Peptic Ulcer - Perforation


DEFINITION
Perforation of a duodenal ulcer.
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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).

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AETIOLOGY
Refer peptic ulcer
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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.
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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).

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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
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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.