What treatment should be given to a patient with a perforated duodenal ulcer who was on Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and has undergone surgical treatment?

Management of Post-Surgical Perforated Duodenal Ulcer in NSAID User

This patient requires all three interventions: immediate NSAID discontinuation, PPI therapy, and appropriate dietary management—these are not mutually exclusive but rather complementary essential components of post-operative care.

Immediate Post-Operative Management

NSAID Discontinuation (Answer C)

• NSAIDs must be stopped immediately and permanently avoided without gastroprotection 1, 2
• Patients with perforated duodenal ulcers have the highest risk for NSAID-associated complications, and continuing NSAIDs significantly increases ulcer recurrence and mortality even with PPI therapy 1, 2
• The American College of Gastroenterology recommends immediately discontinuing all NSAIDs in patients with NSAID-induced gastric complications 2
• For pain management, acetaminophen should be used as an alternative, as it does not cause gastric injury 2

PPI Therapy (Answer B)

• Initiate high-dose PPI therapy immediately post-operatively 1, 2, 3
• The recommended regimen is omeprazole 40 mg once daily (or equivalent PPI) for 4-8 weeks to ensure complete ulcer healing 4, 5, 6
• PPIs are superior to H2-receptor antagonists for both gastric and duodenal ulcer healing, with healing rates of approximately 82% at 4 weeks for duodenal ulcers 4, 5
• After surgical repair of perforated ulcer, PPI therapy reduces rebleeding rates, need for repeat surgery, and mortality 3

Dietary Management (Answer A)

• Patients should be fed within 24 hours after endoscopy or surgical intervention if clinically stable 1
• A gastric-friendly diet should be followed during the healing phase, though this is supportive rather than primary therapy 7

Essential Additional Interventions

H. pylori Testing and Eradication

• All patients with perforated duodenal ulcers must be tested for H. pylori infection 1, 2
• If positive, triple therapy should be initiated: PPI + amoxicillin 1000mg twice daily + clarithromycin 500mg twice daily for 14 days 1, 4
• H. pylori eradication combined with simple omental patch closure prevents reperforation in the majority of cases 7
• Negative H. pylori tests obtained acutely should be repeated, as acute bleeding can cause false negatives 1

Duration of PPI Therapy

• Continue PPI therapy for a full 8 weeks post-operatively to ensure complete mucosal healing 2, 4
• For patients with active ulcer at time of H. pylori eradication therapy, continue omeprazole 20 mg once daily for an additional 18 days after completion of triple therapy 4

Long-Term Management Strategy

If NSAIDs Are Absolutely Required in Future

• The combination of a COX-2 selective inhibitor (celecoxib) plus a PPI is recommended if NSAIDs cannot be avoided 1
• This combination provides the lowest risk for recurrent ulcer complications in high-risk patients 1
• NSAIDs plus PPIs alone still carry clinically important risk for recurrent bleeding 1
• Misoprostol 600 mg/day is an alternative gastroprotective agent but causes diarrhea and abdominal pain in approximately 20% of patients 1

Monitoring and Follow-Up

• Patients should be hospitalized for at least 72 hours post-operatively after surgical repair 1
• Surgical consultation should be readily available if complications develop 1
• Confirmation of H. pylori eradication should be documented 1
• Long-term PPI therapy should be considered for patients who must continue NSAIDs 3

Critical Warnings

Regarding Exercise (Answer D)

• There is no evidence-based recommendation to avoid exercise specifically for perforated ulcer patients post-operatively 1
• Standard post-operative activity restrictions apply, but exercise avoidance is not a primary therapeutic intervention for ulcer healing

Compliance Issues

• Poor compliance with PPI therapy increases the risk of NSAID-induced adverse events 4-6 fold 1, 2
• Patients must understand that PPI therapy only works when taken consistently 1

Alarm Symptoms Requiring Urgent Evaluation

• Hematemesis, melena, significant weight loss, difficulty swallowing, or recurrent vomiting indicate potential complications requiring urgent endoscopy or surgery 2

The correct answer encompasses B (PPI), C (Stop NSAID), and A (appropriate diet), as these are all essential components of comprehensive post-operative management, not mutually exclusive options.