A perforated ulcer of the stomach or duodenum is a serious complication of peptic ulcer disease in which a full-thickness tear occurs in the organ wall. This condition constitutes a surgical emergency because the contents of the stomach or intestine spill into the abdominal cavity, causing inflammation of the peritoneum known as peritonitis [1]. Although in most cases a perforated ulcer requires immediate surgical intervention, conservative treatment is possible in certain carefully selected cases [1].
What Is a Perforated Ulcer and Why Does It Occur?
A peptic ulcer is a defect in the mucosal lining of the stomach or the initial part of the small intestine (duodenum) [1]. The main causes of peptic ulcer disease include Helicobacter pylori infection and the long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) [1, 2, 7]. Other risk factors include smoking and alcohol consumption [2].
Complications of peptic ulcer disease can be extremely dangerous and include bleeding, obstruction (narrowing of the organ lumen), and perforation [1, 3]. In the era of widespread proton pump inhibitor (PPI) use, the incidence of peptic ulcer complications has decreased, but they remain a serious issue [3, 6]. Perforation most frequently occurs in the duodenum (up to 57.1% of cases), but it can also affect the stomach [2, 4].
Symptoms and Diagnosis of a Perforated Ulcer
A perforated ulcer typically presents with sudden, very severe upper abdominal pain, often described as «stabbing» or «knife-like» [1, 7]. The pain may be accompanied by repeated vomiting [1]. Examination reveals tenderness in the epigastric region and the right upper quadrant, and with the development of peritonitis, abdominal wall rigidity and signs of peritoneal irritation [1, 7].
The following methods are used to diagnose a perforated ulcer:
- Complete blood count: often shows an elevated white blood cell count (up to 24,000x10^3/mcL) and C-reactive protein (up to 45.5 mg/dL), indicating an inflammatory process [1].
- Upright chest X-ray: a classic sign of perforation is the presence of free gas under the diaphragm (the «signatures of pneumoperitoneum» or «rules of the dome») [1, 4].
- Abdominal computed tomography (CT): allows for a more precise determination of the perforation site and an assessment of the extent of peritonitis.
Surgical Treatment: The Gold Standard
Surgical intervention is the primary method of treatment for a perforated ulcer [1]. The main goal of surgery is to minimize patient morbidity and mortality [3].
Various surgical approaches exist:
- Perforation closure using an omental patch (Graham patch repair): this method is considered the «gold standard» and involves closing the organ wall defect using a segment of the greater omentum [2, 7].
- Modified Cellan-Jones repair: another variant of perforation closure [2].
- Laparoscopic or open approach: depending on the surgeon's expertise and the patient's condition, a minimally invasive laparoscopic approach or a traditional open surgery may be chosen [2, 7]. The laparoscopic technique demonstrates comparable outcomes to the open approach [2].
- Complex cases: in the presence of concurrent complications such as bleeding, obstruction, or fistulas, more complex procedures may be required, such as ligation of a bleeding vessel, gastrojejunostomy (creation of a connection between the stomach and jejunum), or choledochojejunostomy (creation of a connection between the common bile duct and jejunum) [3]. In some cases, ulcer excision or exclusion combined with a procedure aimed at reducing gastric acidity may be performed [8].
Following perforation closure surgery, it is crucial to eradicate Helicobacter pylori, if detected, to prevent recurrences [4]. The use of pantoprazole in combination with perforation closure improves treatment outcomes and reduces the body's stress response [5].
When Is Conservative Treatment Possible?
In certain cases, with strict patient selection, conservative treatment of a perforated ulcer is possible [1]. This applies to patients who show no signs of generalized peritonitis, and whose perforation is small and spontaneously seals. For example, in one case, a 54-year-old female with a perforated ulcer who was hemodynamically stable, had localized upper abdominal tenderness without signs of generalized peritonitis, and showed free gas under the diaphragm on an X-ray, was successfully managed conservatively [1]. However, such cases require close monitoring and immediate readiness for surgical intervention if the condition deteriorates.
Prevention and Postoperative Management
Prevention is of key importance to prevent recurrences of peptic ulcer disease and its complications. This includes the eradication of Helicobacter pylori, avoiding the use of NSAIDs without a doctor's prescription, and quitting smoking and alcohol abuse [2, 4, 7]. After surgery, patients require careful monitoring for the timely detection of potential complications such as re-perforation, bleeding, or pyloric obstruction [5, 6].
Sources
- 1. Conservative management of a perforated peptic ulcer: a case report. (Cureus, 2024) https://pubmed.ncbi.nlm.nih.gov/38638727/
- 2. Outcomes of laparoscopic modified Cellan-Jones repair versus open repair for perforated peptic ulcer in a community hospital. (Surgical endoscopy, 2023) https://pubmed.ncbi.nlm.nih.gov/35562508/
- 3. Complicated peptic ulcer presenting with bleeding, gastric outlet obstruction, and choledochoduodenal fistula. (Cureus, 2020) https://pubmed.ncbi.nlm.nih.gov/33269120/
- 4. Simple closure of perforated peptic ulcer in children followed by Helicobacter pylori eradication. (Pakistan journal of medical sciences, 2014) https://pubmed.ncbi.nlm.nih.gov/24948965/
- 5. Efficacy of pantoprazole combined with perforation closure in peptic ulcer and its effect on stress response. (World journal of gastrointestinal surgery, 2023) https://pubmed.ncbi.nlm.nih.gov/38222001/
- 6. Short- and long-term outcomes of surgery for peptic ulcer complications in the proton pump inhibitor era. (European journal of trauma and emergency surgery : official publication of the European Trauma Society, 2018) https://pubmed.ncbi.nlm.nih.gov/29354867/
- 7. Perforated duodenal peptic ulcer following laparoscopic Roux-en-Y gastric bypass. (The American surgeon, 2023) https://pubmed.ncbi.nlm.nih.gov/34730448/
- 8. Emergency surgery techniques for high-risk bleeding peptic ulcer stigmata. (Minerva chirurgica, 2014) https://pubmed.ncbi.nlm.nih.gov/24970305/
The information provided in this article is for informational purposes only and cannot replace professional medical advice. Always consult a specialist for diagnosis and treatment.