Peptic Ulcer, Perforated

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Diagnosis and reasoning

This elderly lady has presented with severe upper abdominal pain of abrupt onset. This is strongly suggestive of a catastrophe such as perforation of a peptic ulcer (PPU), rupture of an aortic aneurysm or mesenteric infarction. The possibility of an acute coronary syndrome should also be kept in mind. While acute pancreatitis and acute cholecystitis may also cause severe upper abdominal pain, the onset is usually rapid (i.e. beginning over a few seconds and increasing in severity over a few minutes) rather than instantaneous. Examination shows marked upper abdominal tenderness, which is suggestive of localized peritonitis. This is in favor of PPU, as vascular abdominal pain rarely causes tenderness. Note that while guarding and rigidity are usually found in peritonitis, these signs may be diminished or even absent in the elderly. Note that PPU causes a chemical peritonitis, as gastric acid usually sterilizes the gastroduodenal content. It is only when gastric acid is reduced by treatment or gastric malignancy that bacteria are present in the stomach and duodenum. Perforation of a gastrointestinal viscus (as in PPU) results in leakage of air into the peritoneal cavity. If this occurs in significant quantities, abdominal distention and loss of the normal liver dullness (upon percussion) may become clinically apparent. Note however, that absence of these findings does not exclude a PPU. Two other important clinical findings in this patient are tachypnea (in the absence of dyspnea or obvious lung pathology) and a pulse rate > 90 bpm. These are two manifestations of the systemic inflammatory response syndrome (SIRS) - an inflammatory state affecting the whole body. This indicates severe disease and mandates close evaluation and monitoring. Her normal ECGs exclude an acute coronary syndrome, while her full blood count is only significant for a neutropenia, which is yet another manifestation of SIRS and is believed to result from the acute-phase response accompanying inflammation. As the main differential diagnoses are perforation or a vascular pathology, a contrast CT scan of the abdomen is a good first line imaging investigation. In this patient, the presence of free gas in the abdomen and a subphrenic collection is virtually diagnostic of PPU. Addition of oral contrast confirms this by demonstrating a large gastric ulcer. In addition, the lack of contrast leakage indicates that the perforation has sealed off spontaneously. Her immediate management should consist of resuscitation and insertion of an NG tube. IV antibiotics and proton pump inhibitors should be commenced. Endoscopy should be avoided, as air insufflation may re-open the sealed perforation. A barium meal is not indicated, as it will not provide further information and may even precipitate barium peritonitis. As she is clinically stable, shows no signs of generalized peritonitis and has presented early, and as the perforation has sealed, conservative management may be considered (avoiding the morbidity and mortality associated with surgery). However, this will depend on the policy of the individual surgical unit.


Discussion

Peptic ulcer disease (PUD) is extremely common, affecting up to 10% of the population at some point in their lives. Perforation of a peptic ulcer (PPU) occurs only in 2% to 10% of these patients but accounts for over 70% of deaths associated with PUD. Note that many patients with PUD remain asymptomatic, and their first manifestation of the disease may be PPU ! The peak ages of incidence of PPU are between 40 to 60 years. The main risk factors are a history of PUD, NSAID use and smoking. The anterior wall of the duodeum is the most common site of perforation, accounting for 60% of cases. Antral and lesser-curvature gastric ulcers equally account for the remainder. Note that gastric ulcers have a higher morbidity and mortality, possibly because of associated hemorrhage and obstruction. An important point to keep in mind is that occasionally, malignant gastric ulcers may perforate and present with a similar clinical picture. Patients with PPU classically present with abrupt and severe pain in the upper abdomen (most often the epigastric region), which is exacerbated by movement. In addition, almost half of patients experience nausea and vomiting. Examination may reveal features of localized or generalized peritonitis. However, these features may be masked, atypical or even absent in elderly and immunosuppressed patients. In addition, most patients show a quickened pulse (although frank tachycardia is uncommon) and may be tachypneic. Obliteration of the liver dullness (i.e. frank pneumoperitoneum) is noticed in only one-third of patients, while between 5% to 10% of patients may present with shock. High fever and hypotension are late findings. Imaging choices for detection of PPU include plain X-rays and CT scanning. Erect chest x-rays are rapid to perform and show (free) air under the diaphragm in 80% to 85% of patients. In addition, insufflation of 200cc to 300cc of air via a NG tube may be considered in order to increase the diagnostic yield. Non contrast CT scans will show free air and/or free fluid in the abdomen and are capable of detecting much smaller quantities of free air than plain X-rays. In addition, if oral water soluble contrast is administered, a leak of contrast into the peritoneal cavity may also be seen. Laboratory investigations are usually non-specific, with the common findings being a neutrophil leukocytosis, an elevated CRP and serum creatinine, and a low serum albumin. Their main value lies in excluding alternate diagnoses such as acute pancreatitis. After initial resuscitation and stabilization, key elements of the management include decompression of the stomach via an NG tube (to reduce the volume of gastric contents leaking into the peritoneal cavity), anti-secretory therapy with proton pump inhibitors and IV broad-spectrum antibiotics (preferably covering both Gram-negative, Gram-positive and anaerobic bacteria). In addition, close monitoring (ideally in an intensive care setting) is essential. The further management may be conservative or operative. Conservative management is based on the observation that an estimated 40% to 80% of perforations seal spontaneously. Thus, the aim of management is to aid the natural healing of the ulcer by providing gastric decompression and continuous drainage. While the overall morbidity and mortality of conservative management is comparable to that of surgery, patients who present late (> 12 hours), patients who are > 70 years of age and patients who are hemodynamically unstable have a much worse outcome, and should be treated surgically. In addition, surgery is indicated in patients with features of generalized peritonitis. Note also that these patients should undergo a follow up endoscopy several weeks later to assess the presence of malignancy. Surgical techniques include laparotomy and laparoscopy, both of which have similar results. Simple closure of the perforation may be performed, or an additional vagotomy may be considered. Rarely, a (partial) gastrectomy may prove necessary. Biopsies should be obtained from gastric ulcers, to exclude malignancy. Following definitive management, proton pump inhibitors should be continued for at least 4 to 8 weeks, while Helicobacter pylori eradication therapy should also be considered.


Take home messages

  1. PPU should be prominently considered in the evaluation of severe upper abdominal pain of catastrophic onset.
  2. PPU may be the first manifestation of PUD in certain patients.
  3. Plain upright x-rays of the chest are a fast and safe and reveal air under the diaphragm in 80% to 85% of patients.
  4. CT imaging is more sensitive for detection of pneumoperitoneum and free fluid, and may be used to assess the patency of the perforation.
  5. Conservative management may be attempted in these patients - especially if imaging studies demonstrate sealing of the perforation.
  6. Surgery is preferred in patients who present late, in the elderly (> 70 y), and in patients who are hemodynamically unstable or who have features of generalized peritonitis.

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  1. AFP : Evaluation of Acute Abdominal Pain in Adults (2008)
  2. Digestive Surgery : Perforated Peptic Ulcer Disease : A Review of History and Treatment (2010)
  3. Scandinavian Journal of Gastroenterology : Perforated peptic ulcer : how to improve outcome ? (2009)
  4. Surgical Endoscopy : Laparoscopic correction of perforated peptic ulcer: first choice? A review of literature (2010)