A brief overview on perforated gastric ulcer

1. Peptic Ulcer Disease
By Parthevan Rajasingam

3. Definition
•A peptic ulcer is a mucosal defect which
penetrates the muscularis mucosae and
muscularis propria
•Produced by acid-pepsin aggression.

4. • Peptic Ulcers are chronic, usually solitary lesions:They occur in:
• Duodenum (80%)
• Stomach (19%)
• Duodenum and stomach (4%)
• Other sites (1%) where gastric acid can damage the mucosa (eg oesophagus,
gastroenterostomy, stoma, jejunum, Meckel’s diverticulum
• Predisposing factors for peptic ulceration includes:
• Helicobacter pylori
• Smoking and alcohol
• Drugs: NSAIDS and corticosteroids-both affect mucosal defense
• Stress: burns, major surgeries
• Gastric hypersecretion (e.g Zollinger-Ellison syndrome)

7. Presentation of noncomplicated PUD
The typical symptoms of noncomplicated PUD include episodic
burning pain in the epigastrium relieved by antacids, or
antisecretory agents.
A small proportion of patients will have vomiting, heartburn,
or intolerance to fatty foods. Patients with duodenal ulcers will
be more likely to have pain relieved by food intake than patients
with gastric ulcers.
Weight loss secondary to fear of food intake is more common
with gastric ulceration than with duodenal ulceration.
patients with ZES are more likely to present with diarrhea
as part of their symptomatology.
Physical examination in noncomplicated PUD is unreliable.

8. Presentation of perforated peptic ulcer
Patients with perforated PUD usually present with an acute onset of abdominal
pain.Often, they can tell you the exact time of the perforation.
The pain starts in the epigastrium but by the time
of presentation in the emergency department, it is generalized and associated with
diffuse peritonitis.
It is important to ascertain whether the patient has a history consistent with chronic
PUD, either by prior treatment, current medications or pre-existing symptoms of
noncomplicated disease.

9. Diagnosis of perforated peptic
ulcer disease
History and physical examination
Upright chest radiographs will show pneumoperitoneum
(“free air”) in 80–90% of the cases.
If pneumoperitoneum is identified on plain radiographs, there is
no need for further studies.
Ultrasound is less sensitive for detecting free air but could be
used to identify other indirect findings of perforation such as
free fluid and decreased peristalsis when the diagnosis remains
in question.
Computerized tomography (CT) scans are more sensitive
for detecting pneumoperitoneum than the other modalities
but should ideally be performed at least 6 h following the onset
of symptoms.
the use of oral contrast medium with CT scanning to identify
the site of perforation and the presence of ongoing leakage.

12. What are the potential complications of perforated
peptic ulcer?
• In most cases of perforation, gastric and duodenal content leaks into the
peritoneum.
• This content includes gastric and duodenal secretions, bile, ingested food, and
swallowed bacteria.
• The leakage results in peritonitis, with an increased risk of infection and abscess
formation.
• Subsequent third-spacing of fluid in the peritoneal cavity due to perforation and
peritonitis leads to inadequate circulatory volume, hypotension, and decreased
urine output.
• In more severe cases, shock may develop.

13. What are the potential complications of perforated
peptic ulcer?
• Abdominal distension as a result of peritonitis and
subsequent ileus may interfere with diaphragmatic
movement, impairing expansion of the lung bases.
• Eventually, atelectasis develops, which may compromise
oxygenation of the blood, particularly in patients with
coexisting lung disease.

14. Omental patch closure
Omental patch closure is a quick and simple procedure that is
very useful in perforated PUD.
It has long been the recommended treatment in patients with
multiple comorbidities, those that are
hemodynamically unstable and those
with exudative peritonitis.
It is not useful in Type IV gastric ulcers and may not be the
optimal treatment in a stable patient with a perforated Type I
gastric ulcer
Numerous authors in recent years have prospectively
investigated peptic ulcer recurrence rates after simple patch
closure and H. pylori eradication and have reported high success
rates

19. Highly selectiveVagotomy
HSV is a tedious but safe operation , that can be performed
laparoscopically,with minimal side effects.
It has a higher recurrent ulcer rate than the other procedures (10–20%).
It is not useful forType II orType III gastric ulcers or for complicated
PUD.

21. TruncalVagotomy
Truncal vagotomy and drainage procedure is very useful in
complicated ulcer disease.
Itreduces peak acid secretion by 50%.
Ithas a significant side effect profile and has a recurrent
ulcer rate of 10%.

22. .Truncal vagotomy

24. Vagotomy with antrectomy
Vagotomy with antrectomy is most effective at reducing acid secretion and has a
recurrence rate of 0–2%.
But, this operation has a 20% rate of post-gastrectomy
and post-vagotomy syndromes and has a significant associated mortality.
The mortality risk increases with patient comorbidities and with emergency surgery for
complicated PUD.
It should be avoided in hemodynamically unstable
paitents and those with extensive inflammation since the anastamosis may be
compromised.

27. Post-Operative Complications
• Problems around the anastomoses
• Obstruction
• Leaks
• Oesophagitis
• Bleeding
• Alkaline reflux gastritis and vomiting

28. • Problems due to vagus nerve transection
• Diarrhea
• Gastric atony
• Gastric Outlet Obstruction
• Gallstones
• Problems due to loss of stomach capacity and function
• Dumping
• Vitamin B12 deficiency and iron deficiency anemia
• Malnutrition

31. Take Home Message
• Most occur in patients with pre-existing dyspepsia
• 10% have no previous symptoms
• Classic presentation is with:
• Sudden onset epigastric pain
• Rapid generalisation of pain
• Examination shows peritonitis with absent bowel sounds
• 10% have an associated episode of melaena
• 10% have no demonstrable gas on an erect chest x-ray
• If diagnostic doubt then water soluble contrast enema may confirm perforation
• Can be associated with elevated serum amylase but not to same level as in pancreatitis

32. Management
•Most patients require surgery after appropriate
resuscitation
•Conservative management may be considered if
significant co-morbidity

33. ThankYou!