Perforated Peptic Ulcer Management (WSES 2020)

Algorithm Steps

1. ▶

   Start

   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.

   1. ●

      Action

      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.

      1. ◆

         Decision

         Perforation Confirmed?

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

         1. ●

            Action

            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.

            1. ◆

               Decision

               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%.

               1. ◆

                  Decision

                  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.

                  1. ●

                     Action

                     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.

                     1. ⚠

                        Warning

                        ⚠️ 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.

                  2. ◆

                     Decision

                     Operative Approach Selection

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

                     1. ●

                        Action

                        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.

                        1. ●

                           Action

                           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).

                           1. ✓

                              Outcome

                              Successful Repair

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

                           2. ✓

                              Outcome

                              Monitor for Complications

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

                     2. ●

                        Action

                        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.

                     3. ●

                        Action

                        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).