Gastroduodenal ulcer perforations have decreased in the last few years, largely due to the widespread adoption of medical therapies for peptic ulcer disease and decreasing incidence of helicobacter pylori infection in Western countries. However, ulcer disease is a still common emergency condition worldwide and is associated with mortality rates of up to 30%.
The main etiologic factors include use of non-steroidal anti-inflammatory drugs (NSAIDs), steroids, smoking, Helicobacter pylori (H. pylori) and a diet high in salt. All these factors have in common that they affect acid secretion in the gastric mucosa. Stress ulcers with perforation may occur in critically ill patients in intensive care, where the diagnosis may be obscured owing to lack of signs and symptoms in an unconscious or sedated patient.
Clinical signs and symptoms
- Severe, sudden-onset epigastric pain, which can become generalized
- Abdominal tenderness
- White blood cell
- Leucocyte shift to left (>75 %)
- C-reactive protein
Scores for mortality in patients with gastroduodenal perforation
|Age > 65||1|
|Comorbid active malign disease or AIDS||1|
|Comorbid liver cirrhosis||1|
|Perforation time on admission >24||1|
|Serum creatinine >1.47 mg/dl||2|
|Duration of peptic ulcer perforation > 24 h||1|
- Abdominal x-ray
- Abdominal free air
- Diffuse fluid
– Conservative treatment with a period of observation (intravenous antibiotics, nil per os and a nasogastric tube, anti-secretory and anti-acid medication and a water-soluble contrast imaging study to confirm a sealed leak) in patients with minimal or localized symptoms and in good clinical condition.
– Open or laparoscopic closure of the perforation using interrupted sutures with or without an omental pedicle on top of the closure.
If perforation occurs within 24 hours in patients without comorbidities post-operative antibiotic are not needed.
If perforation occurs over 24 hours antibiotic therapy for 3-5 days.
Empiric antibiotic regimens. Normal renal function
One of the following antibiotics
Amoxicillin/clavulanate 1.2-2.2 g 8-hourly
Ceftriaxone 2 g 24-hourly + Metronidazole 500 mg 6-hourly
Cefotaxime 2g 8-hourly + Metronidazole 500 mg 6-hourly
In patients with beta-lactam allergy
A fluoroquinolone-based regimen
Ciprofloxacin 400 mg 12-hourly + Metronidazole 500 mg 6- hourly