Emergency Medicine
GI Consult: Perforated Peptic Ulcer
Better medical management has reduced the incidence of peptic ulcer disease (PUD), but the burden of the disease and its complications has shifted toward the elderly—who may have only mild symptoms and no PUD history whatsoever when they present with perforation.
By Nasir Hussain, MD, and Bernard Karnath, MD
Dr. Hussain and Dr. Karnath are assistant professors in the division of general internal medicine at the University of Texas Medical Branch in Galveston.
What is the typical presentation in patients with perforated peptic ulcer?
Studies have shown that of patients presenting with complicated peptic ulcer disease (PUD), nearly half have no history of the disease. On endoscopy, unsuspected ulcers have been found in people who were taking nonsteroidal anti-inflammatory drugs (NSAIDs). In younger patients, severe abdominal pain, which may radiate to the shoulder, may be the initial presentation.
In elderly patients, signs and symptoms may be minimal. In one
series that looked at perforated ulcer in patients over age 60,
84% had only mild abdominal pain. Other reported symptoms were dyspepsia,
anorexia, nausea, and vomiting. Severe abdominal pain was present
in only 16% of patients in this series. Duration of symptoms ranged
from 4 hours to 10 days. In this series, most patients had abdominal
tenderness, with 66% having classic signs of peritonitis. About
6% of patients had no abdominal findings.
What role do x-rays and laboratory tests play in the diagnosis of perforated peptic ulcer?
Plain x-rays of the abdomen with the patient in the upright position
have been used in diagnosing perforated ulcer. However, several
case series have shown that in 30% to 50% of patients, the x-ray
may be negative for free air, particularly in the elderly. A left
lateral decubitus film has been shown to be most sensitive in detecting
pneumoperitoneum. Placing the patient in the upright or left lateral
decubitus position for 10 minutes before taking the x-ray may help
detect the condition. Similarly, use of water-soluble contrast medium
with an upper gastrointestinal tract series or computed tomography
scan may increase the diagnostic yield.
How common is perforated peptic ulcer?
Thanks to effective medical management with H2 blockers and proton pump inhibitors and the eradication of Helicobacter pylori, the incidence of PUD and the hospitalization rate for treatment have decreased. However, the rate of complicated PUD appears to be unchanged.
For example, there was a 39.3% decrease in the hospitalization
rate for PUD at Massachusetts General Hospital during the years
after the introduction of cimetidine. During that same period of
time, however, the incidence of perforated peptic ulcer stayed the
same. Also, there has been no change in the number of acute surgical
procedures performed for complicated PUD. The age distribution for
these procedures has shifted toward the elderly—particularly
elderly women.
What are the risk factors for PUD and perforation?
In recent years, patients presenting with perforated PUD have tended to be elderly and chronically ill and taking one or more ulcerogenic drugs. Several studies have shown the mean age of such patients to be more than 60 years.
A history of ulcer disease or symptoms of an ulcer is important.
In one study, one-third of patients had a history of PUD and 32%
of patients who presented with perforation were taking H2
blockers, antacids, or both. A significant percentage of patients
has a history of smoking, alcohol abuse, and postoperative stress.
Does H. pylori infection play a role in perforated peptic ulcer?
While H. pylori is well recognized as a causative factor
in PUD, its exact role in cases of perforated ulcer has not been
established. Chowdhry reported on a series of 45 patients, of which
15 had a perforated duodenal ulcer; none of these 15 patients had
evidence of H. pylori infection. Reinbach and colleagues
also concluded that there was no clear association between H.
pylori infection and duodenal ulcer perforation. In their series
of 80 patients with acute perforated duodenal ulcer, 47% of patients
had evidence of H. pylori infection, which was similar to
the 50% rate in the control group. In contrast, another study by
Ng suggested that H. pylori played an important role in the
etiology of non-NSAID-related ulcers.
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.
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.
Do outcomes in perforated peptic ulcer differ in elderly patients?
There has been a relative increase in PUD among elderly patients, which may be related to higher use of ulcerogenic drugs. Generally, this group of patients requires emergency surgery, and many of them experience postoperative complications. Higher morbidity is due to various factors. Often, there is a delay in diagnosing complicated peptic ulcer, resulting in a delay in definitive treatment. Elderly patients are likely to have other medical problems, which increases preoperative risk and contributes to the higher rate of postoperative complications.
In one series of cases reported by Werbin, a 50% mortality rate was found in patients over age 70 with acute perforation of a duodenal ulcer who presented more than 24 hours after onset of symptoms. In this same series, patients who presented early and were operated on within 24 hours of onset of symptoms had 0% mortality.
In elderly patients with perforation, the ratio of female patients
is higher. A study by Kubler and colleagues found that 57% of patients
age 60 and older with perforated peptic ulcer were women. In this
same study, 89% of patients presented with perforated duodenal ulcer.
What are the treatment options for perforated peptic ulcer?
Principles of conservative treatment include nasogastric suction, pain control, antiulcer medication, and antibiotics. Nonsurgical treatment has been recognized for a long time. The first major series was published by Taylor nearly 50 years ago; it reported a mortality rate of 11% in the nonsurgical treatment group, compared to 20% in the surgical group. Since then, because of improvements in operative and postoperative care, the mortality rate with surgical treatment of perforated peptic ulcer has decreased to about 5%.
Croft and colleagues compared surgical and nonsurgical treatment of perforated peptic ulcer in a randomized trial and concluded that an initial period of nonoperative treatment may be prudent except in patients over age 70. Careful observation is necessary during this period, but it may obviate the need for emergency surgery in 70% of patients. The mortality rate in this study was 5% in each group. Two-thirds of the patients over age 70 required emergency surgery.
Several surgical techniques have been employed in the treatment
of perforated peptic ulcer. These include conservative surgery with
patching of the ulcer, peritoneal lavage, and antiulcer medication,
and definitive surgery with truncal vagotomy, highly selective vagotomy,
or partial gastrectomy. Some studies have reported a high rate of
ulcer recurrence in the conservative surgery group and have recommended
definitive ulcer surgery for perforation.
What measures can be taken to decrease the risk of peptic ulcer disease and perforation?
Nearly one third of patients presenting with perforated peptic
ulcer take NSAIDS. Therefore, decreasing NSAID use is an important
preventive measure. For patients who must take NSAIDs, concomitant
use of a proton pump inhibitor or misoprostol may decrease the risk
of ulcer formation. Smoking cessation and abstinence from alcohol
should also decrease the risk of complicated PUD. Maintaining a
high index of suspicion for the disease, particularly in elderly
patients, will help clinicians diagnose PUD early in its course,
thus reducing morbidity and mortality.
Suggested Reading
Chowdhary SK, et al.: Helicobacter pylori infection in patients with perforated duodenal ulcer. Trop Gastroenterol 19(1):19, 1998.
Crofts TJ, et al.: A randomized trial of nonoperative treatment for perforated peptic ulcer. N Engl J Med 320(15):970, 1989.
Gunshefski L, et al.: Changing patterns in perforated peptic ulcer disease. Am Surg 56(4):270, 1990.
Kane E, et al.: Perforated peptic ulcer in the elderly. J Am Geriatr Soc 29(5):224, 1981.
Ng EK, et al.: High prevalence of Helicobacter pylori infection in duodenal ulcer perforations not caused by non-steroidal anti-inflammatory drugs. Br J Surg 83(12):1779, 1996.
Park KG, et al.: The management of perforated duodenal ulcer. Trop Gastroenterol 8(3):150, 1987.
Reinbach DH, et al.: Acute perforated duodenal ulcer is not associated with Helicobacter pylori infection. Gut 34(10):1344, 1993.
Taylor H: Aspiration treatment of perforated ulcer. Lancet 1:7, 1951.
Werbin N, et al.: Perforated duodenal ulcer in the elderly patient. Can J Surg 33(2):143, 1990.
Windsor JA and Hill AG: The management of perforated duodenal ulcer. N Z Med J 108(994):47, 1995.