- 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
- 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
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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