PERFORATED GASTRIC

ULCER (PGU)

CASE SCENARIO

Mr V.J. is a 51 yr old male. He has a chronic alcohol history. He

complains of chronic lower back pain for which he uses NSAIDS which
he gets from his local pharmacy. Over the past week he complains of
pain progressively getting worse and his NSAID use more than what he
usually takes.

He presents in casualty with sudden onset severe epigastric pain. He

appears distressed and lying down to minimize any abdominal
movement.

On examination his vitals are :

BP = 100/60 Pulse = 110/min T=36.4

General examination shows patient to be slightly anaemic.

Abdominal examination : Severe epigastric tenderness, Rigid boardlike

abdomen with rebound guarding. Minimal bowel sounds.

PR : Brownish stool

INTRODUCTION

Caused by erosion of the ulcer through the wall of the stomach or

duodenum into the peritoneal cavity.

Most perforations occur in elderly patients, in patients taking NSAIDs

and in patients with ulcers in the duodenum or gastric antrum.

Usual presentation is with shock and peritonitis.

Patients should be referred to the emergency department for

surgical evaluation.

Perforation occurs in approximately 2 to 10 percent of peptic ulcers.

Perforations usually occur anteriorly due to the absence of

protective viscera and major blood vessels on this surface.
Immediately after the perforation, the peritoneal cavity is flooded
with gastric secretions and a chemical peritonitis develops.

A small percentage of cases, the perforation becomes sealed by

adherence of the liver or omentum. In such patients the process may
be self limited but a subphrenic abscess may develop.

15% of patients with perforated ulcers die.

CLINICAL FEATURES OF PGU

Sudden, rapidly spreading, severe upper abdominal pain

Exacerbated by movement

May radiate to the right lower abdomen or to both shoulders

Rarely nausea or vomiting.

Patient appears severely distressed, lying to minimize abdominal motion.

Signs of peritonitis:

Generalized abdominal tenderness

Rebound tenderness

Board-like abdominal wall rigidity

Hypoactive or absent bowel sounds

DIAGNOSIS OF PGU
HISTORY TAKING

history of intermittent abdominal pain or gastroesophageal reflux

known peptic ulcer disease that has been inadequately treated or with ongoing symptoms and
sudden exacerbation of pain can be suspicious for perforation.

history of recent trauma or instrumentation followed by abdominal pain and tenderness

PRESENTATION

abdominal pain and peritonitis

PHYSICAL EXAMINATION

physical examination findings may be equivocal, and peritonitis may be minimal or absent,
particularly in patients with contained leaks

INVESTIGATION

Laboratory studies are not useful in the acute setting as they tend to be nonspecific, but
leukocytosis, metabolic acidosis, and elevated serum amylase may be associated with
perforation

Free air under the diaphragm found on an upright chest X-ray is indicative of hollow organ
perforation

DIFFERENTIAL DIAGNOSIS

Perforated intra-abdominal viscus

Non perforated peptic ulcer

Gastritis, duodenitis, esophagitis

Pancreatitis does not have such a sudden onset as perforated ulcer, high
serum amylase

Acute cholecystitis

Intestinal obstruction pain more colic like

MANAGEMENT

Fluid resuscitation

NBM

Nasogastric suction

Intravenous broad-spectrum antibiotics against gram-negative rods,

anaerobes, and oral flora

Conservative vs operative management

Eradication therapy for coexistingH. pyloriinfection

MANAGEMENT OF PGU
- CONSERVATIVE

(1) A perforation which appears to have sealed itself already, as shown by

diminished pain and improved abdominal signs.

(2) Heart or lung disease, which increases the surgical and anaesthetic risks.

(3) The patient who is admitted after a day or two and is almost moribund
with diffuse peritonitis Associated with poor outcome

MANAGEMENT OF PGU
- OPERATIVE

Laparotomy

Simple suture of the ulcer.

Placement of an omental patch (Graham patch

plication) in patients with perforated duodenal
ulcers.

Thorough abdominal lavage

In otherwise healthy patients with a history of

chronic ulcer and minimal peritoneal
contamination, a concurrent, definitive, antiulcer procedure (e.g., vagotomy and drainage,
highly selective vagotomy) may also be
considered.

Perforated gastric ulcers are treated with an

omental patch, wedge resection of the ulcer, or a
partial gastrectomy and reanastomosis.

REFERENCE

World Journal of Emergency Surgery http://www.wjes.org/content/9/1/45

Primary Surgery: Volume One: Non trauma. Chapter 5-The Surgery of the
stomach http://
www.meb.uni-bonn.de/dtc/primsurg/docbook/html/x3617.html

American Family Physician Peptic Ulcer Disease http://

www.aafp.org/afp/2007/1001/p1005.html

Surgical Treatment: Evidence-Based and Problem-Oriented. Malagement of

Perforated duodenal ulcer http://www.ncbi.nlm.nih.gov/books/NBK6926/

Medscape Surgical treatment of perforated peptic ulcer http://

emedicine.medscape.com/article/1950689-overview#a3