What is the most appropriate postoperative advice for a patient after repair of a perforated peptic ulcer with an omental patch?

Post-Operative Management After Perforated Peptic Ulcer 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, 2

Primary Recommendation: NSAID Avoidance (Answer B)

NSAIDs must be completely and permanently discontinued following perforated peptic ulcer repair. 2 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 1, 2
• NSAIDs directly affect gastric mucosal acid secretion and represent a primary etiologic factor for peptic ulcer disease alongside H. pylori infection 2
• The American College of Gastroenterology specifically recommends that patients with a history of peptic ulcer disease must strictly avoid all NSAIDs permanently 2

Secondary Recommendations

H. pylori Testing and Eradication (Answer C - Also Critical)

All patients should undergo H. pylori testing if not already performed, and eradication therapy with appropriate antibiotic regimens should be initiated if infection is confirmed. 2, 3 This is essential because:

• H. pylori infection is a major etiologic factor alongside NSAIDs for peptic ulcer disease 2
• Eradication significantly reduces recurrence risk 4, 5

Additional Risk Factor Modifications

Beyond NSAID avoidance, patients require:

• Complete smoking cessation - smoking is a key etiologic factor affecting gastric acid secretion 2, 3
• Steroid avoidance or minimization when possible, as steroids are associated with increased mortality risk 1, 2
• Reduced dietary salt intake which affects gastric acid secretion 2

Why "Maintain a Healthy Diet" (Answer A) is Insufficient

While dietary modifications have some role, this recommendation is too vague and does not address the primary modifiable risk factors that directly impact mortality and recurrence. 2 The evidence clearly prioritizes specific interventions (NSAID avoidance, H. pylori eradication, smoking cessation) over general dietary advice. 1, 2

Clinical Algorithm for Post-Operative Counseling

1. Immediately counsel on permanent NSAID discontinuation - this is non-negotiable 2
2. Verify H. pylori testing status - if not done, order testing and treat if positive 2, 3
3. Address smoking status - mandate complete cessation 2, 3
4. Review steroid use - discontinue or minimize if medically feasible 2
5. Provide specific dietary guidance - reduce salt intake 2

Common Pitfalls to Avoid

• Never allow NSAID resumption even for "just occasional use" - the risk is too high given the patient's history 2
• Don't assume H. pylori testing was done - verify and treat if not already addressed 2
• Don't provide vague dietary advice without addressing the specific modifiable risk factors that impact mortality 1, 2
• Don't forget to document counseling on NSAID avoidance, as patients may seek NSAIDs from other providers 2