Diagnosis

Perforated ulcer

Etiology

Cause [soq][iis]

• H.pylori with Peptic Ulcer Disease

• Gastric cancer (30% of gastric perforations are associated with malignancy)

• Drug side effects (NSAIDs, SSRIs, corticosteroids, anticoagulants)

• Smoking, alcohol, diet high in salt

• Zollinger-Ellison syndrome

• Trauma

• Iatrogenic (endoscopy, cardiopulmonary resuscitation)

• Foreign bodies (chicken bones or fish bones)

• Spontaneous perforation of the stomach in the neonatal period

Pathophysiology [iis]

1. Acute perforation --> Leakage of acidic gastric juice into the peritoneal cavity

2. Profound chemical peritonitis

3. Contamination from the gastric contents --> Subsequent bacterial peritonitis

4. Perforations occurring over a prolonged period may be contained locally by the inflammatory reaction

Complications [iis]

• Adhesions and bowel obstruction

• Delirium

• Wound infection

• Bacterial peritonitis

• Intraabdominal abscess

• Sepsis

• Multiorgan failure

Epidemiology

Incidence per 100.000 [soq][s88][r7h][so3][ye8][uqk][srz]

Approach

• Blood test

• Hemofec

• Abdominal x-ray [fp7]

• Contrast x-ray [fp7]

• CT abdomen [fp7]

• Endoscopy with biopsy

Treatment

1. Rapid resuscitation: [fp7]

   • Mean arterial pressure ≥ 65 mmHg

   • Urine output ≥ 0.5 ml/kg/h

   • Lactate normalization

2. Non-operative management: selected cases where small perforation has sealed as confirmed on water-soluble contrast study [fp7]

   • Nil by mouth

   • Intravenous hydration

   • Decompression via nasogastric tube

   • Anti-secretory and PPI therapy

   • Antibiotics:

     • Cefotaxime 2 g 8-hourly + Metronidazole 500 mg 6-hourly

     • Piperacillin/tazobactam 4.5 g 6-hourly + Metronidazole 500 mg 6-hourly

   • Antifungal therapy if critically ill, immunocompromised, hospital-acquired infection: Fluconazole, Echinocandin, Amphotericin B

   • Follow-up endoscopy at 4–6 weeks

3. Surgery: pneumoperitoneum, extraluminal contrast leakage or peritonitis [s88][iis]

   • Stable patients --> laparoscopic approach

     • Laparoscopic suture repair

     • Laparoscopic fibrin glue repair

   • Unstable patients --> open surgery

     • Primary closure (with omentopexy)

     • Gastric wedge resection + primary closure (with omentopexy)

     • Billroth I: Gastroduodenostomy

     • Billroth II: Gastrojejunostomy

     • Roux-en-Y gastrojejunostomy

4. Endoscopic treatment: if severe co-morbidity [fp7]

   • Iatrogenic perforations --> endoscopic clips

   • Clips may be ineffective if fibrosis with loss of compliance

   • Covered self-expandable metal stents + laparoscopic drain placement

Differential diagnoses

Acute mesenteric ischemia, Acute pancreatitis, Aortic dissection, Appendicitis, Ascariasis, Cholecystitis, Choledocholithiasis, Cholelithiasis, Colorectal cancer, Constipation, Crohn disease, Diverticulitis, Drug side effects, Endometriosis, Esophageal perforation, Gastric cancer, Gastritis, Gastroenteritis, Gastrointestinal perforation, Ingestion of corrosives, Ischemic colitis, Meckels diverticulum, Ovarian torsion, Pelvic inflammatory disease, Ruptured aortic aneurysm, Small bowel cancer, Splenic injury, Superior mesenteric artery syndrome, Trauma, Typhoid fever, Ulcerative colitis, Ulcer disease