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Perforated Peptic Ulcer Management (WSES 2020)

Perforated Peptic Ulcer Management (WSES 2020): Suspected Perforated Peptic Ulcer → Diagnostic Workup → Perforation Confirmed? → Initial Resuscitation →...

Pathway Overview

15 steps

Algorithm Steps

15 total

  1. 01Start

    Suspected Perforated Peptic Ulcer

    Sudden onset severe epigastric pain, board-like rigidity, peritonitis. History of PUD, NSAID use, or H. pylori. Consider in any patient with acute abdomen.

  2. 02Action

    Diagnostic Workup

    1) Erect CXR: Free air under diaphragm (70-80% sensitive). 2) CT abdomen/pelvis with IV contrast: Gold standard - extraluminal air, fluid, wall thickening. 3) Labs: CBC, BMP, lactate, amylase, type & screen. 4) ECG to rule out cardiac cause of epigastric pain.

  3. 03Decision

    Perforation Confirmed?

    CT showing free air + peritoneal fluid + ulcer crater. Clinical peritonitis with imaging findings. If uncertain, consider diagnostic laparoscopy.

  4. 04Action

    Initial Resuscitation

    1) NPO, NG tube for decompression. 2) IV fluids - crystalloid bolus. 3) Foley catheter. 4) Broad-spectrum antibiotics (ceftriaxone + metronidazole or piperacillin-tazobactam). 5) PPI IV bolus then infusion. 6) Adequate analgesia. 7) Correct coagulopathy.

  5. 05Decision

    Risk Stratification (Boey Score)

    Boey score predicts mortality: 1) Delayed presentation >24h (+1). 2) Preoperative shock (SBP <90) (+1). 3) Severe comorbidities (ASA ≥3) (+1). Score 0: <2% mortality. Score 1: 8%. Score 2: 30%. Score 3: >50%.

  6. 06Decision

    Non-operative Management Candidate?

    RARELY appropriate. Consider ONLY if: 1) Sealed perforation on CT (contained leak). 2) No generalized peritonitis. 3) Hemodynamically stable. 4) Improving with conservative measures. 5) Contrast study shows no leak. High failure rate - close monitoring essential.

  7. 07Action

    Non-Operative Management

    1) NPO, NG tube. 2) IV antibiotics. 3) IV PPI. 4) Serial exams q4-6h. 5) Repeat imaging if deterioration. 6) Immediate surgery if no improvement in 12-24h. 7) Water-soluble contrast study before oral intake.

  8. 08Warning

    ⚠️ Time is Critical

    Every hour of delay beyond 6-12 hours increases mortality. Sepsis develops rapidly with untreated perforation. Non-operative management failure rate is high - low threshold to convert to surgery.

  9. 09Decision

    Operative Approach Selection

    Laparoscopic vs Open based on: Hemodynamic stability, surgeon expertise, perforation size, duration of symptoms, available resources.

  10. 10Action

    Laparoscopic Repair

    Preferred if: Hemodynamically stable, experienced surgeon, perforation <1cm, <24h duration. Procedure: 1) Thorough peritoneal lavage (>6L saline). 2) Primary closure with omental (Graham) patch. 3) Suture or pledgeted repair. Benefits: Less pain, shorter stay, fewer wound complications.

  11. 11Action

    Postoperative Management

    1) Continue IV PPI. 2) Continue antibiotics 3-5 days. 3) NG tube until bowel function returns. 4) H. pylori testing and eradication. 5) NSAID cessation counseling. 6) Follow-up EGD in 6-8 weeks for gastric ulcers (rule out malignancy).

  12. 12Outcome

    Successful Repair

    Patient recovered. Continue PPI, H. pylori eradication, avoid NSAIDs. Follow-up EGD for gastric ulcers.

  13. 13Outcome

    Monitor for Complications

    Watch for: Leak, intra-abdominal abscess, wound infection, ileus, gastric outlet obstruction, recurrent ulcer.

  14. 14Action

    Open Repair (Laparotomy)

    Indications: Hemodynamically unstable, large perforation (>2cm), shock, delayed presentation, no laparoscopic expertise. Procedure: Upper midline incision, thorough lavage, omental patch repair. Consider definitive ulcer surgery (vagotomy, antrectomy) for recurrent disease if patient stable.

  15. Path rejoins step 11Shared downstream outcome
  16. 15Action

    Giant Perforation (>2cm)

    Options: 1) Omental plug with multiple sutures. 2) Partial gastrectomy (Billroth I or II) for gastric ulcers. 3) Jejunal serosal patch (Thal patch). 4) Roux-en-Y reconstruction. 5) Damage control if unstable (pack and return).

  17. Path rejoins step 11Shared downstream outcome
  18. Path rejoins step 09Shared downstream outcome

Guideline Source

WSES Guidelines: Perforated and Bleeding Peptic Ulcer

DOI: 10.1186/s13017-019-0283-9View Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Non-operative management rarely appropriate - use with caution
  • Elderly and immunocompromised may have atypical presentations
  • Local surgical expertise affects approach selection
  • Does not cover giant perforations (>2cm) in detail
  • Pediatric perforations require specialized consideration

Contraindicated Populations

pediatric

Applicable Regions

USEUGlobal

Global: WSES 2020 guidelines widely adopted for PPU management

Version 1Next review: 2028-01-01

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Frequently Asked Questions

What is the Perforated Peptic Ulcer Management (WSES 2020)?

The Perforated Peptic Ulcer Management (WSES 2020) is a emergency clinical algorithm for General Surgery. It provides a structured decision tree to guide clinical decision-making, based on WSES Guidelines: Perforated and Bleeding Peptic Ulcer.

What guideline is the Perforated Peptic Ulcer Management (WSES 2020) based on?

This algorithm is based on WSES Guidelines: Perforated and Bleeding Peptic Ulcer (DOI: 10.1186/s13017-019-0283-9).

What are the limitations of the Perforated Peptic Ulcer Management (WSES 2020)?

Known limitations include: Non-operative management rarely appropriate - use with caution; Elderly and immunocompromised may have atypical presentations; Local surgical expertise affects approach selection; Does not cover giant perforations (>2cm) in detail; Pediatric perforations require specialized consideration. Individual patient factors may require deviation from these recommendations.

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