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Internal Medicine

Perforated peptic ulcer (PPU)

Serious complication of peptic ulcer disease (PUD).

Serious complication of peptic ulcer disease (PUD).

  • Surgical emergency

Etiology

Peptic ulcer disease (PUD) risk factors:

Peptic ulcers are circumscribed loss of epithelial tissue of the gastro-intestinal tract due to corrosive effect of the gastric juice. They occur when there is a breech in the normal mucosal barrier, when excessive acid is produced, or normal gastric juice comes in contact with a mucosa not adapted to its effects.
Mechanisms and factors in pathogenesis of perforated peptic ulcer: (A) an imbalance between between hostile and protective factors start the ulcerogenic process, and (B) although many cotributors are known, helicobacter infection and use of non-steroidal anti-inflammatory drugs appear of importance in disturbing the protective mucosal layer and (C) expose the gastric epithelium to acid. Several additional factors (D) may augment the ulcerogenic process (such as smoking, alcohol and several drugs) that lead to erosion (E). Eventually, the serosal lining is breached (F), and when perforated, the stomach content, including acidic fluid, will enter the abdominal cavity giving rise to intense pain, local peritonitis that may become generalized and eventually lead to a systemic inflammatory response syndrome and sepsis with the risk of multiorgan failure and mortality. | Søreide, K., Thorsen, K., Harrison, E. M., Bingener, J., Møller, M. H., Ohene-Yeboah, M., & Søreide, J. A. (2015). Perforated peptic ulcer. Lancet (London, England), 386(10000), 1288–1298. https://doi.org/10.1016/S0140-6736(15)00276-7

Only about a third of patients with PPU have a previous history of or current known peptic ulcer at time of diagnosis.

Pathophysiology

The ulcerogenesis involves infection (H. pylori), mucosal barrier injury (e.g. use of drugs) and increased acid-production.

Presentation

Classic triad: Hallmark of perforated peptic ulcer

In 1843 Edward Crisp stated that “the symptoms are so typical, I hardly believe that it is possible that anyone can fail in making a diagnosis”
  1. Sudden onset of abdominal pain
  2. Tachycardia
  3. Abdominal rigidity

Other features:

Perforated peptic ulcer (PPU) manifests as a sudden, severe, piercing epigastric pain followed by rapidly developing symptoms of diffuse peritonitis
  • Abdominal distention
  • Vomiting
  • Nausea
  • Severe dyspepsia
  • Constipation
  • Fever

Complications

Hourglass stricture:

A stomach with a central narrowing, dividing it into two cavities, cardiac and pyloric usually due to contracted scar tissue around an ulcer.
Intra-thoracic location of stomach’s fundus and part of stomach’s body with a hourglass stenosis in the esophageal hiatus. | Paraesophageal Hernia as a Cause of Chronic Asymptomatic Anemia in a 6 Years Old Boy; Case Report and Review of the Literature – Scientific Figure on ResearchGate. Available from: https://www.researchgate.net/figure/Intra-thoracic-location-of-stomachs-fundus-and-part-of-stomachs-body-with-a-hourglass_fig2_320218867 [accessed 3 Mar, 2021]

Diagnosis

An urgent erect chest X-ray and serum amylase/lipase is basic essential test in a patient with acute upper abdominal pain.

Erect chest X-ray:

  • Free air under diaphragm (75%)
Erect chest X-ray image of the same patient with equivocal free air under the right hemidiaphragm. | Chung, K. T., & Shelat, V. G. (2017). Perforated peptic ulcer – an update. World journal of gastrointestinal surgery, 9(1), 1–12. https://doi.org/10.4240/wjgs.v9.i1.1

Abdominal X-ray:

Abdominal X-ray performed in patients with suspected PPU when chest X-ray shows free air under the diaphragm
  • Rigler’s sign: Gas on both sides of the bowel wall
  • Football sign: Large volume of free gas resulting in a large round black area
  • Gas outlining soft tissue structures (such as liver edge or falciform ligament)

CT scan:

Computerized tomography scan shows free air under the diaphragm with peri-hepatic free fluid. | Chung, K. T., & Shelat, V. G. (2017). Perforated peptic ulcer – an update. World journal of gastrointestinal surgery, 9(1), 1–12. https://doi.org/10.4240/wjgs.v9.i1.1

Boey’s score:

Used for risk stratification for mortality and morbidity in cases of PPU
Boey’s score | Prabhu, V., & Shivani, A. (2014). An overview of history, pathogenesis and treatment of perforated peptic ulcer disease with evaluation of prognostic scoring in adults. Annals of medical and health sciences research, 4(1), 22–29. https://doi.org/10.4103/2141-9248.126604

Management

Early diagnosis, prompt resuscitation and urgent surgical intervention are essential to improve outcomes. Management is quite challenging as patients present late; with septicaemia, fluid and electrolyte derangements, shock and/or systemic inflammatory response syndrome.

Exploratory laparotomy and Graham (omental) patch repair:

GOLD STANDARD

Gastrectomy:

Recommended in large/malignant ulcer to enhance outcomes; however the outcomes of patients treated with gastric resections remain inferior.

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