Management of Perforated Peptic Ulcer: Current Guidelines
Immediate resuscitation within 1 hour must occur simultaneously with surgical consultation—not sequentially—to reduce mortality in unstable patients with perforated peptic ulcer. 1
Initial Assessment and Diagnosis
Clinical Presentation
- Sudden onset abdominal pain with localized or generalized peritonitis is typical, though peritonitis may be absent in up to one-third of patients, particularly with contained or sealed perforations 2
- Physical examination findings may be equivocal with minimal peritonitis in sealed leaks 2
Laboratory Investigations
- Obtain routine laboratory studies and arterial blood gas analysis immediately (strong recommendation) 2
- Expect leukocytosis, metabolic acidosis, and elevated serum amylase, though these are non-specific 2
- Lactate elevation indicates tissue hypoperfusion and shock; lactate normalization is a critical resuscitation target 1
Imaging Studies
- CT scan is the recommended imaging modality for suspected perforated peptic ulcer (strong recommendation) 2
- If CT is unavailable, perform chest/abdominal X-ray as initial diagnostic assessment to detect free air (strong recommendation) 2
- When free air is not visible but suspicion remains high, add water-soluble contrast (oral or via nasogastric tube) to detect sealed perforations (weak recommendation) 2
Resuscitation Protocol
Critical Timing
- Begin rapid resuscitation immediately—ideally within 1 hour—to reduce mortality 1
- Resuscitation must occur simultaneously with surgical consultation, microbiological cultures, and antibiotic administration 2, 1
ABC Evaluation
- Perform rapid airway, breathing, and circulation assessment first 2
Physiological Targets (Strong Recommendation)
- Mean arterial pressure (MAP) ≥ 65 mmHg 2, 1
- Urine output ≥ 0.5 ml/kg/h 2, 1
- Lactate normalization 2, 1
Hemodynamic Monitoring
- Utilize invasive or non-invasive hemodynamic monitoring to optimize fluid and vasopressor therapy and individualize resuscitation strategy 2
Antimicrobial Therapy
Antibiotic Administration
- Administer antibiotics empirically and promptly (within the first hour of resuscitation) 2, 1
- Antibiotic therapy is strongly recommended for all patients with perforated peptic ulcer 2
Surgical Management
Indications for Surgery
- Surgery is the standard treatment for perforated peptic ulcer 3, 4
- Minimally invasive (laparoscopic) surgery is the preferred approach, with improved outcomes compared to open techniques 3, 4
Surgical Approach Selection
- Laparoscopic repair is preferred over open surgery when feasible, demonstrating fewer surgical site infections, less postoperative pain, and shorter hospital stays 4
- Open surgery remains appropriate for unstable patients or when laparoscopic expertise is unavailable 3
Surgical Techniques
- For small perforations (<2 cm): primary closure with or without omental patch 2
- For large perforations (≥2 cm): omental patch closure is most useful when tissue is friable 2, 3
- Perforated gastric ulcers should be resected when possible; if resection is not feasible, perform closure with biopsy 5
Definitive Ulcer Operations
- Consider vagotomy-pyloroplasty for high-risk patients or vagotomy-antrectomy for lower-risk patients during emergency operations 5
Non-Operative Management (Highly Selected Cases Only)
When to Consider Conservative Management
- Non-operative management should NOT be used routinely (weak recommendation) 2
- Consider only in extremely selected cases where perforation has sealed as confirmed on water-soluble contrast study showing no extravasation 2
Criteria for Non-Operative Management Success
- Normal vital signs in a stable patient 2
- No signs of peritonitis or sepsis 2
- Free air on abdominal X-ray not broader than the first lumbar vertebral column height 6
- No free fluid in intraperitoneal cavity on bedside ultrasound 6
- Resuscitation fluid requirement in first 24 hours not exceeding 5 ml/kg/h 6
Conservative Management Protocol (When Applicable)
- Nasogastric suction 6, 7
- Intravenous fluid resuscitation 6, 7
- Intravenous antibiotics 6, 7
- Intravenous proton pump inhibitor (omeprazole) 6, 7
- Close observation with readiness to operate at any time 7
Failure of Non-Operative Management
- 28% of patients require operation after 12 hours of conservative management 2
- Factors predicting failure: size of pneumoperitoneum, heart rate >94 bpm, abdominal meteorism (distended bowel loops) 2
- Patients over 70 years are less likely to respond to conservative treatment 2
Critical Pitfalls to Avoid
The Fatal Error
- Never delay resuscitation to rush the patient to the operating room—proceeding directly to surgery without resuscitation in a patient with septic shock increases mortality 1
Endoscopic Approaches
- Endoscopic interventions are viable alternatives only for small perforations and in selected cases where general anesthesia is contraindicated 4
- Endoscopic repair shows fewer respiratory complications and shorter hospital stays but is not appropriate for most cases 4
Management of Failed Repairs
- Leak after repair occurs in 12-17% of cases 3
- Approaches to releak include expectant management, radiologic/endoscopic intervention, or repeat surgery 3
- Morbidity and mortality after releak are especially high 3