What is the initial next step for a patient with Peptic Ulcer Disease (PUD) presenting with signs of perforation, such as guarding and rigidity and rebound tenderness?

Initial Management of Perforated Peptic Ulcer

The initial next step is fluid resuscitation (Option A), as rapid resuscitation must occur simultaneously with surgical consultation and preparation for exploratory laparotomy. 1

Rationale for Prioritizing Resuscitation

Unstable patients with perforated peptic ulcer require rapid resuscitation within 1 hour to reduce mortality, and this must take place simultaneously with surgical consultation, not sequentially. 1

The World Society of Emergency Surgery (WSES) 2020 guidelines explicitly state that in unstable patients with perforated peptic ulcer, rapid resuscitation should be performed to reduce mortality (strong recommendation, 1C). 1 This resuscitation must occur simultaneously with surgical consultation, microbiological cultures, and antibiotic administration—not after or before. 1

Critical Resuscitation Targets

The following physiological parameters must be restored during initial resuscitation: 1

• Mean arterial pressure (MAP) ≥ 65 mmHg 1
• Urine output ≥ 0.5 ml/kg/h 1
• Lactate normalization 1

These targets are the same used for sepsis and septic shock, as perforated peptic ulcer with peritonitis represents a surgical emergency with associated sepsis/septic shock. 1

Why Not Immediate Exploratory Laparotomy?

While exploratory laparotomy is the definitive treatment and remains the gold standard for perforated peptic ulcer, the patient must first undergo ABC (airway, breathing, circulation) evaluation and rapid resuscitation. 1

Proceeding directly to the operating room without resuscitation in a patient with signs of peritonitis and likely septic shock would increase mortality. 1 The WSES guidelines emphasize that prompt evaluation, early recognition of sepsis, and prevention of further organ failure are critical to reducing mortality. 1

The Simultaneous Approach

In practice, the correct sequence is: 1

1. Immediate resuscitation begins (fluids, vasopressors if needed to achieve MAP ≥65 mmHg)
2. Simultaneous surgical consultation (surgeon notified immediately)
3. Concurrent diagnostic workup (labs including lactate, blood cultures, imaging if needed)
4. Antibiotic administration (within the first hour)
5. Preparation for exploratory laparotomy (while resuscitation continues)

Clinical Context

This patient presents with classic signs of perforation: guarding, rigidity, and rebound tenderness. 2 These findings indicate diffuse peritonitis, which in the context of peptic ulcer disease represents a medical/surgical emergency. 1

The patient likely has sepsis or septic shock, given the peritonitis from perforation. 1 Symptoms including altered mental state, tachycardia, tachypnea, reduced pulse pressure, decreased urine output, and hyperlactatemia should be evaluated during the emergency department assessment. 1

Common Pitfall to Avoid

The critical error would be delaying resuscitation to rush the patient to the operating room. 1 While surgery is urgent and necessary, the patient must be physiologically optimized during the brief resuscitation period to survive the operation and postoperative period. 1 This resuscitation should ideally occur within 1 hour, not over several hours. 1

Hemodynamic monitoring (invasive or non-invasive) should be utilized to optimize fluid and vasopressor therapy and individualize the resuscitation strategy. 1