Perforated peptic ulcer
Perforated peptic ulcer is a full-thickness gastric or duodenal defect that lets luminal contents leak into the peritoneal cavity, causing sudden severe epigastric pain and diffuse peritonitis. Diagnosis is confirmed by free intraperitoneal air on imaging. Treatment is resuscitation, broad-spectrum antibiotics, and emergency surgical repair, most often an omental patch.
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What this article covers
- Overview
Definition: A perforated peptic ulcer is a full-thickness defect through the gastric or duodenal wall that breaches the serosa, letting acid, bile, and enteric contents spill into the peritoneal cavity.
- Epidemiology
Typical patient: An adult with peptic ulcer disease, chronic NSAID or aspirin use, or H.
- Risk factors
NSAID use: Regular nonsteroidal anti-inflammatory drug use, including low-dose aspirin, is one of the two dominant risk factors, compounded by concurrent corticosteroid or anticoagulant use.
- Pathophysiology
Full-thickness erosion: Peptic ulcers extend through mucosa, submucosa, and muscularis propria; when injury outpaces mucosal defense, the defect crosses the serosa into the peritoneal cavity.
- Clinical features
Onset: Abrupt, severe, constant epigastric pain, sometimes waking the patient from sleep.
- Differential diagnosis
Acute appendicitis: Also progresses to right lower quadrant tenderness, but pain starts periumbilically, not epigastrically, and imaging shows no free air.
- Diagnosis
What establishes the diagnosis: The criteria for perforation are peritoneal signs, an elevated white cell count on CBC, and free intraperitoneal air on an erect chest radiograph or contrast-enhanced…
- Management
First, resuscitate: Keep the patient nil per os (NPO), place two large-bore IV lines, begin isotonic crystalloid resuscitation targeted to vital signs and urine output, place a nasogastric tube for…
- Complications
Ongoing sepsis and abscess: Inadequately controlled peritonitis can progress to intra-abdominal or subphrenic abscess and septic shock, most often within the first several days.
- Prognosis
Mortality: Perforated peptic ulcer disease carries a mortality rate of up to 30 percent, driven mainly by sepsis and multiorgan failure rather than the perforation itself.
- Prevention
Test and treat H. pylori: Test for and eradicate H.
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