What is the appropriate management of a penetrating peptic ulcer?

Management of Penetrating Peptic Ulcer

Surgery is the standard treatment for penetrating (perforated) peptic ulcer and should be performed as soon as possible, as each hour of delay decreases survival by 2.4%, with laparoscopic repair preferred in stable patients and open surgery mandatory for unstable patients. 1, 2

Initial Assessment and Resuscitation

Rapid ABC evaluation and hemodynamic stabilization must occur simultaneously with surgical consultation, blood cultures, and antibiotic administration. 1

Resuscitation Targets for Unstable Patients:

• Mean arterial pressure ≥65 mmHg 1
• Urine output ≥0.5 mL/kg/h 1
• Lactate normalization 1
• Consider invasive or non-invasive hemodynamic monitoring to optimize fluid and vasopressor therapy 1

Severity Assessment:

Evaluate for signs of sepsis including altered mental status, dyspnea, tachycardia, tachypnea, reduced pulse pressure, decreased urine output, hyperlactatemia, arterial hypoxemia, increased creatinine, and coagulation abnormalities. 1

Indications for Surgical vs Non-Operative Management

Surgery is Mandatory When:

• Significant pneumoperitoneum present 1
• Extraluminal contrast extravasation on water-soluble contrast study 1
• Clinical signs of peritonitis 1
• Hemodynamic instability 3
• Age >70 years (even if otherwise stable) 1, 3

Non-Operative Management (Highly Selective Only):

Non-operative management should be avoided routinely and considered only in extremely selected cases where perforation has sealed as confirmed on water-soluble contrast study showing NO extravasation. 1, 3

Prerequisites for Non-Operative Management (All Must Be Present):

• Radiologically undetected leak - water-soluble contrast study showing no extravasation 1, 3
• Hemodynamic stability (MAP ≥65 mmHg, heart rate <94 bpm) 1, 3
• Age <70 years 1, 3
• Localized upper abdominal tenderness WITHOUT diffuse peritonitis 3
• Ability to perform serial abdominal exams every 4-6 hours 1, 3
• Resources for intensive monitoring 1, 3
• Immediate readiness to operate if deterioration occurs 1, 3

Non-Operative Protocol Components:

• NPO status 1, 3
• Nasogastric decompression 1, 3
• Intravenous fluids 1, 3
• Proton pump inhibitor therapy 1, 3
• Broad-spectrum intravenous antibiotics 1, 3
• Follow-up endoscopy at 4-6 weeks 1

Critical caveat: Non-operative management succeeds in only 54-72% of carefully selected patients, with 28-46% requiring surgery. 3 Hospital stay is 35% longer than surgical patients. 1, 4 Elderly patients experience paradoxically higher mortality if non-operative management fails. 1, 3

Surgical Timing

Surgery must be performed as soon as possible, ideally within 1 hour of diagnosis. 1, 2

• Each hour of surgical delay beyond hospital admission is associated with a 2.4% decreased probability of survival over the first 24 hours 1, 2, 3
• Perforation-to-surgery interval >36 hours significantly increases postoperative mortality 1
• Patients operated within 24 hours have zero mortality compared to significantly increased mortality beyond 48 hours 1, 3
• Delay >24 hours is independently associated with poor prognosis 1

Surgical Approach Selection

For Hemodynamically Stable Patients:

Laparoscopic repair is preferred, offering reduced postoperative pain, fewer wound infections, and comparable mortality to open surgery. 1, 2

• Meta-analysis of 8 RCTs (615 patients) showed laparoscopic repair resulted in less postoperative pain in first 24 hours and fewer wound infections 1
• No significant differences in mortality, suture leak, intra-abdominal abscesses, or reoperation rates 1
• Conversion to open surgery occurs in 15-27% of cases, primarily for perforations ≥1 cm or inability to locate perforation 5

For Hemodynamically Unstable Patients:

Open surgery is mandatory due to adverse effects of pneumoperitoneum (increased systemic vascular resistance, mean arterial pressure, afterload, heart rate; decreased stroke volume, venous return, cardiac output). 1, 2

Surgical Technique Based on Perforation Size

Small Perforations (<2 cm):

Primary suture with omental patch reinforcement is the standard treatment. 5, 2

• Simple closure without omental patch shows comparable leak rates and outcomes 5
• Omental patch may be considered when ulcer edges are friable to prevent sutures cutting through tissue 5
• Simple closure takes significantly less operative time for perforations <12 mm 5

Large Perforations (≥2 cm):

A tailored approach based on ulcer location is required, as omental patch repair of large ulcers has leak rates up to 12%. 1, 5

For Large Gastric Ulcers:

• Resection with intraoperative frozen section examination is preferred due to 10-16% malignancy risk 5, 2
• Gastric resection and reconstruction should be the surgical choice for perforated gastric ulcers >2 cm 1
• Mandatory biopsy of ALL gastric perforations to exclude malignancy 5, 2

For Large Duodenal Ulcers:

• Only the first portion of duodenum can be resected easily without risking bile duct or pancreatic head injury 1
• Consider antrectomy with or without D1-D2 resection if ampullary region not involved 1
• Alternative procedures for large defects: jejunal serosal patch, Roux-en-Y duodenojejunostomy, pyloric exclusion, omental plugs 1
• Intraoperative cholangiography may be necessary to verify common bile duct anatomy when perforation is near ampulla of Vater 1, 5

Damage Control Surgery for Critically Ill Patients

In patients with septic shock and severe physiological derangement, employ a damage control strategy rather than definitive repair. 1, 5

Indications for Damage Control:

• Septic shock with progressive organ dysfunction 1
• Hypotension requiring vasopressors 5
• Myocardial depression and coagulopathy 1
• Physical inability to close abdominal fascia without tension 1
• Giant duodenal ulcers with severe tissue inflammation preventing duodenal mobilization 1, 5

Damage Control Procedures:

• Pyloric exclusion with gastric decompression via nasogastric tube or gastrostomy 1
• External biliary diversion via T-tube 1
• Duodenostomy over Petzer tube (last resort only) 1, 5
• Thorough peritoneal lavage and drainage 2
• Temporary abdominal closure if open abdomen required 5

Critical pitfall: Avoid complex definitive resections (e.g., Whipple procedure) in patients with peritonitis due to high physiological burden and increased postoperative complication risk. 1, 5 Focus on controlling contamination and stabilizing physiology. 1, 5

Role of Endoscopic Treatment

Endoscopic treatment such as clipping, fibrin glue sealing, or stenting should be avoided for perforated peptic ulcer. 1, 3

• Clips are ineffective in perforated ulcer cases due to fibrotic tissue with loss of compliance 1, 3
• Combined laparoscopic-endoscopic approaches and stenting are described in case series but not recognized as standard approaches and need further validation 1

Postoperative Management

Risk Factor Modification:

• Strict avoidance of NSAIDs - strongest risk factor for peptic ulcer perforation alongside H. pylori 5
• H. pylori testing and eradication therapy if not already performed - reduces ulcer recurrence from 50-60% to 0-2% 5, 6, 7
• Smoking cessation - key etiologic factor for peptic ulcer disease 5
• Steroid avoidance when possible - associated with increased mortality risk 5

Antibiotic Therapy:

• Empiric broad-spectrum antibiotics covering gram-negative and anaerobic organisms should be initiated immediately 2
• Duration tailored to clinical scenario but typically continues for several days postoperatively 2

Prognostic Factors Associated with Poor Outcome

• Age >70 years 1, 2
• Shock on admission 1, 2
• Preoperative metabolic acidosis 1, 2
• Tachycardia 1
• Acute renal failure 1
• Low serum albumin level 1
• High ASA score 1
• Co-morbidity and use of NSAIDs or steroids 1
• Surgical delay >24-36 hours 1, 2

Common Pitfalls to Avoid

• Never delay surgery for extensive preoperative optimization - mortality increases 2.4% per hour 1, 2, 3
• Never omit biopsy of gastric perforations regardless of size or appearance - 10-16% are malignant 5, 2
• Do not routinely apply omental patch for small perforations (<2 cm) - increases operative time without improving outcomes 5
• Do not attempt definitive resection in unstable patients with severe sepsis - prioritize contamination control and physiological stabilization 1, 5
• Do not attempt non-operative management in patients >70 years - significantly higher failure rates and mortality 1, 3
• Do not pursue laparoscopic approach in hemodynamically unstable patients - adverse effects of pneumoperitoneum preclude this approach 1, 2