What are the symptoms and treatment of gastric perforation?

Gastric Perforation: Clinical Presentation and Management

Symptoms and Clinical Presentation

Gastric perforation presents with sudden, severe abdominal pain that rapidly progresses to generalized peritonitis with characteristic physical examination findings of abdominal rigidity, tenderness, and absent bowel sounds. 1

Cardinal Symptoms

• Sudden onset of severe abdominal pain that may become generalized 1
• Fever as a systemic response to peritoneal contamination 1
• Abdominal distension with progressive worsening 1
• Nausea and vomiting (particularly with acute presentations) 1

Physical Examination Findings

• Abdominal tenderness that is initially localized but becomes diffuse 1
• Abdominal rigidity (board-like abdomen) indicating peritoneal irritation 1
• Masked liver dullness on percussion due to free intraperitoneal air 1
• Absent bowel sounds reflecting paralytic ileus 1

Diagnostic Imaging

• CT with IV contrast is the diagnostic modality of choice, demonstrating extraluminal gas, intra-abdominal fluid, air pockets around the stomach and duodenum, and thick reactive intestinal wall 1
• Ultrasound can be used as an initial screening tool 1
• CT findings include visible bowel wall discontinuity, extraluminal contrast extravasation, and localized fat stranding 2

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Treatment Approach

Immediate Surgical Management

Laparoscopic or open simple/double-layer suture with omental patch is the standard procedure for small perforated gastric ulcers in hemodynamically stable patients. 1

For Stable Patients (Class A/B)

• Primary repair with omental patch is safe and effective for perforations less than 1 cm 1
• Laparoscopic approach is preferred when technically feasible, associated with decreased operative time, blood loss, and length of stay 1
• Biopsies of the perforation edges must be obtained to exclude underlying malignancy (8.8% of perforated gastric ulcers harbor malignancy) 1, 3
• Distal gastrectomy is reserved for large perforations near the pylorus, gastric corpus perforations, or suspicion of malignancy 1

For Unstable Patients (Class C)

• Immediate surgical exploration without delay is mandatory in hemodynamically unstable patients 1
• Damage control surgery with open abdomen should be considered in severe hemodynamic instability with diffuse intra-abdominal infection 1
• Surgery should be performed during or after adequate resuscitation 1

Conservative Management

• Conservative management is only appropriate for highly selected patients with small, covered perforations, no systemic signs of infection, and severe comorbidities precluding surgery 1
• This requires nil per os status and proton pump inhibitor infusion 1

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Antibiotic Therapy

For Immunocompetent, Non-Critically Ill Patients with Adequate Source Control

• Amoxicillin/Clavulanate 2 g/0.2 g every 8 hours for 4 days 1
• For documented beta-lactam allergy: Eravacycline 1 mg/kg every 12 hours or Tigecycline 100 mg loading dose then 50 mg every 12 hours 1

For Critically Ill or Immunocompromised Patients with Adequate Source Control

• Piperacillin/tazobactam 6 g/0.75 g loading dose then 4 g/0.5 g every 6 hours or 16 g/2 g by continuous infusion 1
• For beta-lactam allergy: Eravacycline 1 mg/kg every 12 hours 1
• Duration: up to 7 days based on clinical conditions and inflammation indices 1

For Patients with Inadequate/Delayed Source Control or High Risk of ESBL

• Ertapenem 1 g every 24 hours or Eravacycline 1 mg/kg every 12 hours 1

For Septic Shock

• Meropenem 1 g every 6 hours by extended infusion or continuous infusion 1
• Alternatives: Doripenem 500 mg every 8 hours, Imipenem/cilastatin 500 mg every 6 hours, or Eravacycline 1 mg/kg every 12 hours 1

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Post-Operative Management and Prevention of Recurrence

Essential Follow-Up

• All patients must undergo H. pylori testing and receive eradication therapy if positive, as this is the single most effective intervention to prevent ulcer recurrence 4
• Without eradication, H. pylori-positive patients have a 26% rebleeding/recurrence rate 4
• Standard triple therapy for 14 days: PPI twice daily + clarithromycin 500mg twice daily + amoxicillin 1000mg twice daily 4

NSAID Management

• Discontinue all NSAIDs and aspirin if medically possible, as they are well-established predisposing factors 1, 4
• If NSAIDs must be continued, maintain long-term PPI therapy indefinitely and use the lowest effective dose 4

Surveillance

• Follow-up endoscopy with repeat biopsy is essential to avoid missing underlying malignancy (one study found 1 positive biopsy in 21 follow-up endoscopies after initially negative intraoperative histology) 3
• Confirm H. pylori eradication 4-6 weeks after completing therapy using urea breath test or stool antigen test 4

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Critical Pitfalls to Avoid

• Never delay surgical exploration in unstable patients presenting with peritonitis 1
• Always obtain biopsies of perforated ulcers to exclude malignancy, as 8.8% harbor underlying cancer 1, 3
• Do not assume negative intraoperative histology excludes malignancy—follow-up endoscopy with repeat biopsy is mandatory 3
• Avoid fluid overloading as it can worsen intestinal edema and prolong postoperative ileus 5
• Risk factors requiring heightened suspicion: smoking, NSAID use, steroid use, and H. pylori infection 1, 4