Conservative management of perforated peptic ulcers

Zeeshan Rahman

Peptic ulcer disease

• Most prevalent disease of the gastrointestinal tract.

• Incidence: 0.1 – 0.3 % in western countries.

• Major precipitating factors:1.Helicobacter pylori infection2.NSAID drug abuse

Epidemiology

• Decreasing incidence of peptic ulcer disease

- Discovery of PPI/H2 antagonist- Discovery of H.pylori

• In 2005 Barry J. Marshal and J. Robin Warren discovered the role of H. pylori in peptic ulcer

PUD

• Considered a derangement in the mucosal function of the stomach and duodenum

Complications

• Bleeding

• Perforation

• Obstruction

Perforation

• Incidence : 5 – 10% in patients with active ulcer disease

• Duodenal perforation: 60%• Antral perforation: 20%• Gastric perforation: 20%

Taylor (20th century)

• Study on non-operative management of peptic ulcer.

• 256 patients treated non-operatively for peptic ulcer disease.

• 21 needed surgical intervention• Overall mortality rate was 11%• Usual operative mortality rate – 22%

Reason for poor acceptance

• Need for close clinical monitoring of patients

6-12 hours after perforation : Stage of delusion

- Acute pain of peritonitis subsides- Abdominal rigidity lessens- Leakage of enteric contents continue

Types of peptic ulcer perforations

When to decide to offer conservative management

• Sealed perforations

• Water soluble contrast medium- Gastrograffin study used

• 40% of patients examined – No releak• Incidence of releak – 2 in 109 patients

Treatment options

Conservative management of perforated peptic ulcers