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Perforated Peptic Ulcer
Moshe Schein
There’s a hole in my bucket. … How should I mend it?
Just patch it! (A folk song)
“Every doctor, faced with a perforated ulcer of the stomach or intestine, must
consider opening the abdomen, sewing up the hole, and averting a possible or
actual inflammation by careful cleansing of the abdominal cavity.” (Johan
Mikulicz-Radecki, 1850–1905)
Thanks to effective, modern antiulcer drug management, the incidence of
perforated peptic ulcers has decreased drastically (some say that the incidence
and “virulence” of peptic ulcers started to decline even before such drugs became available and Helicobacter pylori was discovered as a cause)—but not everywhere. Perforated ulcers are still common in socioeconomically disadvantaged
or stressed populations worldwide. Usually, perforations develop against a background of chronic symptomatic ulceration, but for a patient to present with a
perforation “out of the blue,” without previous history of peptic ulcer disease
whatsoever, is not uncommon. In the Western world, perforated duodenal ulcers
(DUs) are much more common than perforated gastric ulcers (GUs), which are
seen more in lower socioeconomic groups.
18
Natural History
In perforated peptic ulcers: “It must be remembered that the exudate in the
early cases is sterile or nearly so, and the peritoneal reaction is a response to chemical irritation by the gastric and duodenal contents rather than the result of bacterial invasion” (John Blair Deaver, 1855–1931).
Classically, the abdominal pain caused by a peptic perforation develops
very suddenly in the upper abdomen. Most patients can accurately time the dramatic onset of symptoms. The natural history of such an episode can be divided
into three phases:
Chemical peritonitis/contamination. Initially, the perforation leads to
chemical peritonitis, with or without contamination with microorganisms. (Note
that the presence of acid sterilizes gastroduodenal contents; it is when gastric acid
Moshe Schein
Marshfield Clinic Ladysmith Center, 906 College Avenue, Ladysmith, WI 54848, USA
M. Schein et al. (eds.), Schein’s Common Sense Emergency Abdominal Surger y,
DOI: 10.1007/978-3-540-74821-2_18, © Springer-Verlag Berlin Heidelberg 2010
157
158 Moshe Schein
is reduced by acid-reducing treatment or disease [e.g., gastric cancer] that bacteria
and fungi are present in the stomach and duodenum). Spillage of gastroduodenal
contents is usually diffuse but may be localized in the upper abdomen by adhesions or the omentum. Spillage along the right gutter into the right lower quadrant, mimicking acute appendicitis, is mentioned in every textbook but almost
never seen in clinical practice (>Chap. 28, about the “Valentino” appendix).
Intermediate stage. After 6–12 hrs, many patients obtain some spontane-
ous relief of the pain. This is probably due to the dilution of the irritating gastroduodenal contents by the ensuing peritoneal exudate.
Intra-abdominal infection. Should the patient escape the scalpel initially,
after 12–24 hrs intra-abdominal infection supervenes. The exact point in time
in the individual patient when contaminating microorganisms become invasiveinfective is unknown. Therefore, you should consider any perforation operated
on with a delay of more than 12 hrs as infection rather than contamination. This
bears on your postoperative antibiotic therapy as discussed in a separate section
here. Neglected patients may present a few days after the perforation in septic
shock. Shock in the earlier stages is very rare although mentioned commonly by
medical students, but when confronted with a combination of shock and abdomi-
nal pain, think about ruptured aortic aneurysm, mesenteric ischemia, or severe
acute pancreatitis. Untreated perforation can lead eventually to an early “septic”
death from peritonitis or the development of an intra-abdominal abscess.
Diagnosis
The vast majority of patients present with signs of diffuse or localized peritoneal irritation; most lie still, groaning, and have a boardlike abdomen as described in textbooks (some call it “textbook peritonitis”). Spontaneous “sealing
off” of the perforation, or localization of the spill or leakage into the lesser sac,
causes atypical and delayed presentation. We had a patient who reperforated his
DU a few years after receiving an omental patch. The second perforation was thus
diverted backward into the retroperitoneum—behind the pancreas, the left colon,
and into the scrotum—while the abdomen remained soft.
In a patient with an abrupt onset of upper abdominal pain and diffuse peritonitis, the diagnosis is simple. It can be summarized in the following formulas:
Sudden onset peritonitis + free gas = perforated viscus
Sudden onset peritonitis + no free gas + normal amylase = perforated viscus
There is free gas under the diaphragm in about two-thirds of perforated
patients. Remember, free gas is visualized better on an upright chest X-ray than
18 Perforated Peptic Ulcer 159
on plain abdominal radiographs (>Chaps. 4 and 5). If your patient cannot stand
or sit up, order a left lateral decubitus abdominal film. Free gas is diagnostic,
although it is not always due to a perforated peptic ulcer. But, so what? It signifies
a perforated viscus, and a laparotomy is almost always indicated. “Almost always”
means “not always”: free gas without clinical peritonitis is not an indication for an
emergency laparotomy. As mentioned in >Chap. 4, there is a long list of “nonop-
erative” conditions that may produce free intraperitoneal gas. Free gas in a soft
abdomen may also mean that the perforation has been spontaneously sealed and
is thus amenable to nonoperative therapy, as discussed in a separate section.
In the absence of free air, acute pancreatitis—the “great simulator”—should
be considered and excluded (>Chap. 19). Normal serum amylase levels would sup-
port a diagnosis of a perforation, while very elevated amylase levels in a “susceptible” patient (e.g., alcoholic, with gallstones) would suggest acute pancreatitis.
The “borderline” patient with atypical presentation and marginal elevation of
amylase remains a problem because perforated ulcer may cause hyperamylasemia.
In the good old days, before imaging techniques replaced clinical skills, our decision to operate or observe would have depended on the whole clinical picture.
Rarely, a Gastrografin contrast study was performed to demonstrate or exclude
leakage. Faced with such a patient today, we would advise you to obtain a computed tomographic (CT) scan of the abdomen, looking for free gas, extraluminal
Gastrografin, and free peritoneal fluid. CT is excellent at picking up minute
amounts of free intraperitoneal gas and is thus a valuable tool in clarifying the
diagnosis in patients with an ambiguous clinical picture. Those of you who are
lucky to practice in the United States know that in most such patients a CT is
obtained before you have a chance to see them.
Philosophy of Treatment
The primary goal of treatment is to save the patient’s life by eliminating the
source of infection and cleaning the abdominal cavity. The secondary goal is to
cure, if possible, the ulcer diathesis. The former goal is achieved by simple closure
of the ulcer; the latter requires a definitive ulcer operation, in other words, to know
when to do what.
This is what we wrote in the previous editions of this book, but is it still
relevant today? Not only are these perforations less frequent and (perhaps) less
nasty, but such ulcers now can be healed in the long term (abolishing the ulcer
diathesis) in most patients by modern antacid drugs and the eradication of the
causative Helicobacter pylori bacteria. This being so, is there any place today for
definitive antiulcer operations?
To find out about the current (2008) practice concerning perforated ulcers
worldwide, we polled the international membership of SURGINET (an online
general surgical discussion group). And, here is what we found:
160 Moshe Schein
How common is the problem? It is very rare in developed countries. Seven
U.K. surgeons, for example, reported two cases per year, while a surgeon in a
small Australian town had seen only one case in 8 years. One respondent from a
large urban American hospital estimated that he saw three cases per year. When
Western lifestyle and availability of medications reaches a previously developing
region, perforated ulcer becomes rare (e.g., Odessa, Ukraine). On the other hand,
perforated ulcers are still common in indigent populations, such as in South
Africa or India, where some surgeons report as many as 25 cases per month.
What is the site of perforated ulcers? The vast majority are situated in the
duodenum. A few are prepyloric or gastric (associated with nonsteroidal antiinflammatory drug [NSAID] use). Because gastric resections for benign disease
are so rarely performed, perforated stomal ulcers have almost disappeared.
Which operation? All responders would use a simple closure as the pre-
ferred operative treatment. Some would add, infrequently, and in special circumstances, a definitive antiulcer procedure, as described below.
Open procedure versus laparoscopy? Unless they are dedicated “advanced
laparoscopists,” most surgeons seem to prefer an open laparotomy.
Who Are the Patients Who May Require
a Definitive Procedure?
The patient who may require a definitive procedure is, according to Dr. Alex
Berzoy of Ukraine: “The patient who would buy vodka instead of a protein pump
inhibitor.” And, he is right. The very patients who are susceptible to perforation
also suffer from substandard access to medical care and reduced compliance, both
adversely affecting successful medical antiulcer therapies. This is obviously much
more common in the developing world. Consequently, if the operation for a perforated ulcer can kill two birds with one stone (especially if the environment around
you cannot ensure optimal medical management and follow-up of your patient),
why not add a definitive procedure (that is, if you know how to do it)? While “intractability” as a real issue seems to be limited to the developing world, other special problems that could indicate a definitive procedure may be present anywhere
(see below).
For Which Patients Is a Definitive Procedure Safe?
Surely, you do not want to embark on a lengthy definitive procedure in a
critically ill and septic patient. Over the years, we encountered surgeons who omitted a definitive procedure because of “severe contamination,” often citing a myth
that vagotomy in a perforated patient may “spread the infection into the
18 Perforated Peptic Ulcer 161
mediastinum.” The Hong Kong group showed that when the following three factors are present, an antiulcer procedure can be safely performed: blood pressure
>90 mmHg, operation within 48 hrs of perforation, and lack of associated medical
illnesses. We found the APACHE II (Acute Physiological and Chronic Health
Evaluation II) scoring system (>Chap. 6) useful in this situation as patients with
perforated ulcers with scores less than 11 can tolerate a definitive procedure of any
magnitude. Conversely, in patients with higher APACHE II scores, the simplest
operation should be performed.
Operative Treatment: Simple Closure (> Fig. 18.1)
Classically, simple closure of the ulcer is best achieved by an omental
Graham’s patch, also called omentopexy. A few “through-all-layers” interrupted
sutures are placed through both edges of the perforation (transversely, not vertically, so the lumen is not narrowed) and are left untied; a pedicle of the greater
omentum is created and flipped over the perforation; the sutures are then gently
tied over the omentum in order not to strangulate it (>Fi g. 18.2). At this stage, the
anesthetist may be asked to inject saline, with or without dye, through the nasogastric tube to ascertain that the patch is waterproof.
More than a few surgeons misunderstand this operation; they initially suture
close the perforation and only then cover the suture line with the omentum.
However, the approximation of the edematous, friable edges of perforation can be
troublesome. Some surgeons omit omental patching altogether and simply suture
the hole. This may be successful in small, fresh perforations when the edges of the
defect are pliable, but in all cases of postoperative duodenal fistula witnessed by
Fig. 18.1. “How should we mend it?”
162 Moshe Schein
Fig. 18 .2. Simple closure. Note the omental patch should “plug” the hole with the sutures tied over it. First suturing the hole and then sticking omentum over the repair is
wrong
us, simple suture closure of a perforated DU was the causative mechanism. Be
smarter, do not stitch the perforation but plug it with viable omentum.
Should you leave a drain behind? Only do this if you think that your omental patch is likely to leak, which should not be the case; thus, the answer is “no”
(>Chap. 42).
Do not forget a course of anti-Helicobacter antibiotics after the operation,
combined with appropriate acid-reducing agents. High-risk elderly patients may
need acid suppression for the rest of their lives. The duration of such management in younger patients, and whether they will be reinfected with the ulcerogenic bacteria, is controverisal.
Special Problems
Special problems are the situations that may require more than simple
closure:
“Kissing” ulcers. Any evidence of a preceding or coexisting upper gastro-
intestinal (UGI) hemorrhage (e.g., finding “coffee ground” or fresh blood in the
nasogastric tube or at the perforation site or in the peritoneal cavity) suggests
the possibility of kissing ulcers—the anterior perforated, the posterior bleeding.
Simple closure of the former without hemostasis for the latter could lead to a severe
postoperative hemorrhage. In such circumstances, enlarge the duodenal perforation into a duodenotomy and explore the inside of the duodenum. If a bleeding
posterior ulcer is found, suture transfix its base as described in
>
Chap. 17.
18 Perforated Peptic Ulcer 163
Perforated giant ulcers. Omentopexy can be easily performed for most
perforated DUs. Rarely, a giant perforated DU creates a huge anterior bulbar-pyloric
defect, which is not amenable to safe closure and thus mandates partial gastrectomy
(>Fig 17.2 in the >Chap. 17).
Perforated GUs. These are usually larger than the duodenal ones. For those
positioned on the greater curvature of the stomach, a wedge resection of the ulcer,
hand sutured or stapled, may be easier and safer than omentopexy. For chronic
and large lesser-curvature ulcers, omentopexy is notoriously difficult and unsafe;
partial gastrectomy may serve the patient better. Perforations of malignant GUs
are very rare in the West (but in India, for example, many gastric perforations are
malignant). Be that as it may, if we decide to patch a gastric perforation, we would
take a few biopsies from its edges before closing it. If positive for cancer, an elective
reoperation for “oncological” gastrectomy may be necessary.
Pyloric obstruction. Perforated DUs are rarely associated with chronic
narrowing of the gastric outlet. But, if the patient gives a history of prolonged
postprandial vomiting or at operation the patient’s stomach appears dilated and
thickened, consider that possibility. Insert your index finger through the duodenal perforation and up the pylorus or feed in a Foley catheter and check whether
the inflated balloon (5 cc) passes easily through the pylorus. Documented pyloric
stenosis would demand the addition of some form of drainage procedure (pyloroplasty or gastrojejunostomy).
Intractable cases. Selected patients with a clear history of chronicity or in-
tractability (e.g., a recurrent perforation) with no easy access to health care and
medications may benefit from a definitive antiulcer procedure. That surgeons
in London or Houston no longer find indications for acid-reducing procedures
does not mean that there are no patients in Calcutta who would benefit from it.
Operative Treatment: Which Definitive Procedure?
Ideally, in an emergency you should choose the antiulcer procedure with
which you are most familiar in the elective situation. The problem is that today you
and other young surgeons are deprived of experience with elective antiulcer operations. Based on our philosophy to avoid, if possible, a gastric resection for a benign
process and on results of elective ulcer operations (good old history!), we recommend an operative policy that tailors the definitive procedure to the specific ulcer
(>Table 18.1). Whatever you do, please remember that if your patient is sick and
you are not a skilled gastroduodenal surgeon, forget about the definitive procedure. Just patch the hole and get out. Anyway, it seems that in a few years no sur-
geon able to decipher Table 18.1 will still be practicing. So, perhaps in future
editions of this book there will be no chapter dedicated to perforated peptic ulcer
or the only operative option mentioned will be omentopexy.
164 Moshe Schein
Table 18.1. Selection of procedures in perforated ulcers
Ulcer type Textbook options We recommend
Good risk Poor risk Good risk Poor risk
Duodenal Omentopexy ±
TV + D or HSV
or TV + A
Prepyloric Omentopexy ±
TV + D
or TV + A
Gastric Omentopexy or
wedge excision
or partial
gastrectomy
TV + D truncal vagotomy and drainage procedure; TV + A truncal vagotomy and antrectomy;
HSV highly selective vagotomy; HSV + D highly selective vagotomy and drainage
Omentopexy Omentopexy
Omentopexy Omentopexy
Omentopexy
or partial
gastrectomy
plus HSV
plus HSV + D
Omentopexy
with HSV + D
or partial
gastrectomy
Omentopexy
Omentopexy
Omentopexy or
partial
gastrectomy
Laparoscopic Management of Perforated Ulcers
Omentopexy and peritoneal toilet can be executed laparoscopically (>Chap. 57).
A large amount of experience with conflicting results has been accumulated in the
treatment of perforated DUs. We suggest that a laparoscopic procedure is a reasonable option in stable and well-resuscitated patients and when the perforation can
be promptly and securely closed. Conversely, a prolonged pneumoperitoneum will
be poorly tolerated in the high-risk or severely septic patients. And of course, you
must be a skilled laparoscopist (do you know any surgeon who does not consider
him—or herself “skilled in everything”?) to be able to perform a safe, watertight
omentopexy.
By the way, any laparotomy for omentopexy need not always be a macro-
laparotomy. Instead, with accurate preoperative diagnosis on CT, you can repair
the perforation and suck out the free peritoneal fluid through a limited transverse
right subcostal incision or a short midline epigastric incision, either of which is
easier on the patient than the traditional long midline approach (>Chap. 10).
Nonoperative Management of Perforated Ulcers
A nonoperative approach consisting of nothing by mouth (NPO, nil per
os), nasogastric suction, systemic antibiotics, and acid secretion inhibitors has
been proven effective by a few enthusiastic groups. The sine qua non for success
18 Perforated Peptic Ulcer 165
is the spontaneous sealing of the perforation by the omentum or other adjacent
structures; if this occurs, a nonoperative approach would be successful in the
majority of cases.
Nonoperative treatment may be of particular value for two types of
patients: the “late presenter” and the “extremely sick.” The late presenter comes
to you a day or more after the perforation occurred, with an already improving
clinical picture and minimal abdominal findings. This, together with radiographic evidence of free air, hints at a localized and spontaneously sealed perforation. Nonoperative treatment, following a Gastrografin UGI study, or contrast
CT, to document that the perforation is sealed should be successful in most
instances. The extremely sick are the other candidates for conservative therapy:
those for whom the risk of any operation could be prohibitive, such as the early
post-massive myocardial infarct patient, the patient with grade IV COPD (chronic
obstructive pulmonary disease), or the patient with an APACHE II score over 25.
Also in this group, however, conservative treatment may be successful only if the
perforation is sealed and radiographically proven to be so. Of course, localized
collections or abscesses developing at the site of the sealed perforation can be
drained percutaneously under CT guidance (>Chap. 49).
Simple Surgical Drainage (in Difficult Circumstances)
In the absence of basic anesthetic facilities (e.g., somewhere in the bush or
remote India) and when confronted with a patient who clearly needs an operation, there is a viable (and well-described) option. Under local anesthesia, the
upper abdomen may be entered through a limited incision, and after aspirating
as much muck and pus as possible, a large drain can be left under the liver in the
region of the duodenum. If the perforation seals spontaneously, the drain helps to
control the associated abscess; if not, then it forms a lifesaving controlled duodenal fistula to be dealt with—conservatively or operatively—later and elsewhere
(not in the bush).
Antibiotics
As soon as the diagnosis of perforation is made and the patient is booked for
a laparotomy, administer a dose of wide-spectrum antibiotics. The vast majority
of patients present for treatment within 12 hrs of perforation and suffer, therefore,
from peritoneal contamination rather than infection. In many of them, in fact, the
peritonitis is chemical and does not contain any micro-organisms. Antibiotics in
this group will serve for prophylaxis. Postoperative therapeutic antibiotics are not
needed in these patients. Those who present later than 12 hrs may suffer from
166 Moshe Schein
intra-abdominal infection; here, antibiotics should be continued in the postoperative phase (>Chap. 47). The antibiotics given, in the form of either monotherapy
or combination therapy, should “cover,” empirically, Gram negatives and anaerobes. Routine culturing of the peritoneal fluid in perforated patients is not indicated (>Chap. 12). Candida, which is a contaminant, does not need specific
therapy.
Conclusions
Patch a perforated ulcer if you can; in most patients this is possible, but if not,
then you must resect. Consider adding a definitive antiulcer procedure on an extremely selective basis and do not forget that a nonoperative approach is possible,
beneficial, and indicated in selected patients. Whatever you do, large studies show
that one-third of these patients will be dead within 5 years; the same factors that
led to the perforation shorten their life.
“We have no responsibility to such patients but to save their lives. Any procedure,
which aims to do more than this, can quite significantly be considered meddlesome
surgery. We have no responsibility during the surgery to carry out any procedure to
cure the patient of his duodenal ulcer.” (Roscoe R. Graham, 1890–1948)
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