Acute Abdomen: Perforated Peptic Ulcer
Definition
- Perforated peptic ulcer (PPU): A full‑thickness breach of the gastric or duodenal wall secondary to a peptic ulcer, leading to leakage of gastric/duodenal contents into the peritoneal cavity and causing an acute surgical abdomen.
Epidemiology
- Accounts for 5–10 % of all peptic ulcer disease (PUD) presentations.
- Incidence: 2–5 per 100 000 population per year in India; higher in males (M : F ≈ 3 : 1).
- Peak age: 40–60 years; rare in children.
- Mortality: 5–15 % overall; up to 30 % in elderly (>70 y) or delayed presentation (>24 h).
Aetiology / Risk Factors
- Helicobacter pylori infection (≈ 60 % of cases).
- Chronic NSAID/aspirin use (especially in the elderly).
- Smoking, alcohol excess.
- Stress‑related mucosal damage (critical illness, burns).
- Corticosteroids, bisphosphonates, chemotherapy agents.
- Previous ulcer surgery (e.g., vagotomy) – rare.
Pathophysiology
- Ulcer formation → loss of mucosal protection → erosion through muscularis mucosa.
- Progressive deepening → transmural necrosis.
- Perforation → free communication with peritoneal cavity.
- Chemical peritonitis: gastric acid and pepsin cause immediate irritation → diffuse fibrinous exudate.
- Bacterial contamination (colony of gut flora) → secondary bacterial peritonitis if not promptly controlled.
- Systemic response: cytokine release → SIRS → possible sepsis, ARDS, renal dysfunction.
Clinical Features
- Sudden onset of severe, generalized abdominal pain (often described as “tearing” or “splitting”).
- Rigidity & board‑like abdomen within minutes to hours.
- Absent bowel sounds early; later may become hyperactive.
- Shoulder tip pain (Kehr’s sign) due to diaphragmatic irritation.
- Nausea/vomiting (often non‑bilious).
- Fever, tachycardia, hypotension – signs of systemic inflammation/sepsis.
- History clues: prior dyspepsia, NSAID use, H. pylori treatment, alcohol.
Investigations
| Modality | Findings | Comments |
|---|---|---|
| Plain X‑ray abdomen (erect) | Free sub‑diaphragmatic air (pneumoperitoneum) – most sensitive sign. | Present in ~ 70 % of PPUs; may be missed if early. |
| Chest X‑ray (erect) | Air under diaphragm; may be clearer than abdominal film. | |
| Ultrasound | Free fluid, echogenic “dirty” peritoneal fluid; limited for air detection. | |
| CT abdomen (contrast) | Gold standard: free air, site of perforation, associated fluid collections, and rule‑out other causes. | Recommended when X‑ray equivocal or patient unstable but CT feasible. |
| Laboratory | ↑ WBC, CRP, serum lactate; possible metabolic acidosis. | Not diagnostic but helps assess severity. |
| H. pylori testing (post‑recovery) | Urea breath test, stool antigen, or biopsy. | Guides eradication therapy after acute phase. |
Management
Initial Resuscitation (within “Golden 6 h”)
- ABC – secure airway, breathing, circulation.
- IV crystalloids 1–2 L bolus; target MAP ≥ 65 mmHg.
- Broad‑spectrum antibiotics: Piperacillin‑tazobactam 4.5 g IV q6h or Ceftriaxone 2 g + Metronidazole 500 mg IV q8h. (Guideline: IAP‑Surgery 2022).
- Nasogastric tube – decompress stomach; low‑volume suction.
- Analgesia – IV paracetamol; avoid NSAIDs.
Definitive Surgical Options (based on timing, size, patient fitness)
| Procedure | Indication | Technique | Post‑op notes |
|---|---|---|---|
| Simple Omental Patch (Graham patch) | Small perforation (< 1 cm), stable patient, early presentation (< 12 h). | Laparoscopic or open; omental patch sutured over perforation with absorbable sutures. | Most common; 85–90 % success. |
| Definitive Ulcer Surgery (e.g., truncal vagotomy + antrectomy) | Large (> 1 cm) or recurrent perforation, chronic ulcer disease, poor response to medical therapy. | Open; resection + vagotomy ± gastrojejunostomy. | Higher morbidity; reserved for selected cases. |
| Laparoscopic Repair | Hemodynamically stable, experienced team, perforation ≤ 2 cm. | 3‑port technique; intracorporeal suturing + omental patch; CO₂ insufflation ≤ 12 mmHg. | Faster recovery, less wound infection; comparable leak rates. |
| Damage‑control surgery | Massive contamination, shock, coagulopathy. | Rapid closure, peritoneal lavage, temporary abdominal dressing; definitive repair later. | ICU support essential. |
Guideline reference: National Institute for Health and Care Excellence (NICE) NG125, 2023 – recommends early laparoscopic repair when expertise available; otherwise open Graham patch within 24 h.
Post‑operative Care
- Continue IV antibiotics for 3–5 days; switch to oral when afebrile, tolerating diet.
- PPI infusion (e.g., Pantoprazole 8 mg/h) for 48 h, then oral PPI for 4–6 weeks.
- H. pylori eradication (if positive): Clarithromycin‑based triple therapy (Clarithromycin 500 mg BID + Amoxicillin 1 g BID + PPI BID) for 14 days.
- Early ambulation, DVT prophylaxis, analgesia (avoid NSAIDs).
- Nutritional support: clear liquids → soft diet as tolerated (usually POD 2–3).
Complications
- Intra‑abdominal abscess (subphrenic, pelvic).
- Septic shock – high mortality if delayed.
- Wound infection / dehiscence (higher in open repair).
- Fistula formation (enterocutaneous).
- Re‑perforation (rare, < 2 %).
- Pulmonary complications: atelectasis, pneumonia, ARDS.
- Renal failure secondary to hypovolemia/sepsis.
High‑Yield Exam Points
- “Free air under diaphragm on erect X‑ray” is pathognomonic for perforated viscus.
- Graham patch is the standard surgical repair for most PPUs.
- NSAID use is a major reversible risk factor – stop immediately.
- H. pylori eradication reduces recurrence; give after acute phase.
- Laparoscopic repair is preferred if surgeon expertise and patient stability allow (per NICE 2023).
- Kehr’s sign (shoulder tip pain) indicates diaphragmatic irritation from free air.
- Mortality rises sharply after 24 h of symptom onset – “golden period”.
- Broad‑spectrum antibiotics must cover gram‑negative, anaerobes, and streptococci.
- Serum lactate > 2 mmol/L predicts severe sepsis and poor outcome.
Practice questions
1. A 55‑year‑old man on chronic ibuprofen presents with sudden severe epigastric pain radiating to the shoulders. Erect chest X‑ray shows free air under the right hemidiaphragm. The best immediate surgical management is:
- A) Primary closure with omental patch (open)
- B) Laparoscopic omental patch repair
- C) Truncal vagotomy and antrectomy
- D) Conservative management with antibiotics only
Answer: B — Laparoscopic omental patch is preferred in a stable patient with expertise, offering quicker recovery.
2. Which of the following statements about perforated duodenal ulcer is FALSE?
- A) Perforation size > 2 cm usually requires definitive ulcer surgery.
- B) H. pylori eradication is unnecessary after successful repair.
- C) Early administration of PPIs reduces postoperative ulcer recurrence.
- D) Broad‑spectrum antibiotics should be started pre‑operatively.
Answer: B — Eradication of H. pylori is essential to prevent recurrence.
3. According to the 2023 NICE guideline, the recommended timing for surgical repair of a perforated peptic ulcer is:
- A) Within 6 hours of symptom onset
- B) Within 12 hours of diagnosis
- C) Within 24 hours of presentation
- D) After 48 hours if the patient is stable
Answer: C — Surgery should be performed within 24 hours of presentation to reduce morbidity and mortality.
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