Perforated peptic ulcer

Complications of peptic ulcer disease are now much less common than 20 years ago due to improved medical management (see Peptic Ulcer, below), but perforations still imply a mortality of approximately 10% (higher in older patients). The well-recognised risk factors for developing a perforation are long-term non-steroidal anti-inflammatory drug (NSAID) use, and Helicobacter pylori infection.

The usual presentation is a sudden onset of severe epigastric pain, followed quickly by signs of peritonitis. Patients with perforated ulcers will lie still with a 'rigid abdomen', are often pale and clammy, and may show hypotension, tachycardia, tachypnoea, and pyrexia. Breathing will be shallow as well as rapid because of peritonitis. Sometimes in elderly patients, and those taking steroids, the early symptoms may be mild, or absent. The initial peritonitis is chemical due to the presence of gastric and/or duodenal fluid in the peritoneal cavity, but within hours a bacterial peritonitis supervenes. Delays in appropriate treatment being started result in higher mortality and morbidity - after 24 h the mortality rate has increased by seven times.

The diagnosis is made on clinical grounds, and supported by the presence of free gas seen under the diaphragm on an erect chest X-ray, but it must be remembered that 20-30% of perforations do not show free gas. If the diagnosis is in doubt a left lateral, decubitus abdominal X-ray may show free gas more clearly against the liver, and contrast studies with water-soluble agents can confirm an ongoing leak from a perforation. Ultrasound and CT examinations may show free intraperi-toneal fluid, and/or localised collections in late presentations, but are not part of the usual work-up of this condition.

The management of perforated ulcers includes initial resuscitation, treatment of the perforation and treatment of the ulcer. Resuscitation and optimisation requires intravenous fluids and antibiotics, urethral catheterisation to aid accurate fluid balance, naso-gastric drainage, oxygen by facemask, and prompt, adequate analgesia (usually opiates). A variety of options are available for treating the perforation, and are classified as conservative or surgical.

Conservative treatment relies on the fact that perforations have a tendency to seal themselves (up to 50% are sealed at time of presentation), and seeks to provide conditions for spontaneous healing to occur and persist, while also dealing with intra-abdominal sepsis. IV fluids, antibiotics, and acid anti-secretory drugs (H2 blockers or proton pump inhibitors (PPI)) are given, and patients kept under close review. Contrast studies are helpful here to confirm sealed leaks, and ultra-sound/CT scanning will show collections, which may then be drained percutaneously. A low threshold to revert to surgical management is important for those patients who deteriorate, or fail to improve.

Surgical treatment has two main aims: to close the perforation, and to deal with intra-abdominal sepsis. Surgery used also to include definitive treatment for the ulcer in the form of vagotomy and pyloroplasty, partial gastrectomy, or other anti-ulcer procedure. With current medical management being so effective, it is unusual to perform such procedures, unless the ulcer is too large to close adequately, or the ulcer has failed to respond to maximum medical treatment already. The majority of surgeons will deal with perforations at laparotomy, though it is possible to obtain similar results with a laparoscopic approach in certain cases. At lapar-otomy the perforation must first be identified, sometimes requiring exploration of the lesser sac to see the posterior wall of the stomach. Once the perforation has been found it may be closed by interrupted sutures, but if this is not possible a patch of omentum is sutured over the defect, taking care not to render the omentum ischaemic. Even after suture closure an omental patch should be performed as additional security. If the ulcer is in the stomach then a biopsy from its edge must be taken to exclude the possibility of malignancy. Thorough peritoneal lavage is performed, and there is no benefit in using solutions containing antibiotics or antiseptics compared to sterile water or normal saline. Whether to leave a drain in the abdomen is contentious, as it may be linked to increased morbidity, but many surgeons do drain the peritoneum after laparotomy.

Once the perforation has been successfully dealt with, the peptic ulcer must be treated with full medical management as described below. This will include eradication of H. pylori if present, stopping NSAIDs as appropriate (or switching to alternative analgesia), and a healing course of anti-secretory medication.

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