What is the treatment for Upper Intestinal Perforation (UIP)?

Treatment of Upper Intestinal Perforation

Surgery is the treatment of choice for perforated peptic ulcers, with simple closure using an omental patch being the standard approach for small perforations (<2 cm), while endoscopic closure should be pursued when feasible for esophageal and gastric perforations, with specific techniques selected based on perforation size. 1

Immediate Resuscitation and Stabilization

• Keep the patient NPO (nothing by mouth) immediately and initiate aggressive intravenous fluid resuscitation 1, 2
• Start broad-spectrum antibiotics covering gram-negative and anaerobic organisms without delay 1, 2
• Place a nasogastric tube for gastric decompression to minimize spillage through the perforation 1, 2
• Minimize carbon dioxide insufflation during any endoscopic procedures to avoid compartment syndrome 1
• Position the patient to bring the perforation into a non-dependent location to reduce contamination 1, 2
• Aspirate liquids and keep the perforation area clean to prevent spillage of gastrointestinal contents 1

Diagnostic Confirmation

• Obtain urgent CT scan to confirm perforation and assess extent of contamination, as it is more sensitive than plain radiographs for detecting free air 2
• Check white blood cell count and C-reactive protein to assess inflammatory response 2
• Obtain urgent surgical consultation even if endoscopic repair appears technically successful 1

Treatment Algorithm by Location and Size

Esophageal Perforations

• For perforations <2 cm: Use through-the-scope clips (TTSCs) or over-the-scope clips (OTSCs) 1
• For perforations >2 cm: Use endoscopic suturing 1
• Reserve esophageal stenting with self-expanding metal stents (SEMS) for cases where primary closure is not possible 1

Gastric Perforations

• For perforations <2 cm: Use TTSCs or OTSCs 1
• For perforations >2 cm: Use endoscopic suturing or combination of TTSCs and endoloop 1

Duodenal Perforations

• For large type 1 duodenal perforations (lateral wall tear >3 cm): Make urgent surgical consultation while assessing feasibility of endoscopic closure, recognizing the difficulty in closing them endoscopically 1
• For type 2 periampullary (retroperitoneal) perforations: Close with TTSCs if feasible and/or place a fully covered SEMS into the bile duct across the ampulla 1
• Carefully assess gas pattern on fluoroscopy to avoid missing subtle retroperitoneal perforations and request CT scan if concerned 1

Peptic Ulcer Perforations

• Surgery is the definitive treatment for perforated peptic ulcers 1
• Simple closure with or without an omental patch is safe and effective for small perforated ulcers (<2 cm) 1
• Perform surgery as early as possible, ideally within 24 hours of diagnosis, as every hour of delay increases mortality 2

Critical Timing Considerations

• Operate within 24 hours of diagnosis whenever possible, as delayed intervention significantly increases mortality 2
• Elderly patients (>70 years) have worse outcomes with delayed intervention and are less likely to respond to conservative management 2
• Clinical improvement should occur within 24 hours if conservative treatment is attempted; failure to improve mandates immediate surgical intervention 2, 3

Conservative Management (Highly Selective Cases Only)

Conservative management may be considered only if all of the following criteria are met:

• No contrast extravasation on water-soluble contrast study 3
• Hemodynamically stable (heart rate <94 bpm, mean arterial pressure ≥65 mmHg) 3
• No signs of peritonitis or sepsis 3
• Perforation is truly sealed off 3

If conservative management is attempted, it must include:

• Absolute bowel rest with NPO status 3
• Nasogastric tube decompression 3
• Intravenous proton pump inhibitor therapy 3
• Broad-spectrum intravenous antibiotics 3
• Serial clinical examinations every 3-6 hours with readiness for immediate surgery if deterioration occurs 3

Special Populations Requiring Surgical Management

• Immunocompromised patients and transplant recipients should undergo surgical management regardless of perforation size 2, 3
• Elderly patients (>70 years) should have a lower threshold for surgical intervention due to worse outcomes with conservative management 2, 3

Post-Treatment Monitoring

• Admit all patients for observation with continuous monitoring 1, 2
• Perform water-soluble upper GI series before initiating clear liquid diet to confirm absence of ongoing leak 1, 2
• Monitor for development of peritoneal signs, fever, tachycardia, or sepsis 3
• Continue strict clinical and biochemical follow-up even after initial improvement 3

Critical Pitfalls to Avoid

• Do not delay surgical consultation even if endoscopic closure appears successful 1, 2
• Do not attempt conservative management in patients with peritoneal signs or hemodynamic instability 2
• Do not be misled by initial stability – patients may appear stable initially but deteriorate suddenly with sealed perforations 3
• Recognize that complication rates and hospital stays are significantly higher in patients requiring delayed surgery after failed conservative management compared to those treated surgically from the outset 3
• Be aware that the presence of free air alone does not mandate surgery, but clinical judgment must prevail 3