What is the immediate management of a suspected gastric perforation?

Immediate Management of Gastric Perforation

In patients with suspected gastric perforation, immediate surgical exploration is mandatory for hemodynamically unstable patients or those with signs of peritonitis, while stable patients with perforations less than 1 cm should undergo laparoscopic primary repair with omental patch. 1, 2

Initial Diagnostic Approach

Imaging Strategy:

• CT scan with IV contrast is the diagnostic modality of choice, demonstrating extraluminal gas, intra-abdominal fluid, air pockets around the stomach, and thick reactive intestinal wall 2
• Plain upright chest X-ray can detect free air in 30-85% of cases, but a negative X-ray does not rule out perforation 1
• If CT shows no free air but clinical suspicion remains high, administer water-soluble contrast orally or via nasogastric tube to improve diagnostic sensitivity 1
• In peripheral hospitals without prompt CT access, plain X-ray showing free air combined with clear peritonitis on physical examination is sufficient to justify immediate surgical exploration 1

Clinical Presentation:

• Sudden onset of severe abdominal pain with localized or generalized peritonitis is typical, though peritonitis may be absent in up to one-third of patients with contained leaks 1
• Laboratory findings are non-specific but typically include leukocytosis, metabolic acidosis, and elevated serum amylase 1

Immediate Resuscitation

Hemodynamic Stabilization:

• Initiate aggressive fluid resuscitation and correct electrolyte imbalances immediately while preparing for surgery 3
• Prompt evaluation and early recognition of sepsis is critical to prevent organ failure and reduce mortality 1
• Start broad-spectrum IV antibiotics covering gram-negative, gram-positive, and anaerobic organisms within 1 hour of presentation 3, 2

Critical Pitfall: Do not delay surgery attempting complete hemodynamic stabilization—time from admission to surgery is a critical determinant of survival, with survival rates falling to 0% when surgery is delayed beyond 6 hours 4

Surgical Management Algorithm

For Hemodynamically Stable Patients:

• Laparoscopic primary repair with omental patch is the treatment of choice for perforations less than 1 cm, associated with decreased operative time, blood loss, and length of stay 1, 2, 5
• Use simple or double-layer suture technique with omental patch 2
• Mandatory intraoperative biopsy of perforation edges to exclude malignancy, which is present in 8.8% of perforated gastric ulcers 2, 5
• If primary repair is not feasible due to large perforation or extensive tissue loss, consider stapled resection or partial gastrectomy 1
• Consider gastrostomy tube placement proximal to perforation if significant postoperative ileus is anticipated 1

For Hemodynamically Unstable Patients:

• Immediate surgical exploration without delay is mandatory 1, 3
• Damage control surgery with abbreviated laparotomy and open abdomen technique is recommended for patients with persistent instability, severe peritonitis, and septic shock 1, 3
• Perform source control (repair or resection), drain all infected foci, and plan re-laparotomy every 36-48 hours until peritonitis resolves 3

Antibiotic Therapy

For Immunocompetent, Non-Critically Ill Patients:

• Amoxicillin/Clavulanate 2g/0.2g IV every 8 hours for 4 days with adequate source control 2

For Critically Ill or Immunocompromised Patients:

• Piperacillin/tazobactam 6g/0.75g loading dose, then 4g/0.5g IV every 6 hours 2
• Adjust based on culture results and continue until clinical improvement 3

Post-Operative Management

Immediate Monitoring:

• Serial clinical and imaging monitoring every 3-6 hours in the immediate postoperative period 3

Prevention of Recurrence:

• All patients must undergo H. pylori testing and receive eradication therapy if positive—this is the single most effective intervention to prevent ulcer recurrence 2
• Standard triple therapy for 14 days: PPI twice daily + clarithromycin 500mg twice daily + amoxicillin 1000mg twice daily 2
• Discontinue all NSAIDs and aspirin if medically possible 2
• If NSAIDs must be continued, maintain long-term PPI therapy indefinitely at the lowest effective dose 2

Follow-Up Endoscopy:

• Mandatory follow-up endoscopy with repeat biopsy is essential, as initial negative intraoperative histology can miss underlying malignancy 5

Special Considerations

Risk Stratification:

• Consider using Boey, PULP, or ASA scoring systems for risk stratification and outcome prediction, with hypoalbuminemia being the strongest single predictor of mortality 1

Target Time for Surgery:

• The target time for favorable outcome is within 6 hours from admission for patients with septic shock 4