From the Guidelines
A perforated duodenal ulcer is a serious medical emergency requiring immediate surgical intervention, typically through laparoscopic or open repair, with initial management including nothing by mouth (NPO), intravenous fluids, broad-spectrum antibiotics, and proton pump inhibitors. The patient should be rushed to the hospital for emergency surgery to close the perforation. Initial management includes NPO, intravenous fluids, broad-spectrum antibiotics (such as piperacillin-tazobactam 3.375g IV every 6 hours or ceftriaxone 1g IV daily plus metronidazole 500mg IV every 8 hours), and proton pump inhibitors (such as pantoprazole 40mg IV twice daily) 1. Nasogastric tube decompression is often necessary to reduce gastric contents and prevent further contamination.
Surgical Approach
The surgical approach depends on the size of the perforation. For small perforations (< 2 cm), primary repair is suggested, with no clear benefit from the use of an omental patch 1. However, for large perforations (≥ 2 cm), a tailored approach based on the location of the ulcer is recommended, with consideration of resection, repair, or pyloric exclusion/external bile drainage 1.
Endoscopic Treatment
Endoscopic treatment, such as clipping, fibrin glue sealing, or stenting, is not recommended for perforated peptic ulcers due to limited evidence and potential ineffectiveness in fibrotic tissue 1.
Postoperative Management
Following surgery, patients require Helicobacter pylori eradication therapy if positive, typically with triple therapy consisting of amoxicillin 1g twice daily, clarithromycin 500mg twice daily, and a PPI for 14 days. Long-term PPI therapy (such as omeprazole 20mg daily) for 4-8 weeks is recommended to allow complete healing. Risk factors, including NSAID use, H. pylori infection, smoking, and alcohol consumption, should be addressed to prevent recurrence. Perforated duodenal ulcers are life-threatening due to the risk of chemical peritonitis, bacterial peritonitis, sepsis, and death if not treated promptly 1.
From the Research
Diagnosis and Treatment of Perforated Duodenal Ulcer
- Perforated duodenal ulcer is a serious condition that requires prompt diagnosis and treatment 2.
- Computed tomography with intravenous and oral contrast is the most valuable imaging technique to identify duodenal perforation 2.
- Treatment depends on the nature of the disease process, timing, location, and extent of the injury, as well as the clinical condition of the patient 2.
Surgical Management
- Simple closure of the perforation is a common treatment approach, but it may not be sufficient for all patients 3, 4.
- Definitive surgery, such as truncal vagotomy and drainage, may be necessary for patients with a history of ulcers or those who are at high risk of recurrence 3, 4.
- Minimally invasive surgery is a safe and effective alternative to conventional open surgery in selected patients with duodenal perforations 2, 5.
Conservative Management
- Conservative management may be feasible in stable patients with sealed perforations 2, 6.
- Patients with a perforated duodenal ulcer who have already been evaluated for H. pylori and are not infected or have received appropriate therapy may undergo an ulcer-definitive operation if they are suitable surgical candidates 6.
Outcomes and Complications
- The mortality rate for perforated duodenal ulcer can range from 2.8% to 6.7% depending on the treatment approach and patient population 3, 4.
- Morbidity and mortality after releak are especially high, and complete healing of the leak may take time 5.
- Recurrent ulcer symptoms are common after simple closure, and definitive surgery may be necessary to prevent recurrence 3, 4.