60. Perforated peptic ulcer

1. Definition

• Perforated peptic ulcer → full-thickness breach of a gastric or duodenal ulcer with leakage of contents into the peritoneal cavity
• Free perforation → into the general peritoneal cavity
• Covered (sealed) perforation → plugged by omentum, liver or fibrin
• Penetration → ulcer erodes into an adjacent organ (pancreas, liver) without free leak

2. Epidemiology

• Lifetime risk in peptic ulcer disease → 2–10%
• Mortality → 5–15% despite surgery

3. Aetiology and risk factors

• Helicobacter pylori (H. pylori) → 70% of perforated duodenal ulcers (DU); 80% excluding NSAID users
• Non-steroidal anti-inflammatory drugs (NSAIDs) → especially gastric ulcer (GU) and the elderly
• Steroids
• Smoking
• Gastric cancer, lymphoma, gastrointestinal stromal tumour (GIST) → perforated GU in a minority

4. Pathogenesis

• Site → anterior wall of the first part of the duodenum (most common), prepyloric, lesser curvature
• Spillage of gastroduodenal contents:
  1. Chemical peritonitis (acid, bile, enzymes)
  2. Bacterial superinfection after 6–12 h
  3. Systemic inflammatory response syndrome (SIRS)
  4. Multi-organ dysfunction
• Fluid tracks down the right paracolic gutter → right iliac fossa pain
• 50% have sealed spontaneously by the time of admission
• Classical clinical phases:
  1. Shock phase → first 6 h, severe pain, rigidity
  2. Phase of false calm → 6–12 h, pain eases, rigidity persists
  3. Phase of diffuse peritonitis → after 12 h, sepsis

5. Classification

• By site → duodenal, pyloric, gastric
• By size:
  • Small → < 1 cm (most DU perforations)
  • Giant → > 2 cm
• By course → free, covered, atypical (into the lesser sac or retroperitoneum)
• Boey score (risk factors):
  1. Major medical illness
  2. Preoperative shock (systolic blood pressure (SBP) < 100 mmHg)
  3. Perforation > 24 h
• Boey score 0, 1, 2, 3 → mortality 0%, 10%, 45.5%, 100%
• Peptic Ulcer Perforation (PULP) score → 8 variables; predicts 30-day mortality better than Boey

6. Clinical picture

Symptoms

• Sudden, severe epigastric pain ("dagger-like"), rapidly generalised
• Shoulder-tip pain → diaphragmatic irritation
• Vomiting
• History of dyspepsia → absent in 1/3
• Elderly, steroid users, inpatients → subtle presentation

Signs

• Board-like rigidity of the abdomen
• Patient lies still; shallow breathing
• Tachycardia, hypotension → shock
• Loss of liver dullness on percussion → free gas
• Right iliac fossa tenderness → fluid in the right paracolic gutter
• Absent bowel sounds → later

7. Diagnosis

Laboratory

• Full blood count → leucocytosis
• Serum amylase → mildly raised; a very high level suggests pancreatitis
• Urea, creatinine, electrolytes
• Arterial blood gas, lactate
• Group and save, clotting

Imaging

• Erect chest X-ray → free subdiaphragmatic gas in up to 70%
• Left lateral decubitus X-ray → if the patient cannot sit up
• Computed tomography (CT) → most sensitive; free gas, fluid, site; less useful < 6 h from onset
• Water-soluble contrast study → confirms sealing before non-operative treatment
• Ultrasound → free fluid

8. Differential diagnosis

• Acute pancreatitis
• Perforated appendicitis
• Acute cholecystitis
• Mesenteric ischaemia
• Ruptured abdominal aortic aneurysm
• Perforated diverticulitis
• Inferior myocardial infarction, basal pneumonia

9. Treatment

Conservative

• Resuscitation in all patients:
  • Intravenous fluids
  • Nasogastric tube
  • Urinary catheter
  • Intravenous antibiotics
  • Intravenous PPI (proton pump inhibitor)
  • Analgesia
• Non-operative treatment (Taylor method) → selected patients only:
  • Sealed perforation on water-soluble contrast
  • Young, stable, no generalised peritonitis
  • Nasogastric suction, intravenous antibiotics, PPI
  • 28% fail and need surgery within 12 h
  • Poor results > 70 years

Surgical

• Operation of choice → simple closure with omental patch and peritoneal lavage
• Approach → laparoscopic or upper midline laparotomy
• Laparoscopy → less pain, shorter stay, fewer wound infections; longer operation, more suture-site leaks
• Open surgery preferred → Boey score 3, age > 70 years, symptoms > 24 h
• Steps:
  1. Aspirate fluid; send for culture
  2. Identify the perforation; check the posterior stomach through the lesser sac if none found
  3. Place 3 interrupted sutures (3-0 absorbable), 5 mm from each edge, left untied
  4. Lay a viable pedicle of omentum over the perforation
  5. Tie the sutures over the omentum, side sutures first
  6. Lavage with 5–10 L warm saline
  7. Close the abdomen; drain optional
• Graham patch → free omental plug; replaced by pedicle omentopexy (Cellan-Jones)
• Perforated GU → biopsy the edge or excise the ulcer; resection only if neither is possible
• Giant perforation (> 2 cm) → options:
  • Seromuscular sutures with omental plug
  • Controlled tube duodenostomy
  • Distal gastrectomy with Roux-en-Y reconstruction
• Definitive acid-reducing surgery → no longer routine; emergency resection raises mortality
• After surgery:
  • H. pylori eradication (triple therapy, 14 days) + PPI for 3 months
  • Ulcer recurrence after eradication → about 5% at 1 year (35% without)
  • Repeat endoscopy at 12 weeks → mandatory after perforated GU

10. Complications

• Subphrenic, subhepatic or pelvic abscess
• Leak from the repair, reperforation
• Duodenal fistula
• Duodenal obstruction → persistent vomiting
• Wound infection, burst abdomen
• Pneumonia
• Multi-organ failure

11. Prognosis

• Mortality → 5–15%
• Worse with age > 65 years, shock, comorbidity, delay > 24 h, perforation during hospital stay