The hole and the patch should be commensurateThomas Jefferson
We have already encountered the peptic ulcer disease. However, we have only seen one side of the coin, the bleeding, but not the other, the perforation.
Last time, we have skipped the usual introduction to the disease.
The peptic ulcer disease is the consequence of the harmful action of the gastric acids to the gastroduodenal mucosa. If this action is protracted in time, it will result in mucosal erosion, thus exposing the underlying tissues to the digestive action of gastro-duodenal secretions. This may lead in 10-20% of cases to complications (i.e. perforation and bleeding), with bleeding being 6-fold more common than perforation.
Risk factors are well known and are Helicobacter pylori infection, nonsteroidal anti-inflammatory drugs use, alcohol consumption, and smoking.
The complications may involve the stomach (40%) or the duodenum (60%), and, usually, the gastric ulcers are bigger than the others.
Patients with a perforated peptic ulcer usually complain about the sudden onset of upper abdominal pain, nausea/vomiting, fever, and peritonism.
On arrival, patients need fluids, pain killers, proton pump inhibitors (read our previous post for the correct protocol), and a nasogastric tube (NGT).
In the case of patients in shock, extensive resuscitation may be required. Endpoints of resuscitation should be a mean arterial pressure (MAP) ≥65 mmHg, urine output ≥0.5 mL/kg/h, and lactate within normal limits.
At this point, it is possible to stratify the patients’ risk using the Boey score. It can help to decide how aggressive our treatment needs to be. The Boey score includes three parameters (i.e. severe medical illness, preoperative shock, and duration of perforation >24 h), each one scoring 1 point if positive. Needless to say, the higher the score, the higher the risks (e.g. a patient with the Boey score of 3 has a 77% chance of developing complications, and 38% of death).
Another prognostic tool is the PULP score, but it is quite complex, and we don’t like complex scores… Rule number one must be “keep it simple”.
The diagnostic workup includes:
- Laboratory exams: blood cells count, creatinine, urea, glucose, electrolytes, amylase and lipase (they may be elevated in case of a perforated posterior peptic ulcer involving the pancreas), CRP, coagulative status, arterial blood gas;
- Chest x-ray: it must be acquired in an erect position to detect suprahepatic free abdominal air (plain abdominal x-ray should not be used anymore, it does not give any key information and, mainly, it does not make the diagnosis);
- Abdominal US: it may detect abdominal free fluid, free air, perigastric or periduodenal fluid collections, and thickened gastric/duodenal wall;
- Abdominal x-ray with oral water-soluble contrast: there is not a clear benefit over using an abdominal CT scan with oral contrast;
- Contrast-enhanced abdominal CT scan with/without oral contrast: the gold standard in the diagnosis of perforated peptic ulcer. However, it may be normal in up to 12% of patients. Typical features of perforated peptic ulcer are intraperitoneal free fluid, pneumoperitoneum, bowel wall thickening (mainly at the level of the stomach and/or the duodenum), mesenteric fat stranding, and extraluminal contrast extravasation.
Yes… You have read correctly… It is possible to apply conservative management even in perforated patients. The inclusion criteria are very strict, though. In fact, remember that every hour of delay to surgery increases mortality by 2.4%; so, stick to them firmly.
Five conditions must be present to undertake this path:
- Perforation occurred >24 h;
- Hemodynamically stable patient;
- No sepsis/peritonitis;
- No extraluminal contrast extravasation at CT scan;
- Availability of close monitoring with repeated clinical examinations.
Additionally, there is another group of patients who are manageable with conservative treatment: the extremely sick… Those who are poor surgical candidates.
Conservative management includes:
- Nil per Os (NPO), NGT, IV crystalloids: there is no indication about how long the patient must be kept NPO and with the NGT in place
- IV broad-spectrum antibiotics: they should cover Gram+, Gram-, and anaerobic bacteria (not antifungal agents). They should be started as soon as possible, and continued for 3-5 days or until inflammatory markers normalize
- IV PPI
A follow-up endoscopy after 4-6 weeks is recommended. In patients with gastric ulcer and low risk of cancer (e.g. young patients…), the follow-up endoscopy may be avoided. The same can be said about asymptomatic patients who had a duodenal ulcer (the risk of cancer is very low).
Not all guidelines advocate the use of endoscopy in the treatment of perforated peptic ulcers. Yet, we think in selected patients (e.g. hemodynamically stable) and selected centers, it could be a useful alternative to surgery. The endoscopic treatment should be considered mainly in patients with perforations occurred <24 h since it is technically easier because the inflammatory changes are still mild.
The possible endoscopic approaches to perforated peptic ulcers are:
- Through-the-scope clips: for linear perforations <1 cm in diameter
- Over-the-scope clips: for bigger perforations (up to 3 cm)
- Self-expandable metal stents: they may be an alternative in duodenal perforations
As stated before, if surgical treatment is necessary, it must not be delayed, otherwise, the mortality increases.
Surgery is certainly indicated in patients with significant pneumoperitoneum, extraluminal contrast extravasation, and those who are hemodynamically unstable.
The recommended surgical approach is laparoscopy. However, open surgery should be preferred in patients who are hemodynamically unstable with simultaneous bleeding, who have contraindications to pneumoperitoneum, or a hostile abdomen, and, of course, if the surgeon is not proficient in laparoscopy.
Intraoperative collection of samples for microbiological analysis for both bacterial and fungi should be performed in all patients, allowing subsequent antibiotic therapy adjustments.
If the ulcer is <3 cm in diameter, the primary repair is recommended. If the ulcer involves the stomach, and it does not jeopardize the success of the surgical procedure, taking biopsies of the ulcer edges would be desirable to exclude malignancy.
The choice of which closure technique to use depends on the ulcer’s characteristics:
- Viable and easily opposable edges: direct suturing with/without an omental patch;
- Friable, edematous, and/or difficult to approach edges: omental patch with/without sealant devices.
There are basically two types of omental patch:
- Cellan-Jones: the omental patch is pedicled;
- Graham: the omental patch is free.
Remember that the omental patch should be plugged into the hole and not above the suture line.
If the ulcer is bigger than 3 cm, a tailored approach should be applied. Factors needing to be considered are:
- Site of perforation: gastric ulcers have a higher risk of malignancy (10-16%), where duodenal ulcers have a higher leakage rate and risk of injury to the common bile duct;
- Local status: if tissues are severely inflamed, ischemic, or necrotic.
Depending on the parameters described above, the possible options are:
- Simple repair (as per smaller ulcers): it can be associated with the positioning of a gastrostomy, retrograde duodenostomy, and a feeding jejunostomy;
- Resection: antrectomy, Billroth I or II;
- Damage control surgery;
- Additional techniques: duodenojejunostomy, jejunal serosal patch, pyloric exclusion along with gastrojejunostomy, selective vagotomy.
A “kissing” ulcer is kind of a duodenal mixed type ulcer with an anterior component perforated, and a posterior one bleeding. It should be suspected when there are signs of fresh or old blood in the NGT or around the perforation site. If this ulcer is treated as a perforated one, suturing the perforation, the posterior bleeding aspect would be missed, and it may lead to severe postoperative hemorrhage. The correct approach to these ulcers is to perform a duodenotomy at the perforation site, and, if a posterior ulcer is found, to suture-transfix its base, accomplishing a trans-duodenal gastroduodenal artery ligation.
Helicobacter pylori Infection Management
Helicobacter pylori has a prevalence of 20-50% among patients admitted for bleeding peptic ulcers. Therefore, all patients should be tested for H. pylori, and, if positive, must undertake the appropriate therapy.
There are several diagnostic tests available to detect H. pylori infection.
|Serology||76-84%||79-90%||Noninvasive. Cheap. Not useful after treatment, because it may reflect the previous infection|
|Urea breath test||>95%||>95%||Noninvasive. Quite expensive. It should not be used after the recent use of PPI, antibiotics, or bismuth preparations. It needs trained personnel.|
|Stool antigen test||96%||97%||Noninvasive. It should not be used after the recent use of PPI, antibiotics, or bismuth preparations.|
|Histology||95%||99%||Invasive. Expensive. It may give additional information about the gastric mucosa. It needs trained personnel.|
|Rapid urease test||90%||93%||Invasive. Requires endoscopy. Less accurate after treatment.|
|Culture||58%||100%||Invasive. It allows antibiotics sensitivity testing. It needs trained personnel.|
The first-line therapy in H. pylori infection consists of PPI once or twice daily, clarithromycin 500 mg twice daily, amoxicillin 1 g twice daily, and/or metronidazole 500 mg three times per day. The therapy should be continued for 14 days.
In case of known clarithromycin high resistance rate, the treatment regimen should be the “sequential therapy”, consisting of 10 days of PPI twice a day associated with amoxicillin 1 g two times daily for the first 5 days, and followed by clarithromycin 500 mg twice daily and metronidazole 500 mg three times a day for the next 5 days.
After the first-line therapy, patients must be tested again after 4 weeks.
In the case of treatment failure, second-line therapy should be started. It consists of PPI twice daily, levofloxacin 250 mg twice daily (or 500 mg once per day), and amoxicillin 1 g twice daily.
- Tarasconi A, et al. Perforated and bleeding peptic ulcer: WSES guidelines. World Journal of Emergency Surgery 2020;15:3.
- Ansari D, et al. Diagnosis and management of duodenal perforations: a narrative review. Scandinavian Journal of Gastroenterology 2019;54:939-44.
- Schein M. Perforated peptic ulcer. In: Schein M, et al. eds. Schein’s Common Sense Emergency Abdominal Surgery. 2nd Ed. Berlin, Germany: Springer; 2005:143-150.
- Chey WD, et al. ACG Clinical Guideline: Treatment of Helicobacter pylori infection. Am J Gastroenterol 2017;112:212-38.
How to Cite This Post
Bellio G, Marrano E. The Feeling of Having a Pit in the Stomach. Surgical Pizza. Published on October 10, 2020. Accessed on May 5, 2021. Available at [https://surgicalpizza.org/emergency-surgery/the-feeling-of-having-a-pit-in-the-stomach/].