Perforated peptic ulcer

  • 50 years ago perforated peptic ulcer was a disease of young men
  • Today it is a problem seen mainly in elderly women
  • Overall incidence for admission with peptic ulceration is falling
  • The number of perforated ulcers remains unchanged
  • Sustained incidence possibly due to increased NSAID in elderly
  • 80% of perforated duodenal ulcers are H. pylori positive

Clinical features

  • Most occur in patients with pre-existing dyspepsia
  • 10% have no previous symptoms
  • Classic presentation is with:
    • Sudden onset epigastric pain
    • Rapid generalisation of pain
    • Examination shows peritonitis with absent bowel sounds
  • 10% have an associated episode of melaena
  • 10% have no demonstrable gas on an erect chest x-ray
  • If diagnostic doubt then water soluble contrast enema may confirm perforation

free gas under the diaphragm

  • Can be associated with elevated serum amylase but not to same level as in pancreatitis

Management

  • Most patients require surgery after appropriate resuscitation
  • Conservative management may be considered if significant co-morbidity
  • More likely to fail if perforation is of a gastric ulcer
  • Laparoscopic techniques have recently been described

Preoperative preparation

  • Fluid resuscitation with CVP or Swan Ganz monitoring
  • Analgesia
  • Antibiotics
  • Nasogastric intubation

Operation

  • Oversew of ulcer first performed by Dean in 1894
  • Usually performed through an upper midline incision
  • Oversew perforation with omental patch
  • Use 2/0 synthetic absorbable.
  • Take 1 cm bites either side of ulcer

oversew of a perforated duodnal ulcer

Picture provided by Vitoon Chinswangwatanakul, Siriraj Hospital, Bangkok, Thailand

  • Thorough wash out and irrigation of peritoneal cavity with 0.9% saline
  • If unable to find perforation open the less sac
  • Remember that multiple perforations can occur
  • If closure secure and adequate toilet then a drain is not required
  • Prepyloric ulcer behave as duodenal ulcers
  • All gastric ulcers require biopsy to exclude malignancy
  • Definitive ulcer surgery probably not required
  • 50% patients develop no ulcer recurrence
  • Postoperatively patients should receive H. pylori eradication therapy

Outcome

  • Operative mortality depends on four major risk factors
    • Long period from perforation to admission
    • Increasing age
    • Coexisting medical disease
    • Hypovolaemia on admission

Bibliography

Barksdale A R,  Schwartz R W.  Current management of perforated peptic ulcer.  Curr Surg 2000;  57:  594-599.

Lee F Y,  Leung K L,  Lai P B,  Lau J W.  Selection of patients for laparoscopic repair of perforated peptic ulcer.  Br J Surg 2001;  88:  133-136.

Kate V,  Ananthakrishnan N,  Badrinath S.  Effect of Helicobacter pylori eradication on the ulcer recurrence rate after simple closure of perforated duodenal ulcer: retrospective and prospective randomised controlled studies.  Br J Surg 2001;  88:  1054-1058.

Ng E K W,  lam Y H,  Sung J J Y et al.  Eradication of Helicobacter pylori prevents recurrence of ulcer after simple closure of duodenal ulcer perforation.  Ann Surg 2000;  231:  153-158.

 

 
 

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