Gastroduodenal ulcer perforations have decreased in the last few years, largely due to the widespread adoption of medical therapies for peptic ulcer disease and decreasing incidence of helicobacter pylori infection in Western countries. However, ulcer disease is a still common emergency condition worldwide and is associated with mortality rates of up to 30%.
The main etiologic factors include use of non-steroidal anti-inflammatory drugs (NSAIDs), steroids, smoking, Helicobacter pylori (H. pylori) and a diet high in salt. All these factors have in common that they affect acid secretion in the gastric mucosa. Stress ulcers with perforation may occur in critically ill patients in intensive care, where the diagnosis may be obscured owing to lack of signs and symptoms in an unconscious or sedated patient.
DIAGNOSIS
Clinical signs and symptoms
- Severe, sudden-onset epigastric pain, which can become generalized
- Abdominal tenderness
Laboratory markers
- White blood cell
- Leucocyte shift to left (>75 %)
- C-reactive protein
PULP score
| PULP score | Points |
|---|---|
| Age > 65 | 1 |
| Comorbid active malign disease or AIDS | 1 |
| Comorbid liver cirrhosis | 1 |
| Shock | 1 |
| Perforation time on admission >24 | 1 |
| Serum creatinine >1.47 mg/dl | 2 |
| ASA 2 | 1 |
| ASA 3 | 3 |
| ASA 4 | 5 |
| ASA 5 | 7 |
| High score | >6 |
| Total score | 0-18 |
BOEY score
| BOEY Score | points |
|---|---|
| Medical illness | 1 |
| Preoperative shock | 1 |
| Duration of peptic ulcer perforation > 24 h | 1 |
| High score | >1 |
| Total score | 0-3 |
Imaging
- Abdominal x-ray
- US
- CT
Imaging findings
- Abdominal free air
- Diffuse fluid
TREATMENT
- – Conservative treatment with a period of observation (intravenous antibiotics, nil per os and a nasogastric tube, anti-secretory and anti-acid medication and a water-soluble contrast imaging study to confirm a sealed leak) in patients with minimal or localized symptoms and in good clinical condition.
- – Open or laparoscopic closure of the perforation using interrupted sutures with or without an omental pedicle on top of the closure.
- +/-
- Antibiotic therapy
- If perforation occurs within 24 hours in patients without comorbidities post-operative antibiotic are not needed.
- If perforation occurs over 24 hours antibiotic therapy for 3-5 days.
Empiric antibiotic regimens. Normal renal function
- One of the following antibiotics
- Amoxicillin/clavulanate 1.2-2.2 g 8-hourly
- Ceftriaxone 2 g 24-hourly + Metronidazole 500 mg 6-hourly
- Cefotaxime 2g 8-hourly + Metronidazole 500 mg 6-hourly
- or
- In patients with beta-lactam allergy
- A fluoroquinolone-based regimen
- Ciprofloxacin 400 mg 12-hourly + Metronidazole 500 mg 6- hourly
