Diagnosis programmer
X-ray examination of abdominal cavity organs for presence of free gas (pneumoperitoneum, fig. 17).
Fibergastroduodenoscopy (FGDS) + X-ray examination.
Ultrasonic of abdominal cavity (pneumoperitoneum, fig. 18) + laparocentesis (peritoneal exudate).
Laparoscopy.
Laparotomy.
CT with oral contrast may also demonstrate extravasation of contrast in the presence of a perforated ulcer. If history and physical examination raise the possibility of perforation, upright chest radiography and an upper digestive tract contrast study with water-soluble contrast are the diagnostic studies of choice. Do not perform CT scanning in this situation.
Figure 17 – X-ray examination of abdominal cavity, pneumoperitoneum
Figure 18 – Ultrasonic of abdominal cavity, pneumoperitoneum
Laboratory Studies
CBC count (leucocytosis with left shift is found in most cases).
Serum gastrin level. Gastrin levels greater than 1000 pg/mL are suggestive of gastrinoma.
Serum H pylori antibody detection. Antibodies (immunoglobulin G [IgG]) to H pylori can be measured in serum, plasma, or whole blood. However, results from whole blood tests using finger sticks are less reliable.
Urea breath tests. Urea breath tests are used to detect active H pylori infection by testing for the enzymatic activity of bacterial urease. In the presence of urease produced by H pylori, labeled carbon dioxide (heavy isotope, carbon-13, or radioactive isotope carbon-14) is produced in the stomach, absorbed into the bloodstream, diffused into the lungs, and exhaled.
Faecal antigen tests. Faecal antigen testing is used to identify active H pylori infection by revealing the presence of H pylori antigens in stools.
This test is more accurate than antibody testing and less expensive than urea breath tests.
Treatment of perforated peptic ulcer
Treatment policy in patients with perforated peptic ulcer is surgical.
Conservative treatment is temporary measure when surgery is impossible. Conservative treatment includes the following (Taylor’s method):
nasogastric decompression;
replacement of fluid and electrolytes;
proton pump inhibitor;
broad-spectrum antibiotics;
hypothermia of abdominal wall.
Conservative treatment is associated with high risk of septic complications (formation of abscess, peritonitis).
Surgical treatment
Preoperative details. Fluid resuscitation should be initiated as soon as the diagnosis is made. Essential steps include insertion of a nasogastric tube to decompress the stomach and a Foley catheter to monitor urine output. Intravenous infusion of fluids is begun, and broad-spectrum antibiotics are administered. In select cases, insertion of a central venous line may be necessary for accurate fluid resuscitation and monitoring. As soon as the patient has been adequately resuscitated, emergent surgery should be performed.
Simple closure of perforation. Simple closure of perforation may be performed by laparotomy or laparoscopy.
The 1st step of the operation is the exploration of the abdominal cavity, which allows confirming the diagnosis of generalized peritonitis. In addition, it allows differentiating between the septic and the clinical peritonitis, and especially it permits to determine the possibility of the laparoscopic repair.
A very important step of the operation is the aspiration of peritoneal fluid, which should be as complete as possible. This is followed by extensive irrigation of the abdominal cavity.
The next step is the exact localization of the perforation, which sometimes may be covered by the liver, gallbladder or omentum. In this case, the perforation is identified on the anterior aspect of the duodenum.
Ideal repair of the perforation is direct closure by absorbable or non-absorbable sutures. Treatment of perforation may include also an epiploplasty in addition to the closure. An omental flap is chosen and is placed over the suture and fixed with 1 or 2 absorbable stitches. When a reliable direct suture of the opening cannot be achieved, closure can be completed by application of biological glue. The operation is completed by final extensive abdominal irrigation.
Ulcer excision, pyloroduodenoplasty
Ulcer excision and pyloroduodenoplasty is the simplest open surgical treatment for duodenal ulcer and in selected instances it can be used in the treatment of bleeding, obstruction, perforation. The operation carries low morbidity and mortality rates.
The operation usually consists of a Judd procedure. A longitudinal excision is made around the ulcer defect beginning from distal stomach to the proximal duodenum and closed transversely, so that the action of the pyloric valve is obliterated.
In other cases, when the proximal duodenum is badly deformed by scar, a Finney procedure (essentially a side-to-side gastroduodenostomy) or a Jaboulay procedure (gastric resection plus side-to-side gastroduodenostomy) is used after ulcer excision.