Perforation of Peptic Ulcer - Surgical Approach

Etipathogenesis, clinical features, complications, diagnosis and treatment of perforated peptic ulcer

1. Perforation

Duodenal and Gastric ulcers can
perforate.

More commonly anterior duodenal
ulcer is the cause of perforation
peritonitis.
Posterior duodenal ulcer bleeds.

2. Causes of perforation of DU

Chronicity of the ulcer

Bouts of excessive alcohol intake

Use of cortisone in a patient with
silent DU

NSAIDs

3. Perforation of C.D.U.

Anterior duodenal ulcer perforates in
the peritoneal cavity (greater sac ).

Posterior ulcer can perforate in lesser
sac, but usually it causes bleeding.

Presents as an acute onset
abdominal pain with vomiting,
dehydration, board like rigidity of
abdominal wall and lately as septic
shock .

4. Pathophysiology

As an ulcer becomes chronic the
borders become fibrosed and
unyeilding, floor is destroyed by
pepsin.

Supported by a thin layer of
serosa, which breaks suddenly to
allow the liquid and gaseous
contents of stomach to go in the
peritoneal cavity.

5. Stages of peritonitis
1. Stage of Chemical Peritonitis.
2. Stage of Reaction (illusion).
3. Stage of Bacterial Peritonitis.

6. Types of Peritonitis

Primary

Secondary

Tertiary

7. REMEMBER

“DANGER LIES IN DELAY NOT IN
OPERATION”

“SUN SHOULD NOT SET ON A
PATIENT WITH PERITONITIS OR
OBSTRUCTION”

8. Management of perforation
peritonitis.

Acute abdominal catastrophe which
needs urgent, competent
management.

“Management “ means starting of
the treatment while you are
investigating the case.

Delay is lethal. Ideally perforation
should be closed within an hour of
diagnosis.

9. Investigations

Plain X ray of chest or erect film
of abdomen is diagnostic.

Other investigations are done to
asses the patient’s ability to stand
an operation under anaesthesia.

CBC, Renal and Hepatic functions,
Australia antigen, HIV, ECG, Echo.

10. Gas under the right dome of
diaphragm

11. Treatment

Intravenous fluids to correct losses

Nasogastric aspiration for
decompression.

Catheterization to monitor urine
output.

Broad spectrum antibiotics.

Prepare for urgent operation.

12. Operative options.

Open surgery or Laparoscopy.

Repair of perforation by interrupted
sutures of non absorbable material
with or without re enforcement by
omental flap with drainage of
peritoneal cavity

Definitive surgery for ulcer is usually
not done.

13. Perforation of Gastric ulcer

Gastric ulcers are comparatively
uncommon. Therefore perforations of
gastric ulcers are less seen.

Perforated gastric ulcer could be
malignant.

Biopsies from the edges MUST be
taken before closure.

14. Treatment of Perforated
Gastric ulcer

Suspicion of malignancy will need a
partial gastrectomy.

If patient’s general condition does
not permit then a local wide excision
of the ulcer bearing stomach wall
with truncal vagotomy be performed.

Post operative endoscopy after 2
mthsof anti ulcer regime.

15. Sealed perforation

As soon as the ulcer perforates or
starts leaking from a puncture ,
omentum comes and wraps it.

Some leaked fluid causes minimal
disturbance but patient has no
systemic manifestation at that time.

Patient may come later with an
intra abdominal abscess.

16. Complications of Peptic
ulcers.

Perforation.

HAEMATEMESIS

MALENA

Sealed perforation leading to intra
abdominal abcess.

Gastric outlet obstruction.

Teapot deformity.

Hourglass stomach.

Penetration of pancreas.

Carcinoma of stomach.

17. Bleeding Peptic Ulcer

Chronic bleeding from peptic ulcer can
present with severe anemia and/or
malaena.

Acute bleeding can be life threatening.

D.U. (posterior) bleeds from
gastroduodenal.

G.U. At lesser curvature bleeds from left
gastric artery

18. Preciptating factors

Chronicity

Irritation due alcohol, NSAIDs

Atherosclerotic vessels.

Anticogulants, Aspirin, Clopidogrel.

19. Presentation

Catastrophic bleed, sudden
collapse.

Large bouts of haematemesis,
hemorrhagic shock ,can also have
frank blood in stools.

Should be differentiated with
hemoptysis.

20. Management

Resuscitation from shock.

Empty the stomach by NGT.

ABC, antibiotics, adequate blood
transfusions,careof airway.

Urgent OGDscopy by an expert

21. Medical or conservative
management

Aspiration of stomach, irrigation with
cold normal saline, instillation of cold
antacids and/or sucralfate every two
hourly.

Replacement of blood.
Prevention/correction of shock.

i/v Ranitidine 50 mg 8 hourly.

i/v Pantoprazole 40 mg with 200 ml
DNS.

22. Non surgical interventions

Laser coagulation using Nd yag laser.

Sclerotherapy using 1:10000
epinephrine
Or 2% ethanolamine.

Haem clip application.

Bipolar coagulation.(high failure rate )

23. Surgical options
GastroDuodenotomy, under running of
bleeding vessel followed by
pyloroplasty with a truncal vagotomy.
Partial gastrectomy in a case of gastric
ulcer which includes the ulcer bearing
area.
Carries a high mortality (20%) because
of comorbidities and late decisions.

24. Complications of Peptic
ulcers.

Perforation.

Haemetemesis

Malena

Sealed perforation leading to intra
abdominal abcess.

GASTRIC OUTLET OBSTRUCTION

Teapot deformity.

Hourglass stomach.

Penetration of pancreas.

Carcinoma of stomach.