What is the appropriate emergency management of a penetrating peptic ulcer?

Emergency Management of Penetrating Peptic Ulcer

Immediate resuscitation must begin simultaneously with surgical consultation—not sequentially—targeting mean arterial pressure ≥65 mmHg, urine output ≥0.5 mL/kg/h, and lactate normalization within the first hour, followed by urgent exploratory laparotomy for source control. 1

Initial Resuscitation Protocol

Resuscitation takes absolute priority and must occur in parallel with surgical preparation:

• Perform rapid ABC (airway, breathing, circulation) assessment immediately upon presentation 2, 1
• Initiate aggressive intravenous fluid resuscitation within 1 hour to reduce mortality 2, 1
• Obtain blood cultures and microbiological specimens concurrently with resuscitation 1
• Administer empiric broad-spectrum antibiotics within the first hour, regardless of operative plan 1

Critical physiologic targets during resuscitation:

• Mean arterial pressure (MAP) ≥65 mmHg 2, 1
• Urine output ≥0.5 mL/kg/h 2, 1
• Lactate normalization (or trending downward) 2, 1
• Use invasive or non-invasive hemodynamic monitoring to individualize fluid and vasopressor therapy 2, 1
• If MAP remains <65 mmHg despite adequate fluid loading, initiate vasopressors immediately 1

Diagnostic Workup During Resuscitation

Obtain these studies while resuscitation is ongoing:

• Complete blood count, coagulation studies, electrolytes, renal function, blood typing and cross-matching 3
• Arterial blood gas analysis to assess metabolic acidosis and hyperlactatemia 2, 3
• Contrast-enhanced CT scan is the preferred imaging modality (93-96% sensitivity, 93-100% specificity for perforation) 3
• If CT unavailable, obtain upright chest and abdominal X-ray to detect free intraperitoneal air 1

Assess for sepsis/septic shock using:

• Altered mental status, tachycardia, tachypnea, hypotension, oliguria, hyperlactatemia 3
• SOFA or qSOFA scoring systems to stratify severity 2, 3

Surgical Intervention Timing

The critical balance:

• Exploratory laparotomy must NOT be delayed, but should NOT proceed before resuscitation has started 1
• Proceeding directly to the operating room without resuscitation markedly increases mortality 1
• Resuscitation and surgical preparation occur in parallel—this is not an either/or decision 1

Operative approach based on perforation size:

• Small perforations (<2 cm): Primary closure with or without omental patch 1
• Large perforations (≥2 cm) or friable tissue: Omental patch closure 1
• Simple closure is sufficient in the majority of cases; definitive acid-reduction surgery is no longer justified 4

Damage-Control Surgery Indications

Consider abbreviated damage-control approach when:

• Progressive organ dysfunction develops during resuscitation 1
• Refractory hypotension requiring vasopressors persists 1
• Myocardial depression or coagulopathy emerges 1

Damage-control technique:

• Rapid source control (simple closure or omental patch) 1
• Extensive peritoneal irrigation 1
• Temporary abdominal closure 1
• ICU-based continued resuscitation before definitive repair 1

When Non-Operative Management is Contraindicated

Unstable patients with septic shock are NOT candidates for conservative treatment: 1

• Hemodynamic instability is an absolute contraindication to non-operative management 1
• Non-operative management requires: stable vital signs, sealed perforation confirmed on water-soluble contrast study, and absence of diffuse peritonitis 2, 1
• Approximately 28% of conservatively managed patients will fail and require surgery after 12 hours 1
• Patients >70 years have reduced likelihood of successful conservative treatment 1

Common Pitfalls to Avoid

The lethal error is delaying resuscitation to rush the patient to surgery:

• Never proceed to laparotomy without initiating resuscitation first 1
• Do not create a false dichotomy between "resuscitation OR surgery"—both must happen together 1
• Avoid non-operative management in unstable patients or those with diffuse peritonitis 1
• Do not delay antibiotic administration—give within the first hour 1