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

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.
 

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