• Acute onset of severe upper abdominal pain
• Immediate chemical peritonitis from gastroduodenal secretions followed by bacterial peritonitis in 12–24 hours
• Free air on abdominal x-ray
EPIDEMIOLOGY
• The patient may or may not have had preceding chronic symptoms of peptic ulcer disease
• Perforation complicates peptic ulcer about half as often as hemorrhage
• Most perforated ulcers are located anteriorly
• 15% mortality rate correlates with increased age, female sex, and gastric perforations
• The diagnosis is overlooked in about 5% of patients
• In < 10% of cases, acute bleeding from a posterior “kissing” ulcer complicates the anterior perforation
• Severity of illness and occurrence of death are directly related to the interval between perforation and surgical closure
- CLINICAL FINDINGS
SYMPTOMS AND SIGNS
• Perforation usually elicits a sudden, severe upper abdominal pain
• The patient appears severely distressed, lying quietly with the knees drawn up and breathing shallowly to minimize abdominal motion
• Fever is absent at the start but spikes within 12–24 hours
• Rebound tenderness and abdominal rigidity
• Reduced or absent bowel sounds
• Free air in the abdomen with abdominal distention and diffuse tympany
LABORATORY FINDINGS
• A mild leukocytosis in the range of 12,000/L in the early stages followed by rise to 20,000/L within 12–24 hours
• Mild rise in the serum amylase caused by absorption of the enzyme from duodenal secretions within the peritoneal cavity
• Infection with Helicobacter pylori
IMAGING FINDINGS
• Abdominal x-rays: Reveal free subdiaphragmatic air in 85% of patients
• If no free air is demonstrated and the clinical picture suggests perforated ulcer, an emergency upper GI contrast radiographic series should be performed
DIAGNOSTIC CONSIDERATIONS
• Pain may be localized to the right lower quadrant if gastroduodenal contents collect in the right lateral peritoneal gutter
• Atypical perforations occur in patients already hospitalized for some unrelated illness, and the significance of the new symptom of abdominal pain is not appreciated
• Free air in the abdomen in a patient with sudden upper abdominal pain should clinch the diagnosis
RULE OUT
• Acute pancreatitis and acute cholecystitis
• The simultaneous onset of pain and free air in the abdomen in the absence of trauma usually means perforated peptic ulcer
–Free perforation of colonic diverticulitis and acute appendicitis are other rare causes
WORK-UP
• Diagnosis and treatment should be simultaneous
• Whenever a perforated ulcer is considered, an NG tube should be inserted to reduce further contamination of the peritoneal cavity
• CBC, electrolytes, lipase and amylase
• IV antibiotics (eg, cefazolin, cefoxitin)
• Fluid resuscitation precedes diagnostic measures
• X-rays as soon as the clinical status will permit
WHEN TO admit
• Nearly all cases of free perforation require surgical intervention and necessitate admission
TREATMENT AND MANAGEMENT
SURGERY
• All free perforations should be repaired by secure closure of the hole with omentum (Graham-Steele closure) sutured into place rather than bringing together the 2 edges with sutures
Indications
• Perforation usually associated with peptic ulcer disease; addition of parietal cell vagotomy or truncal vagotomy and pyloroplasty vs treatment of H pylori is controversial
MEDICATIONS
• Treatment of H pylori infection
• H2 blockers, proton pump inhibitors
• Antibiotics (cefazolin, cefoxitin)
TREATMENT MONITORING
• Clinical improvement
Complications omplications
• Other complications of peptic ulcer disease (bleeding, obstruction, intractability)
Prognosis
• 15% mortality, most accounted for by delay in treatment, advanced age, and comorbid diseases
RESOURCES
REFERENCES
• Millat B et al. Surgical treatment of complicated duodenal ulcers: controlled trials. World J Surg. 2000;24:299.
• Svanes C. Trends in perforated peptic ulcer: incidence, etiology, treatment, and prognosis. World J Surg. 2000;24:277.
• Calam J, Baron JH: ABC of the upper gastrointestinal tract: pathophysiology of duodenal and gastric ulcer and gastric cancer. BMJ 2001;323:980.
• Leontiadis GI et al: Systematic reviews of the clinical effectiveness and cost-effectiveness of proton pump inhibitors in acute upper gastrointestinal bleeding. Health Technol Assess 2007;11:iii, 1.
• Zittel TT, Jehle EC, Becker HD: Surgical management of peptic ulcer disease today—indication, technique and outcome. Langenbecks Arch Surg 2000;385:84.
