Acute perforation is a common complication of gastric and duodenal ulcers. It has a sudden onset, progresses rapidly, and is often severe, requiring urgent management.
Etiology and Pathology
Gastric ulcer perforations commonly occur along the lesser curvature of the stomach, while duodenal ulcer perforations are often found on the anterior wall of the duodenal bulb. Perforation allows acidic gastric contents to spill into the abdominal cavity, leading to chemical peritonitis. The irritation of the peritoneum results in severe abdominal pain and exudation. Bacterial proliferation begins 6–8 hours after the perforation, eventually causing purulent peritonitis, commonly involving mixed infections with Escherichia coli and Streptococcus species. Significant fluid loss, combined with the absorption of bacterial toxins, may lead to shock. Posterior wall duodenal ulcer perforations can result in localized adhesion and encapsulation, forming chronic penetrating ulcers.
Clinical Manifestations
Patients often have a history of peptic ulcer disease. Before perforation, ulcer symptoms may worsen, or precipitating factors such as physical exhaustion, psychological stress, or a history of nonsteroidal anti-inflammatory drug (NSAID) or corticosteroid use may be present. Patients typically experience sudden, knife-like, severe upper abdominal pain, which quickly spreads throughout the abdomen.
Patients may exhibit pallor, cold sweating, and often nausea or vomiting. Severe cases can involve symptoms of shock, including reduced blood pressure. Clinical presentation varies depending on the size, location, and timing of the perforation, whether the stomach is empty, and the patient’s age and overall condition.
At the time of examination, patients may show signs of distress, adopt a flexed position, and avoid movement. Abdominal (diaphragmatic) breathing is reduced or absent, and bowel sounds are diminished or absent. Generalized abdominal tenderness and rebound tenderness are prominent, and abdominal muscles are tense, forming a "board-like abdomen." Percussion may reveal reduced or absent liver dullness, with shifting dullness potentially present. Laboratory tests typically show elevated white blood cell counts. On an upright abdominal X-ray, crescent-shaped free air beneath the diaphragm is visible, and abdominal CT scans may also detect free air in the abdominal cavity.
Diagnosis and Differential Diagnosis
A history of peptic ulcer disease, sudden knife-like severe upper abdominal pain, along with signs such as a "board-like abdomen" and radiological evidence of free air under the diaphragm, typically confirm the diagnosis. However, elderly, debilitated patients or those with small perforations occurring on an empty stomach may present atypical symptoms and abdominal findings, requiring thorough history-taking and careful physical examination for differentiation.
Differentiation involves ruling out the following conditions:
Acute Cholecystitis
This is characterized by colicky pain in the right upper abdomen that worsens intermittently, with pain radiating to the right shoulder. An enlarged, tender gallbladder may be palpable. When gangrene and perforation occur, diffuse peritonitis may develop, but X-ray findings reveal no free air under the diaphragm. Ultrasound may indicate cholecystitis or gallstones.
Acute Pancreatitis
The onset of abdominal pain in acute pancreatitis is typically less abrupt than ulcer perforation, with a gradual progression from mild to severe. Pain is often located in the upper abdomen and radiates to the back, with relatively mild muscle tension. Serum, urine, and peritoneal fluid amylase levels are markedly elevated. X-rays do not reveal free air under the diaphragm, and CT or ultrasound may show pancreatic swelling and surrounding exudation.
Acute Appendicitis
After an ulcer perforation, digestive fluid may flow along the right paracolic gutter to the lower right abdomen, causing localized pain and peritonitis signs, which can mimic acute appendicitis. However, symptoms of appendicitis are generally milder, with localized findings in the lower right abdomen, absence of board-like rigidity, and no free air under the diaphragm on X-rays.
Treatment
Surgical closure of the perforation is the primary treatment for acute gastric and duodenal ulcer perforations. Postoperatively, standard medical treatment is needed to eradicate the ulcer. Definitive surgery, such as partial gastrectomy, may be considered to address both the perforation and the ulcer.
Whether performed via laparoscopy or open surgery, the perforation is sutured along the longitudinal axis of the stomach or duodenum. Full-thickness sutures are placed, passing through one side of the perforation and exiting on the opposite side. The number of sutures depends on the size of the perforation, typically three.
Specific considerations during perforation closure include:
- Suspected malignancy may warrant pathological examination of tissue from the perforation site.
- Full-thickness suturing should avoid involving the opposite gastric or intestinal wall.
- In cases of significant edema at the perforation site, suture tension should be moderate to prevent tissue cutting.
- If necessary, the repaired site can be reinforced by covering it with a free omental graft, which is then fixed in place.
Patients with small, empty-stomach perforations, shorter onset times, and mild peritoneal contamination may be managed non-surgically. This approach includes gastrointestinal decompression, intravenous hydration, intravenous antibiotics, and medications to inhibit gastric acid secretion.