1. Perforated Peptic Ulcer
A peptic ulcer is a mucosal defect which penetrates the muscularis mucosae and
muscularis propria
Produced by acid-pepsin aggression
• 70-90% of ulcers are associated with helicobacter pylori a
spiral-shaped bacterium that lives in the acidic environment
of the stomach
• Ulcer can be caused or worsened by drugs such as
Aspirin,Plavix, NSAIDS
• About 4% of ulcers are caused by a malignant tumor , so
multiple biopsies are needed to exclude cancer.
• Duodenal ulcer are generally benign
3. Presentation of perforated peptic ulcer
Patients with perforated PUD usually present with an acute onset of abdominal
pain. Often, they can tell you the exact time of the perforation.
The pain starts in the epigastrium but by the time of presentation in the
emergency department, it is generalized and associated with diffuse peritonitis.
It is important to ascertain whether the patient has a history consistent with
chronic PUD, either by prior treatment, current medications or pre-existing
symptoms of noncomplicated disease.
4. Diagnosis of perforated peptic ulcer
disease
History and physical examination
Upright chest radiographs will show pneumoperitoneum (“free air”) in 80–90% of the
cases.
If pneumoperitoneum is identified on plain radiographs, there is no need for further
studies.
Ultrasound is less sensitive for detecting free air but could be used to identify other
indirect findings of perforation such as free fluid and decreased peristalsis when the
diagnosis remains in question.
Computerized tomography (CT) scans are more sensitive for detecting
pneumoperitoneum than the other modalities but should ideally be performed at least
6 h following the onset of symptoms.
The use of oral contrast medium with CT scanning to identify the site of perforation and
the presence of ongoing leakage.
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8. What are the potential complications of
perforated peptic ulcer?
In most cases of perforation, gastric and duodenal content leaks into the peritoneum.
This content includes gastric and duodenal secretions, bile, ingested food, and swallowed bacteria.
The leakage results in peritonitis, with an increased risk of infection and abscess formation.
Subsequent third-spacing of fluid in the peritoneal cavity due to perforation and peritonitis leads to
inadequate circulatory volume, hypotension, and decreased urine output.
In more severe cases, shock may develop.
Abdominal distension as a result of peritonitis and subsequent ileus may interfere with
diaphragmatic movement, impairing expansion of the lung bases.
Eventually, atelectasis develops, which may compromise oxygenation of the blood, particularly in
patients with coexisting lung disease.
9. Management
In practical terms, when the diagnosis of a perforated duodenal ulcer is
established the patient is aggressively resuscitated, nasogastric suction begun, and
board spectrum antibiotic cover instituted.
If a tension pneumoperitoneum embarrasses repiration this can be aspirated to
release the pneumoperitoneum
A gastroduodenogram is performed to confirm self sealing
The peritonitis should resolve in 4 to 6 hours and if there is continued major fluid
loss after this time or if there are progressive signs of peritonitis or increase
pneumoperitoneum the surgical intervention is required
10. Graham omental patch
Omental patch closure is a quick and simple procedure that is very useful in perforated
PUD.
It has long been the recommended treatment in patients with multiple comorbidities,
those that are hemodynamically unstable and those with exudative peritonitis.
It is not useful in Type IV gastric ulcers and may not be the optimal treatment in a
stable patient with a perforated Type I gastric ulcer
