What is a Perforated Ulcer?
A perforated peptic ulcer is a full-thickness breach in the gastric or duodenal wall that allows gastroduodenal contents to spill into the peritoneal cavity, almost invariably leading to peritonitis and representing a surgical emergency with mortality rates ranging from 1.3% to 30%. 1, 2, 3
Pathophysiology and Clinical Significance
The perforation creates a direct communication between the gastrointestinal lumen and peritoneal cavity, resulting in chemical and bacterial peritonitis. 1 The spillage of gastroduodenal contents triggers:
- Immediate peritoneal contamination with gastric acid, bile, and digestive enzymes 1
- Polymicrobial infection involving gram-positive, gram-negative, and anaerobic bacteria 1
- Potential fungal contamination, particularly in high-risk patients 1
Morbidity and Mortality Profile
Perforated peptic ulcer carries substantial mortality risk, with 30-day mortality reaching 20% and 90-day mortality up to 30%. 2, 3 The associated morbidity burden is significant:
- Overall morbidity ranges from 17% to 63% 1
- Most common complications include pulmonary infections and wound infections 1
- Mortality is significantly higher in patients with positive peritoneal fluid cultures, especially mixed bacterial and fungal infections 1
Clinical Presentation
The classic triad consists of sudden onset abdominal pain, tachycardia, and abdominal rigidity. 2 However, presentations can be highly variable:
- In critically ill patients, classical symptoms are frequently absent 4
- Nonspecific manifestations may include unexplained ileus, hypotension, or respiratory distress 5, 4
- Diagnosis is often delayed, particularly in complicated or critically ill patients 5, 4
Diagnostic Considerations
Erect chest radiograph can miss up to 15% of cases with pneumoperitoneum. 2 Key diagnostic points include:
- Free air under the diaphragm is the hallmark radiographic finding, but absence does not exclude perforation 2, 6
- Advanced imaging (CT) may be required when clinical suspicion is high despite negative plain films 6
- In critically ill patients, perforation may first be suspected on routine imaging showing pneumoperitoneum 4
Anatomical and Size Variations
Ulcer size and location significantly impact surgical approach and outcomes. 1
- Small perforations (< 2 cm) are typically managed with simple closure or omental patch 1
- Large perforations (≥ 2 cm) require tailored approaches based on location 1
- In critically ill patients, ulcers are characteristically very large (> 2 cm) with minimal surrounding inflammation 4
- Large gastric ulcers should raise suspicion for malignancy (10-16% of gastric perforations are caused by gastric carcinoma) 1
Immediate Life-Threatening Complications
Patients can rapidly progress to severe sepsis and septic shock with progressive organ dysfunction, hypotension, myocardial depression, and coagulopathy. 1 This progression necessitates: