What are the immediate management steps for a patient with peptic ulcer perforation, including pharmacological and surgical interventions, taking into account their past medical history and current health status?

Immediate Management of Peptic Ulcer Perforation

For patients with peptic ulcer perforation, proceed immediately to laparoscopic surgical repair (simple closure with or without omental patch) in hemodynamically stable patients, or open surgery if unstable, as every hour of delay decreases survival by 2.4%. 1

Initial Resuscitation and Diagnosis

• Start aggressive fluid resuscitation and initiate empiric broad-spectrum antibiotics covering gram-negative and anaerobic organisms immediately upon diagnosis 1
• Confirm diagnosis with upright chest X-ray (detects free air in 85% of cases) or CT scan with oral contrast if X-ray is negative 2, 3
• Look specifically for pneumoperitoneum, extraluminal contrast extravasation, or clinical peritonitis—these mandate operative intervention 1

Surgical Timing: Critical Prognostic Factor

Surgery must be performed as soon as possible after diagnosis, particularly in patients with delayed presentation (>24 hours) or age >70 years. 1 Each hour of surgical delay beyond hospital admission decreases survival probability by 2.4% 1, 4. Do not delay for extensive preoperative optimization 4.

Surgical Approach Selection

Laparoscopic Surgery (Preferred)

• Use laparoscopic repair for all hemodynamically stable patients with normal vital signs and no shock 1, 4
• Laparoscopic approach offers reduced postoperative pain, fewer wound infections, shorter recovery, and comparable mortality to open surgery 1, 5

Open Surgery (Mandatory Indications)

• Hemodynamically unstable patients or those in shock—pneumoperitoneum worsens hemodynamics 1
• Lack of laparoscopic expertise or equipment 1
• Technical difficulties requiring conversion 1
• Patients with severe generalized peritonitis 6

Surgical Technique by Location

Duodenal Ulcer Perforation

• Perform simple closure (primary suture repair) with or without omental patch reinforcement 1, 4
• For small perforations (<2 cm) with healthy edges, direct suture alone is sufficient 4
• For large perforations (≥2 cm) with friable tissue, use omental patch reinforcement to reduce leak risk (12-17% leak rate with simple closure alone) 4, 5
• Biopsy is optional for duodenal ulcers (malignancy rare) 7

Gastric Ulcer Perforation

• Always obtain biopsy or resect gastric ulcers when possible, as 10-16% are malignant 4
• Small perforations (<2 cm): simple closure with or without omental patch 4
• Large perforations (≥2 cm) with friable edges or suspected malignancy: gastric resection with frozen section 4, 3

Essential Intraoperative Steps

• Perform thorough peritoneal lavage and drainage regardless of approach 1
• Use intraoperative endoscopy if perforation site is difficult to localize 7
• Avoid definitive acid-reducing procedures (vagotomy, gastrectomy) in the emergency setting—these are no longer necessary with modern proton pump inhibitors 7, 8

Non-Operative Management: Highly Selected Cases Only

Non-operative management may be considered only in patients meeting ALL of the following strict criteria 2, 9:

• Hemodynamically stable with normal vital signs
• No clinical signs of generalized peritonitis (localized upper abdominal tenderness only)
• Small perforation with contained leak on CT (no free extravasation)
• Presentation within 12 hours of symptom onset
• Patient has been fasting (nil per os) for extended period before perforation 2

Treatment protocol: NPO, IV fluids, IV broad-spectrum antibiotics, high-dose IV proton pump inhibitor, and intensive monitoring with readiness for immediate surgery if deterioration occurs 2, 9. This approach has 70-90% success rate in highly selected patients but requires surgical expertise for immediate conversion if needed 9.

Postoperative Management

• Continue antibiotics for several days postoperatively, tailored to clinical response 1
• Maintain high-dose proton pump inhibitor therapy 4
• Test and treat for H. pylori—this is the most important intervention for preventing recurrence 4
• Strictly avoid NSAIDs, which cause 36% of peptic ulcers and increase mortality 4

Key Prognostic Factors Predicting Poor Outcome

• Age >70 years 1
• Shock on admission 1
• Preoperative metabolic acidosis 1
• Surgical delay >24-36 hours 1
• Large perforation size (≥2 cm) 4

Critical Pitfalls to Avoid

• Do not attempt simple closure on large perforations (≥2 cm) with friable tissue without omental reinforcement—leak rates reach 12-17% 4, 5
• Do not miss occult gastric malignancy—maintain high suspicion and biopsy all gastric ulcers 4
• Do not delay surgery for medical optimization in patients with peritonitis—mortality increases 2.4% per hour 1, 4
• Do not perform laparoscopy in hemodynamically unstable patients 1