Dr Ahmad abanamy hospitalDr Nuaman danawargeneral& gastrointestinal surgeon

Perforated peptic ulcer

• 50 years ago perforated peptic ulcer was a disease of young men

• Today it is a problem seen mainly in elderly women • Overall incidence for admission with peptic ulceration

is falling • The number of perforated ulcers remains unchanged • Sustained incidence possibly due to increased NSAID

in elderly • 80% of perforated duodenal ulcers are H. pylori

positive

• Clinical features• Most occur in patients with pre-existing dyspepsia • 10% have no previous symptoms • Classic presentation is with:

– Sudden onset epigastric pain – Rapid generalisation of pain – Examination shows peritonitis with absent bowel sounds

• 10% have an associated episode of melaena • 10% have no demonstrable gas on an erect chest x-ray • If diagnostic doubt then water soluble contrast enema may

confirm perforation • Can be associated with elevated serum amylase but not to

same level as in pancreatitis

Free airUnder RT hemi diaphragm

• Management• Most patients require surgery after appropriate

resuscitation • Conservative management may be considered if

significant co-morbidity • More likely to fail if perforation is of a gastric

ulcer • Laparoscopic techniques have recently been

described

• Preoperative preparation• Fluid resuscitation with CVP or Swan Ganz

monitoring • Analgesia • Antibiotics • Nasogastric intubation

• Operation• Oversew of ulcer first performed by Dean in 1894 • Usually performed through an upper midline incision • Oversew perforation with omental patch • Use 2/0 synthetic absorbable. • Take 1 cm bites either side of ulcer • Picture provided by Vitoon Chinswangwatanakul, Siriraj Hospital, Bangkok,

Thailand• Thorough wash out and irrigation of peritoneal cavity with 0.9% saline • If unable to find perforation open the less sac • Remember that multiple perforations can occur • If closure secure and adequate toilet then a drain is not required • Pre-pyloric ulcer behave as duodenal ulcers • All gastric ulcers require biopsy to exclude malignancy • Definitive ulcer surgery probably not required • 50% patients develop no ulcer recurrence • Postoperatively patients should receive H. pylori eradication therapy • Surgery increasingly performed laparoscopically • Associated with no increased morbidity and reduced hospital stay

• Outcome• Operative mortality depends on four major

risk factors – Long period from perforation to admission – Increasing age – Coexisting medical disease – Hypovolaemia on admission