PERFORATED GASTRIC ULCER

(PGU)

CASE SCENARIO Mr V.J. is a 51 yr old male. He has a chronic alcohol history. He

complains of chronic lower back pain for which he uses NSAIDS which he gets from his local pharmacy. Over the past week he complains of pain progressively getting worse and his NSAID use more than what he usually takes.

He presents in casualty with sudden onset severe epigastric pain. He appears distressed and lying down to minimize any abdominal movement.

On examination his vitals are :BP = 100/60 Pulse = 110/min T=36.4

General examination shows patient to be slightly anaemic. Abdominal examination : Severe epigastric tenderness, Rigid

boardlike abdomen with rebound guarding. Minimal bowel sounds. PR : Brownish stool

INTRODUCTION Caused by erosion of the ulcer through the wall of the stomach or

duodenum into the peritoneal cavity. Most perforations occur in elderly patients, in patients taking

NSAIDs and in patients with ulcers in the duodenum or gastric antrum.

Usual presentation is with shock and peritonitis. Patients should be referred to the emergency department for

surgical evaluation. Perforation occurs in approximately 2 to 10 percent of peptic

ulcers. Perforations usually occur anteriorly due to the absence of

protective viscera and major blood vessels on this surface. Immediately after the perforation, the peritoneal cavity is flooded with gastric secretions and a chemical peritonitis develops.

A small percentage of cases, the perforation becomes sealed by adherence of the liver or omentum. In such patients the process may be self limited but a subphrenic abscess may develop.

15% of patients with perforated ulcers die.

CLINICAL FEATURES OF PGU

Sudden, rapidly spreading, severe upper abdominal pain Exacerbated by movement May radiate to the right lower abdomen or to both shoulders

Rarely nausea or vomiting. Patient appears severely distressed, lying to minimize abdominal motion. Signs of peritonitis:

Generalized abdominal tenderness Rebound tenderness Board-like abdominal wall rigidity Hypoactive or absent bowel sounds

DIAGNOSIS OF PGUHISTORY TAKING history of intermittent abdominal pain or gastroesophageal reflux known peptic ulcer disease that has been inadequately treated or with ongoing

symptoms and sudden exacerbation of pain can be suspicious for perforation. history of recent trauma or instrumentation followed by abdominal pain and

tenderness

PRESENTATION abdominal pain and peritonitis

PHYSICAL EXAMINATION physical examination findings may be equivocal, and peritonitis may be minimal or

absent, particularly in patients with contained leaks 

INVESTIGATION Laboratory studies are not useful in the acute setting as they tend to be nonspecific,

but leukocytosis, metabolic acidosis, and elevated serum amylase may be associated with perforation

Free air under the diaphragm found on an upright chest X-ray is indicative of hollow organ perforation

DIFFERENTIAL DIAGNOSIS

Perforated intra-abdominal viscus Non perforated peptic ulcer Gastritis, duodenitis, esophagitis Pancreatitis – does not have such a sudden onset as perforated ulcer,

high serum amylase Acute cholecystitis Intestinal obstruction – pain more colic like

MANAGEMENT

Fluid resuscitation NBM Nasogastric suction Intravenous broad-spectrum antibiotics against gram-negative rods,

anaerobes, and oral flora Conservative vs operative management Eradication therapy for coexisting H. pylori infection

MANAGEMENT OF PGU- CONSERVATIVE (1) A perforation which appears to have sealed itself already, as

shown by diminished pain and improved abdominal signs. (2) Heart or lung disease, which increases the surgical and

anaesthetic risks. (3) The patient who is admitted after a day or two and is almost

moribund with diffuse peritonitis – Associated with poor outcome

MANAGEMENT OF PGU - OPERATIVE Laparotomy Simple suture of the ulcer. Placement of an omental patch (Graham

patch plication) in patients with perforated duodenal ulcers.

Thorough abdominal lavage In otherwise healthy patients with a history

of chronic ulcer and minimal peritoneal contamination, a concurrent, definitive, anti-ulcer procedure (e.g., vagotomy and drainage, highly selective vagotomy) may also be considered.

Perforated gastric ulcers are treated with an omental patch, wedge resection of the ulcer, or a partial gastrectomy and reanastomosis.

REFERENCE

World Journal of Emergency Surgery http://www.wjes.org/content/9/1/45

Primary Surgery: Volume One: Non trauma. Chapter 5-The Surgery of the stomach http://www.meb.uni-bonn.de/dtc/primsurg/docbook/html/x3617.html

American Family Physician – Peptic Ulcer Disease http://www.aafp.org/afp/2007/1001/p1005.html

Surgical Treatment: Evidence-Based and Problem-Oriented. Malagement of Perforated duodenal ulcer http://www.ncbi.nlm.nih.gov/books/NBK6926/

Medscape – Surgical treatment of perforated peptic ulcer http://emedicine.medscape.com/article/1950689-overview#a3