Perforated peptic ulcer

Perforated peptic ulcer

Epidemiology

Despite the widespread use of gastric anti-secretory agents and eradication therapy, the incidence of perforated peptic ulcer has
changed little Previously, most patients were middle aged, with a ratio of 2:1 of men:women. With time, however, there has been a steady increase in the age of the patients suffering from this complication and an increase in the number of women affected, such that perforations now occur most commonly in elderly female patients. NSAIDs appear to be responsible for most of these perforations.
Clinical features
The classic presentation is instantly recognisable.The patient, who may have a history of peptic ulceration, develops sudden-onset, severe, generalised abdominal pain as a result of the irritant effect of gastric acid on the peritoneum. Although the contents of an acid-producing stomach are relatively low in bacterial load, bacterial peritonitis supervenes over a few hours, usually accompanied by a deterioration in the patient’s condition. Initially, the patient may be shocked with a tachycardia but a pyrexia is not usually observed until some hours after the event.The abdomen exhibits a board-like rigidity and the patient is disinclined to move because of the pain. The abdomen does not move with respiration. Patients with this form of presentation need an operation, without which they will deteriorate with a septic peritonitis.
This classic presentation of the perforated peptic ulcer is observed less commonly than in the past. Very frequently, the elderly patient who is taking NSAIDs will have a less dramatic presentation, perhaps because of the use of potent anti-inflammatory drugs. The board-like rigidity seen in the abdomen of younger patients may also not be observed and a higher index of suspicion is necessary to make the correct diagnosis. In other patients, the leak from the ulcer may not be massive. They may present only with pain in the epigastrium and right iliac fossa as the fluid may track down the right paracolic gutter.
Sometimes perforations will seal as a result of the inflammatory response and adhesion within the abdominal cavity, and so the perforation may be self-limiting. All of these factors may combine to make the diagnosis of perforated peptic ulcer difficult.
By far the most common site of perforation is the anterior aspect of the duodenum. However, the anterior or incisural gastric ulcer may perforate and, in addition, gastric ulcers may perforate into the lesser sac, which can be particularly difficult to diagnose. These patients may not have obvious peritonitis.