Peptic Ulcer Perforated


Article Author:
Evan Stern
Kavin Sugumar


Article Editor:
Jonathan Journey


Editors In Chief:
Kranthi Sitammagari
Mayank Singhal


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
6/5/2019 5:14:26 PM

Introduction

Peptic ulcer disease refers to an insult to the mucosa of the upper digestive tract resulting in ulceration that extends beyond the mucosa and into the submucosal layers. Peptic ulcers most commonly occur in the stomach and duodenum though they can occasionally be found elsewhere (esophagus or Meckel's diverticulum).[1] While the majority of peptic ulcers are initially asymptomatic, clinical manifestations range from mild dyspepsia to complications including gi bleeding, perforation, and gastric outlet obstruction.  This article will provide a brief overview of peptic ulcer disease with a primary focus on the complexity of perforated peptic ulcer from an Emergency Medicine perspective.

Etiology

Peptic ulcer disease was traditionally thought to be the result of increased acid production, dietary factors, and even stress. However, Helicobacter Pylori infections and the use of nonsteroidal anti-inflammatory drugs (NSAIDs) including low-dose aspirin are now the more popular etiologies leading to the development of peptic ulcer disease. [1][2][3]. Other factors such as smoking and alcohol may also contribute. 

Epidemiology

The lifetime prevalence of peptic ulcer disease is declining and is currently estimated to be between 5-10%. It tends to be less prevalent in developed countries. Just as there has been a downward trend in the overall incidence of peptic ulcer disease, so too has there been a decline in the overall rate of complications. [1]  Even though the overall incidence of complications is declining, complications including bleeding, perforation, and obstruction are responsible for nearly 150,000 hospitalizations annually in the United States. [4] Upper GI bleeding is the most common complication of peptic ulcer disease. The next most common complication is a perforation.  The annual incidence of upper gi bleeding secondary to a peptic ulcer is estimated to be between 19 to 57 cases per 100,000 individuals. In comparison, ulcer perforation is expected to be 4 to 14 cases per 100,000 individuals. Advanced age is a risk factor as 60% of patients with PUD are older than 60. Infections with Helicobacter Pylori and the use of nonsteroidal anti-inflammatory drugs (NSAIDs) are each identified as risk factors for the development of bleeding ulcers and peptic ulcer perforation.[5]

Pathophysiology

The ulcerogenic process occurs as a result of damage to the protective mucosal lining of the stomach and duodenum. H pylori infections and the use of NSAIDs and low dose aspirin are known to damage the mucosal lining. The cost to the mucosal lining in the setting of an H pylori infection is the result of both bacterial factors and second the host's inflammatory response. In the case of NSAID (and aspirin) use, mucosal damage is secondary to inhibition of cyclooxygenase 1 (COX-1) derived prostaglandins which are important in maintaining mucosal integrity.[1] Once the mucosal layer is disrupted, the gastric epithelium is exposed to acid, and the ulcerative process ensues. If the process continues, the ulcer deepens reaching the serosal layer. A perforation occurs once the serosal layer is breached at which point the gastric contents are released into the abdominal cavity.  [6]

History and Physical

Although approximately 70% of patients with peptic ulcer disease may initially be asymptomatic, most patients with a perforated peptic ulcer will present with symptoms. Special populations such as the extremes of age (young or elderly), immunocompromised and those with altered level of consciousness may prove to be more challenging in obtaining a reliable history. When an honest account is obtainable, a detailed history may identify other symptoms that may have been present before ulcer perforation. The most common symptom in patients with peptic ulcer disease is dyspepsia or upper abdominal pain. This pain may be vague upper abdominal discomfort or it may be localized to either right upper quadrant, left upper quadrant, or epigastrium. Gastric ulcers may be worsened by food whereas pain from a duodenal ulcer may be delayed 2-5 hours after eating. Patients who are experiencing bleeding from a peptic ulcer may complain of nausea, hematemesis or melanotic stools. Some patients may report bright red blood per rectum or maroon colored stool if the upper gi bleeding is brisk. 

Patients with peptic ulcer perforation typically will complain of sudden and severe pain epigastric pain. Pain while initially localized, quickly becomes more generalized in location. Patients may present with symptoms of lightheadedness or syncope secondary to hypotension from blood loss or SIRS/Sepsis. After several hours, abdominal pain may temporarily improve though it is still reproducible by movement. If there is a delay in seeking medical attention and the perforation is not walled off, patients are likely to experience increasing abdominal distension along with clinical manifestations of systemic inflammatory response syndrome (SIRS)/ sepsis.[4][7]

A thorough physical examination should be done on all patients complaining of abdominal pain. Those with a perforated peptic ulcer are likely to have diffuse abdominal tenderness that progresses to guarding and rigidity. Rectal examination may demonstrate positive guaiac stools. Patients are likely to be tachycardic and may be hypotensive. They may be febrile and have mental status changes if there has been a delay in presentation.[4]

Evaluation

The evaluation of a patient in whom perforated peptic ulcer is suspected should be done quickly as this is a sick patient population in which mortality increases significantly with time. Even if a perforated peptic ulcer is the suspected cause due to history and physical examination, diagnostic studies should be obtained to confirm the diagnosis and to rule out other possible etiologies. Typical workup includes labs and imaging studies. Standard labs should include CBC, chemistry panel, liver function tests, coags, and lipase. Blood type and screening should be done. A set of blood cultures and lactic acid should be done on patients meeting SIRS criteria. Lactic acid should also be performed if entertaining the diagnosis of mesenteric ischemia. A urinalysis can be done in patients with similar pain or those with urinary symptoms. Imaging studies should be obtained once the patient is stabilized. While plain abdominal films or chest x-ray may demonstrate free air, CT scan of the abdomen and pelvis will have the highest yield diagnostically. No IV or oral contrast is required to illustrate pneumoperitoneum, but IV contrast may be used in the patient with undifferentiated abdominal pain/peritonitis. 

Treatment / Management

Perforated peptic ulcers are life-threatening conditions with a mortality rate that approaches 30%. Early surgery and aggressive management of sepsis are mainstays of therapy. [6]  An initial emergent surgery consultation is required in all patients with peritonitis even before definitive diagnosis. Patients should be resuscitated with IV fluids and analgesics. Administration of early IV antibiotics should be considered, especially to patients presenting with SIRS criteria. Once the diagnosis of peptic ulcer perforation is made, a nasogastric tube should be placed, an IV proton pump inhibitor should be administered, IV antibiotics should be given, and a stat surgical consult should be obtained. Then the decision can be made regarding whether the patient will require surgery. 

Sepsis accounts for approximately half of all mortalities in the setting of perforated peptic ulcers.  [6] Given the high prevalence of sepsis and its associated mortality, antibiotics should be administered to all in patients with perforated peptic ulcer. Antibiotics should be broad spectrum and cover gram-negative rods and anaerobes. Combination of a third-generation cephalosporin and metronidazole is a reasonable choice as is monotherapy with a combination beta-lactam/beta-lactamase inhibitor (i.e., ampicillin-sulbactam, piperacillin-tazobactam).[8]

Intravenous Proton Pump Inhibitors help bleeding cessation and facilitate healing, but efficacy in perforated ulcers has not been established. That said, IV PPI administration should be given that a neutral pH aids in maintaining platelet aggregation and hence should promote a more rapid sealing of perforated ulcers.[1][9]

The mainstay treatment for a perforated peptic ulcer is early operative intervention as mortality significantly increases with surgical delay. [10] Surgery will typically consist of a peritoneal lavage followed by an interrupted sutured closure of the perforated ulcer followed by an omental patch. This procedure can be done by open approach or laparoscopically as there have been no significant differences in terms of mortality or clinically significant outcomes when comparing the two methods. A select number of patients may be chosen to forego surgery in favor of medical treatment alone. This option is a decision that would be made by the surgical consultant and would be limited to patients < 70 years old with early presentation (<24 hours), mild/localized symptoms, and in stable condition.[6][9]

Differential Diagnosis

Differential diagnosis includes but is not limited to the following:

  • AAA
  • Acute Coronary Syndrome
  • Aortic Dissection
  • Appendicitis
  • Boerhaave's Syndrome
  • Cholecystitis
  • Cholelithiasis 
  • Choledocholithiasis
  • Diverticulitis
  • Duodenitis
  • Esophagitis
  • Foreign Body Ingestion
  • Gastritis
  • Hepatitis
  • Hernia
  • Mesenteric Ischemia
  • Neoplasm
  • Nephrolithiasis
  • Pyelonephritis
  • Small Bowel Obstruction
  • Ureterolithiasis
  • Volvulus

Prognosis

Mortality rate 10x higher than that seen with acute appendicitis or cholecystitis. Though bleeding is more common complication than perforation (6:1), the mortality rate is 5-fold higher with a perforated peptic ulcer compared with bleeding peptic ulcer. [6] The estimated 30-day mortality rate with perforation is 24%.[5] Patients with comorbidities or those older than 65 have a worse prognosis. Similarly, patients who have a delayed presentation or have a shock on initial presentation also have increased mortality. [5]

Complications

Complications of untreated peptic ulcer perforation include hypovolemia, SIRS, sepsis, abscess formation, gastrocolic fistula formation.

Enhancing Healthcare Team Outcomes

Managing a patient with a perforated peptic ulcer can be challenging given the morbidity and mortality associated with the disease. Hence it requires a multidisciplinary approach to maximize the chances of a favorable outcome. Diagnosis relies on suspicion of the underlying disorder. This treatment begins with the nurse triaging the patient and continues with the emergency medicine provider. Once suspected, resuscitative measures must be initiated while diagnostic studies are being obtained. This takes a coordinated effort between the ED provider and staff members of nursing, pharmacy, and radiology departments. Once the diagnosis is made, further communication is required between the ED provider and the on-call surgeon. Interprofessional communication is central to an expedited workup and treatment with the ultimate goal of getting the appropriate patient to the operating room promptly as surgical delay has been related to mortality. 


  • Image 8592 Not availableImage 8592 Not available
    Image courtesy S Bhimji MD
Attributed To: Image courtesy S Bhimji MD

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Peptic Ulcer Perforated - Questions

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An 85-year-old male is brought to the emergency department with complaints of acute-onset abdominal pain for the last 3 hours. He has pain throughout the abdomen along with abdominal fullness. He also had one episode of emesis and has passed flatus in the morning. He is a chronic smoker and alcoholic for the past 20 years. His vital signs include a temperature of 100.3 degrees Fahrenheit, the pulse rate: 115/minute, respiration 28/minute, and blood pressure 90/60 mm of Hg. Abdominal exam shows diffuse tenderness and rigidity. X-ray of the abdomen (standing) shows free air beneath the diaphragm. The patient is decided to be taken for surgery and pathology is found to be located in the lesser curvature of the stomach. Which of the following is required for this condition in this patient?



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A 62-year-old male presents to the emergency department with a 6-hour history of sudden onset, severe abdominal pain. He reports a 3-month history of epigastric pain after meals, for which he has been taking over-the-counter antacids. His vital signs include a temperature of 38.1C, pulse 120 beats/min, respiratory rate 22/min, and blood pressure 100/50 mmHg. On exam, bowel sounds are absent, and the abdomen is rigid with involuntary guarding. Plain films show air under the diaphragm. What is the most likely diagnosis?



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An 80-year-old female is brought to the emergency department with acute generalized abdominal pain. She has a history of rheumatoid arthritis and is taking methotrexate and prednisone. Vital signs show temperature of 37 degrees C, pulse 110 bpm, respiration 22, and blood pressure 80/40 mm Hg. Abdominal exam shows diffuse tenderness. Plain radiographs show free air beneath the diaphragm. CBC shows WBC of 32,000/microliter with 95% PMNs and hemoglobin of 10 g/dL. The patient agrees to surgery. Which of the following is a contraindication to a laparoscopic approach?



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A 43-year-old male who is a chronic alcoholic is brought to the emergency department with symptoms of acute onset, severe abdominal pain. The pain started 2 hours back and is unbearable and continuous in nature, associated with abdominal distension. He does not report any episode of vomiting and has passed flatus previous morning. His vital signs include a temperature of 100 degrees Fahrenheit; pulse rate: 120 beats/min; respiratory rate: 22/min, and blood pressure: 100/50 mmHg. During the examination, he has a bout of hematemesis. His blood pressure falls to 80/55 mm of Hg and he becomes pale and semi-conscious. He is started on bolus Ringer lactate and re-examined. His bowel sounds are absent, and the abdomen is rigid with involuntary guarding. Plain films show air under the diaphragm. Which of the following is the most common source of bleeding in this patient?



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A 64-year-old male is brought to the emergency department with sudden-onset abdominal pain. He has pain all over the abdomen along with abdominal distension. He also had two episodes of vomiting and has not passed stools since last evening. He works in a call center with erratic work hours in the night and he is forced to take 5-7 cups of coffee to keep himself awake. He also admits to having spicy food since childhood. His vital signs include a temperature of 99.8 degrees Fahrenheit, the pulse rate: 110/minute, respiration 26/minute, and blood pressure 80/40 mm of Hg. Abdominal exam shows diffuse tenderness. X-ray of the abdomen (standing) shows free air beneath the diaphragm. Which of the following locations could be the site of the pathological insult with least malignant potential in this patient?



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A 46-year-old male presents with epigastric pain that worsened today. He has had mild discomfort for the last month in the same area, worsened with eating. He drinks 6 beers a day and does not see a medical provider. His WBC is 16,000 cells/mm3, and other labs are normal. His heart rate is 110 beats/min, BP is 145/85 mmHg, and respiratory rate is 20 breaths/min. An abdominal x-ray series shows free air under bilateral diaphragms. What is the most likely diagnosis?



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Peptic Ulcer Perforated - References

References

Lanas A,Chan FKL, Peptic ulcer disease. Lancet (London, England). 2017 Aug 5;     [PubMed]
Gisbert JP,Legido J,García-Sanz I,Pajares JM, Helicobacter pylori and perforated peptic ulcer prevalence of the infection and role of non-steroidal anti-inflammatory drugs. Digestive and liver disease : official journal of the Italian Society of Gastroenterology and the Italian Association for the Study of the Liver. 2004 Feb;     [PubMed]
Kavitt RT,Lipowska AM,Anyane-Yeboa A,Gralnek IM, Diagnosis and Treatment of Peptic Ulcer Disease. The American journal of medicine. 2019 Jan 3;     [PubMed]
Lau JY,Sung J,Hill C,Henderson C,Howden CW,Metz DC, Systematic review of the epidemiology of complicated peptic ulcer disease: incidence, recurrence, risk factors and mortality. Digestion. 2011;     [PubMed]
Kempenich JW,Sirinek KR, Acid Peptic Disease. The Surgical clinics of North America. 2018 Oct;     [PubMed]
Søreide K,Thorsen K,Harrison EM,Bingener J,Møller MH,Ohene-Yeboah M,Søreide JA, Perforated peptic ulcer. Lancet (London, England). 2015 Sep 26;     [PubMed]
Krobot K,Yin D,Zhang Q,Sen S,Altendorf-Hofmann A,Scheele J,Sendt W, Effect of inappropriate initial empiric antibiotic therapy on outcome of patients with community-acquired intra-abdominal infections requiring surgery. European journal of clinical microbiology     [PubMed]
Surapaneni S,S R,Reddy A VB, The Perforation-Operation time Interval; An Important Mortality Indicator in Peptic Ulcer Perforation. Journal of clinical and diagnostic research : JCDR. 2013 May;     [PubMed]
Satoh K,Yoshino J,Akamatsu T,Itoh T,Kato M,Kamada T,Takagi A,Chiba T,Nomura S,Mizokami Y,Murakami K,Sakamoto C,Hiraishi H,Ichinose M,Uemura N,Goto H,Joh T,Miwa H,Sugano K,Shimosegawa T, Evidence-based clinical practice guidelines for peptic ulcer disease 2015. Journal of gastroenterology. 2016 Mar;     [PubMed]
Møller MH,Adamsen S,Thomsen RW,Møller AM, Preoperative prognostic factors for mortality in peptic ulcer perforation: a systematic review. Scandinavian journal of gastroenterology. 2010 Aug;     [PubMed]
Rosenstock S,Jørgensen T,Bonnevie O,Andersen L, Risk factors for peptic ulcer disease: a population based prospective cohort study comprising 2416 Danish adults. Gut. 2003 Feb;     [PubMed]
Chernyshev VN,Aleksandrov IK, [Classification of stomach ulcers and choice of the surgery method]. Khirurgiia. 1992 Sep-Oct;     [PubMed]
Lv SX,Gan JH,Ma XG,Wang CC,Chen HM,Luo EP,Huang XP,Wu SH,Qin AL,Ke-Chen,Wang XH,Wei-Sun,Li-Chen,Ying-Xie,Hu FX,Dan-Niu,Walia S,Zhu J, Biopsy from the base and edge of gastric ulcer healing or complete healing may lead to detection of gastric cancer earlier: an 8 years endoscopic follow-up study. Hepato-gastroenterology. 2012 May;     [PubMed]
Amorena Muro E,Borda Celaya F,Martínez-Peñuela Virseda JM,Borobio Aguilar E,Oquiñena Legaz S,Jiménez Pérez FJ, [Analysis of the clinical benefits and cost-effectiveness of performing a systematic second-look gastroscopy in benign gastric ulcer]. Gastroenterologia y hepatologia. 2009 Jan;     [PubMed]

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