What advice should be given to a patient with a history of perforated peptic ulcer who underwent surgical repair with an omental (omentum) patch?

Post-Surgical Management of Perforated Peptic Ulcer After Omental Patch Repair

The most appropriate advice is to strictly avoid NSAIDs permanently, as they represent one of the strongest independent risk factors for peptic ulcer perforation and recurrence, with demonstrated association with increased mortality in perforated peptic ulcer patients. 1

Primary Post-Operative Recommendation: NSAID Avoidance

NSAIDs must be completely and permanently discontinued because they directly affect gastric mucosal acid secretion and represent a primary etiologic factor for peptic ulcer disease. 1 The evidence supporting this recommendation is compelling:

• A systematic review of 29,782 patients demonstrated strong evidence that NSAID use is independently associated with mortality in perforated peptic ulcer patients. 2, 1
• The American College of Gastroenterology specifically recommends that patients with a history of peptic ulcer disease must strictly avoid all NSAIDs permanently. 1
• Patients with prior peptic ulcer disease who use NSAIDs have a greater than 10-fold increased risk for developing a GI bleed. 1

This is not merely a suggestion for "maintaining a healthy diet" - it is a specific, evidence-based intervention targeting the primary modifiable risk factor for recurrence.

Secondary Critical Recommendation: H. pylori Testing and Eradication

All patients should undergo H. pylori testing if not already performed, as H. pylori infection is a major etiologic factor alongside NSAIDs. 3, 1

• Eradication therapy with appropriate antibiotic regimens should be initiated if infection is confirmed. 1
• H. pylori colonization of the antral mucosa causes aberrations in gastric and duodenal mucosal function that contribute to ulcer formation. 4
• Patients treated with surgery alone have higher rebleeding rates compared to those who also receive H. pylori eradication therapy. 4

Additional Risk Factor Modifications

Beyond NSAID avoidance and H. pylori eradication, patients require:

• Complete smoking cessation - smoking is a key etiologic factor affecting gastric acid secretion. 3, 1
• Steroid avoidance when possible - steroids are associated with increased mortality risk and represent a modifiable risk factor for ulcer recurrence. 2, 1
• Reduced dietary salt intake - salt affects gastric acid secretion. 3, 1

Why "Maintain a Healthy Diet" Alone is Insufficient

While dietary modifications have a role (particularly salt reduction), this advice is too vague and misses the critical evidence-based interventions. 3, 1 The guidelines do not support routine physical activity restriction after successful omental patch repair, and patients typically return to daily activities within a short period post-operatively. 3

Algorithmic Approach to Post-Operative Counseling

1. First priority: Discontinue all NSAIDs permanently 1
2. Second priority: Test for H. pylori and treat if positive 3, 1
3. Third priority: Eliminate smoking and minimize steroid use 1
4. Fourth priority: Modify diet to reduce salt intake 3, 1

Common Pitfalls to Avoid

• Do not allow patients to resume NSAIDs even for other medical conditions - alternative pain management strategies must be employed. 1
• Do not skip H. pylori testing assuming it was addressed during hospitalization - confirm testing was completed and treatment initiated if positive. 1
• Do not provide generic dietary advice without specifically addressing salt reduction and its mechanism in affecting gastric acid secretion. 3, 1

The answer is B. Avoid NSAIDs as the single most important post-operative advice, though H. pylori testing (option C) is also critical and should be performed concurrently. 1