Peptic Perforation Management
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Direct answer
A sudden "bursting" epigastric pain followed by board-like rigidity and a silent abdomen in a patient with ulcer history, non-steroidal anti-inflammatory use or alcohol intake is a perforated peptic ulcer until excluded; an erect chest radiograph shows free air under the diaphragm in roughly two-thirds of cases, and a water-soluble contrast study or CT settles the doubtful ones. Initial management is resuscitation — nil by mouth, nasogastric decompression, intravenous proton pump inhibitor, broad-spectrum antibiotics, analgesia and fluid — followed by surgery in almost all cases: simple closure of the perforation with an omental Graham patch, laparoscopic or open, with thorough peritoneal lavage. Definitive acid-reducing procedures are rarely performed today; Helicobacter pylori eradication after recovery is the recurrence-preventing step.
What you must remember
- Site and demography: anterior duodenal or gastric ulcers perforate, posterior duodenal ulcers erode into the gastroduodenal artery and bleed — a classic surgical aphorism (front perforates, back bleeds) with posterior gastric ulcers eroding the splenic artery.
- Indian context: non-steroidal anti-inflammatory drugs, often self-prescribed and cheap, and steroid use drive many perforations; delayed presentation is common because patients reach hospital after 48-72 hours of peritonitis, raising mortality.
- Diagnosis: erect chest X-ray (free air under both diaphragms, about 60-70 per cent sensitivity) is the screening test; CT with oral water-soluble contrast is both sensitive and specific; never give barium in suspected perforation.
- Clinical evolution: chemical peritonitis from gastric contents in the first hours produces the board-like abdomen; a deceptive improvement after some hours ("calm before the storm") precedes bacterial peritonitis and septicaemia; tachycardia with a scaphoid, motionless abdomen and absent bowel sounds is the sign cluster.
- Conservative (Taylor) regime: nil by mouth, nasogastric tube on suction, intravenous proton pump inhibitor and antibiotics, reserved for patients presenting late (beyond 48-72 hours) with a sealed-off perforation who are haemodynamically stable and improving — and it fails more often than surgery in fit patients.
- Operation: Graham patch omentoplasty — the perforation is closed with a few sutures and buttressed with a vascularised omental pedicle — plus copious warm saline lavage of all four quadrants; laparoscopic repair gives equivalent results in experienced hands.
- Gastric versus duodenal biopsy: every gastric perforation is biopsied from the edge to exclude malignancy; duodenal perforations are almost never biopsied.
- Post-operative essentials: Helicobacter pylori testing and eradication (typical triple therapy with a proton pump inhibitor, clarithromycin and amoxicillin for 14 days), cessation of non-steroidal drugs, and repeat endoscopy for gastric ulcers to confirm healing.
A worked perforation pathway
A 45-year-old labourer on regular diclofenac for back pain collapses with sudden severe epigastric pain two hours ago; his abdomen is rigid like a wooden board, bowel sounds are absent, and he is tachycardic with a blood pressure of 100/60. Reasoning in order: resuscitate first (intravenous line, crystalloid, analgesia, nasogastric tube, broad-spectrum antibiotic covering gram-negatives and anaerobes, intravenous pantoprazole), then confirm with an erect chest film — free air under the right diaphragm settles it. Straight to theatre: laparoscopic or upper-midline open, find the punched-out anterior duodenal perforation, patch it with omentum, and lavage litres of warm saline until the returns are clear. Had this man presented after four days, haemodynamically stable with a walled-off collection on CT, the Taylor regimen with close monitoring is defensible; had the perforation been gastric, edge biopsies would accompany the patch. Post-operatively, test for H. pylori and eradicate it, stop the non-steroidal drug permanently, and counsel that the patch closes the hole but the ulcer diathesis is treated medically.
How the exam frames it
Three discriminations dominate. First, perforation versus pancreatitis: both give acute epigastric pain and raised serum amylase (amylase rises modestly in perforation from resorption), but the abdomen is rigid in perforation and softer, with radiation to the back, in pancreatitis — free air settles the argument. Second, the X-ray: a normal erect film does not exclude perforation in about a third of cases, so a negative film with a convincing abdomen still goes to CT or theatre. Third, the timing trap: the patient who "feels better" at six hours is deteriorating, not recovering, because chemical peritonitis is quietly becoming bacterial peritonitis — the tested next step is surgery, not discharge.
Frequently asked questions
Which investigation best supports a diagnosis of perforated peptic ulcer?
An erect chest radiograph showing free air under the diaphragm, positive in about two-thirds of cases; a CT with water-soluble oral contrast is used when the plain film is negative but suspicion persists.
What is the standard surgical treatment of a perforated duodenal ulcer?
Simple closure of the perforation with an omental (Graham) patch and thorough peritoneal lavage, performed open or laparoscopically; definitive acid-reducing procedures are rarely added today.
When is conservative management of a perforated ulcer acceptable?
In patients presenting late (beyond 48-72 hours) who are stable with evidence of a sealed perforation — the Taylor regimen of nasogastric decompression, intravenous proton pump inhibitor and antibiotics, with surgery on any deterioration.
Why are gastric perforations biopsied but duodenal ones not?
Because a gastric perforation may represent perforated gastric carcinoma, whereas duodenal ulcers are virtually never malignant.
What is done after surgical closure to prevent recurrence?
Testing and eradication of Helicobacter pylori, withdrawal of non-steroidal anti-inflammatory drugs, and continued proton pump inhibitor therapy, with follow-up endoscopy for gastric ulcers.