Peptic Ulcer Perforation

• • 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

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/µL in the early stages followed by rise to 20,000/µL 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

• • 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

• • 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 ...