Peptic Ulcer - Perforation
DEFINITION
Perforation of a duodenal ulcer.
D I A B M I M
INCIDENCE
Refer peptic ulcer.
- duodenal more commonly duodenal than gastric ulcers.
- anterior more common than posterior perforation (no viscera or
blood
vessels)
Perforation is extremely rare in a
patient on a therapeutic dose of PPIs (Hill).
D I A
B M I M
AETIOLOGY
Refer peptic
ulcer
D I A
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BIOLOGICAL BEHAVIOUR
Pathophysiology
The ulcer ulcerates through the thickness of the anterior wall.
All the contents of the stomach / duodenum pour out into the
peritoneal
cavity due
to the perforation.
This sets off a wild chemical peritonitis.
--> after ~2-24hrs, bacterial infection and sepsis ensue
Note the 'Period of Illusion' (Cope)
- often after 3-6 hours, the pain settles as the gastric juices
released into the
cavity become diluted through massive transudation of fluid into the
cavity.
- the patient thinks they are getting better.
- they are not, they are getting worse.
Contents track down the R paracolic gutter
--> pain follows a similar pattern.
Posterior
perforation
Less common
- may become contained with a lesser sac abscess if stomach
- leakage through the foramen then leads to peritoneal irritation.
Can be joint posterior bleed and anterior perf ulcers but rare.
D I A
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MANIFESTATIONS
Depends on degree of contamination.
From localised epigastric peritonism to generalised peritonitis.
Beware that 1/3 have atypical (less obvious) picture.
Symptoms
2/3 have history of chronic duodenal
ulcer.
Local
Sudden upper abdo pain.
- later shifts to lower abdo / generalises.
Beware period of illusion (above).
Signs
Observe
Unable to move.
Rigid abdomen.
Palpate
Local / generalised peritonitis usual.
Pelvic tenderness possible on rectal.
Percuss
Loss of liver dullness due to the presence of free air in
peritoneal
cavity (unreliable).
INVESTIGATIONS
Bloods
Mild WCC at firs (12ish) then >20 once peritonitis takes hold
Imaging
Free air under the diaphragm on an erect chest film (only 50-85% sensitive)
- or lateral decubitus film.
If perforation suspected, but not supported by free air, reassess in
2-3 hours
- diagnostic uncertainty decreases with time.
- can instill 400mL of air into stomach through an NG and repeat
D I A
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MANAGEMENT
Basic Care
O2
Pass an NG and suck.
IV antibiotics.
Fluid resuscitation.
Analgesia / antiemetics
Surgery
Urgent surgery, wash-out and closure of the defect with a patch of
omentum (Graham-Steele closure).
- with the advent of PPIs, vagotomy is almost never performed.
- consent should include partial gastrectomy and chance of negative
laparotomy.
- no need to drain the abdomen.
All patients should undergo post-op H pylori
eradication if applicable.
Delay in treatment, old age and systemic diseases account for most
deaths.
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References
Hill J. Surgical Emergencies.