- Perforation is more common in duodenal ulcer
- Mortality is higher in gastric ulcer perforation
1. PERFORATED DUODENAL ULCER
Epidemiology/Etiology
- Most common in males between 35 -45 years old
- Anterior ulcer is more likely to perforate
- May be precipitated by steroids, NSAIDs, alcohol, antimalarials
Stages of perforation
Stage of chemical peritonitis
- After perforation, stomach contents escape into peritoneal cavity
- Acid causes chemical peritonitis – severe epigastric pain, vomiting, tenderness, guarding, rigidity, tachycardia, sweating
Stage of reaction (illusion)
- Peritoneum secretes a lot of fluid to neutralise the escaped content
- Pain temporarily reduced and the patient feels better
- Lasts for 6 hours
Stage of diffuse bacterial peritonitis
- Bacteria from GIT migrate from site of perforation causing diffuse peritonitis
Clinical features
- Initially, severe persistent epigastric pain
- Later there is pain on the right side of the abdomen – inflammatory fluid spills along the right paracolic gutter
- Eventually pain becomes generalised
- Pain often radiates to right scapular region
- Abdominal distension, guarding, rigidity
- Blumberg sign – tenderness and rebound tenderness all over abdomen
- Fever, vomiting, dehydration, oliguira
- Patient is toxic, with tachycardia, hypotension, tachypnea
- Obliteration of liver dullness – due to collection of escaped gas under the diaphragm
- Absence of bowel sounds
- Tenderness on rectal exam
- Terminal stage – oliguria, septicaemia, shock, multiple organ dysfunction
Investigations
- XR abdomen – gas under diaphragm, shown by
- Cupola sign – crescent shaped radiolucency under the diaphragm
- Football sign – collection of gas in the centre of the diaphragm
-
Inverted V sign – gas on either side of the falciform ligament
- US abdomen – free fluid and gas
- CT abdomen – rules out pancreatitis
- Blood urea, creatinine, total count, electrolytes
Treatment
- IV fluids – Ringer lactate, normal saline, dextrose saline
- Antibitoics – cefotaxime, metronidazole, amikacin
- Catheterisation
- Nasogastric tube
Surgery
- Emergency laparotomy through upper midline incision – infected fluid sucked out
- Graham patch – omental patch is used to cover the perforation due to its adhesive properties
- Peritoneal wash using saline
- Follow-up gastroscopy after 12 weeks
Dry perforation
- A perforated duodenal ulcer that is sealed by omentum
- Patient is ambulatory
- Vomiting is absent
- Rigidity confined to epigastrium and right hypochondrium
2. PERFORATED GASTRIC ULCER
- Ulcer in the lesser curvature near the antrum perforates most commonly
- Amount of gas escaped is more than in perforated duodenal ulcer
- Malignancy should always be suspected
- Mortality is high – 20%
- Distal gastrectomy including ulcer area – if patient is stable