperative period 2
• Continue broad-spectrum antibiotics until clinical improvement, adjusting based on culture results 2
• Avoidance of NSAIDs, smoking, and other ulcerogenic factors 1

Common Pitfalls to Avoid

• Failure to obtain biopsies during repair is a critical error that may miss malignancy 1
• Attempting complex resections in hemodynamically unstable patients increases mortality 1
• Underestimating the severity of peritonitis, which may require damage control rather than definitive repair 1
• Missing the classic triad of sudden abdominal pain, tachycardia, and abdominal rigidity that is the hallmark of perforation 3
• Relying solely on erect chest radiograph, which misses 15% of cases with free air 3

Special Populations

In patients with previous bariatric surgery and perforated marginal ulcer:

• Laparoscopic primary repair with omental patch remains the recommended approach 1
• Explore all anastomoses, the stomach, and excluded segments thoroughly 2
• Always evaluate for gastro-gastric fistula or jejuno-jejunostomy stenosis if diffuse peritonitis is present 2