Perforated gastric or duodenal ulcer

Classically, when a patient's peptic ulcer perforates, it floods his peritoneum with the acid contents of his stomach, and gives him a sudden agonizing pain. He may be able to tell you the moment the pain began; it is constant, it spreads across his entire upper abdomen and later all over, and is made worse by deep breathing or movement. Usually, he lies still in excruciating pain, and breathes shallowly without moving his abdomen. Occasionally, he writhes about in agony. He is pale, sweating, and hypotensive, with a fast pulse (usually), a normal temperature, and a stomach which is not distended. Typically, his abdomen has a board-like rigidity, unlike that in any other disease, which may be so complete that you cannot elicit tenderness, except when you examine him rectally.

After 3 to 6 hours his pain and rigidity lessen, he feels better and a ''silent interval' begins. Then, at about 6 hours, signs of diffuse peritonitis develop, accompanied by abdominal distension and absent bowel sounds.

There are difficulties: (1) So many patients have dyspepsia, that a previous dyspeptic history is not much help. (2) You may have difficulty in distinguishing the exacerbation of a peptic ulcer from a subacute perforation (a small sealed leak)[md]so remember this possibility and watch him carefully. (3) Fluid may track down his right paracolic gutter and cause pain and tenderness in his right iliac fossa, simulating appendicitis. (4) If he perforates in bed while he is suffering from something else, which is not uncommon, the dramatic onset may be absent. Instead, he may merely ''take a turn for the worse', his pulse rate rises, and you find that he has upper abdominal guarding.

If he has perforated, he needs an urgent laparotomy. If he is fit, and you operate within 8 hours, the result will be good. If you delay 12 hours, his chances of survival fall greatly. If you can suture his perforation, he has a 50% chance of having no more symptoms, and a 25% chance of having dyspepsia which will not be severe enough to need major surgery.

Although the standard treatment is an urgent laparotomy, to close the hole in his duodenum or stomach, and to wash out his peritoneal cavity, there are some indications for treating him non-operatively, as described below. This is less demanding technically, but it needs more time, and you will need good judgement to know: (1) When you have made a wrong diagnosis, and (2) when non-operative treatment is failing, so that you need to operate.

The rule in all emergency surgery is to do only what is necessary. Closing the perforation is not difficult, but be sure to wash out his peritoneum when it has been contaminated. For this you will need plenty of warm saline.

PERFORATED PEPTIC ULCER DIFFERENTIAL DIAGNOSIS. The main diagnostic difficulty is appendicitis, which is important because it needs a different incision. Find out the relative frequency of these two diseases in your community.

Suggesting perforation[md]referred shoulder pain, usually on the patient's right, the absence of fever[md]this develops late in a perforation[md]shock (when generalized rigidity is the result of appendicitis, he is not usually shocked), and a litre or more of stomach aspirate.

Suggesting appendicitis (12.1)[md]a colicky onset, fever, a small stomach aspirate of mucoid or bile-stained fluid.

X-RAYS. If the diagnosis is clear, these are unnecessary and unkind. If you take them, give him some intravenous morphine and aspirate his stomach first. Take an erect AP chest film. Make sure he is upright and the tube is horizontal. Look for a thin linear gas shadow between his diaphragm and his liver or stomach. If he cannot sit or stand, take a lateral decubitus film and look for air under his anterior abdominal wall.

If his ulcer has perforated into his lesser sac, you may see a large irregular gas shadow in the centre of his upper abdomen, with an outline which is different from that of a loop of gut.

CAUTION ! (1) An ulcer can perforate almost silently in the very old, or in the course of another disease. (2) The absence of gas does not exclude the presence of a perforated ulcer. (3) Gas can also come from a ruptured diverticulum or an appendix (uncommon).

NON-OPERATIVE TREATMENT [s7]FOR A PERFORATED PEPTIC ULCER INDICATIONS. (1) A perforation which appears to have sealed itself already, as shown by diminished pain and improved abdominal signs. (2) Heart or lung disease, which increases the surgical and anaesthetic risks. (3) The patient who is admitted after a day or two and is almost moribund with diffuse peritonitis. Non-operative treatment may be best, because it is unlikely that he would have survived so long with an open perforation.

CONTRAINDICATIONS. (1) An uncertain diagnosis. (2) The absence of really good nursing by day and night. (3) The seriously ill patient, with a short history, whose only hope is vigorous resuscitation and an urgent laparotomy. If you do decide that such a patient is ''not fit for surgery', wait to do so until vigorous resuscitation has failed[md]don't make the decision when he is first admitted.

METHOD. Give him morphine 5 to 10 mg intravenously. As soon as this has had time to act, pass a large tube and empty his stomach. When it is empty, pass as wide a radio-opaque nasogastric tube as he will tolerate. Take him to the X-ray department and take AP erect films of his chest and lower abdomen. These should show that there are no fluid levels in his stomach, and that the tube is well placed. If not, adjust it and take more films. Look for subdiaphragmatic gas to confirm the diagnosis.

Back in the ward, ask a nurse to aspirate his stomach every 15 minutes initially. Set up an intravenous drip, and monitor his pulse and blood pressure hourly.

He is progressing well if: (1) His pain eases, so that he does not need more analgesics, and (2) another erect film 12 hours later (optional) shows no fluid level, and no increase in the gas under his diaphragm. Continue to ''suck and drip him' for 4 or 5 days, until his abdomen is no longer tender and rigid, and his bowel sounds return.

If pain persists, or the gas under his diaphragm increases, operate.

LAPAROTOMY [s7]FOR A PERFORATED PEPTIC ULCER EQUIPMENT. A general set. Several litres of warm saline. Two assistants make upper abdominal surgery easier.

PREPARATION. Pass a nasogastric tube and aspirate his stomach (4.9). He will have lost much fluid into his peritoneal cavity, so correct at least part of his fluid loss before you operate, as in Section A 15.3. If he is dehydrated or hypotensive, give him 1 to 3 litres of fluid rapidly. If more than 12 hours have elapsed since he perforated, he will need even more. Operate soon, but not before you have resuscitated him. He has not bled, so he does not need blood.

PERIOPERATIVE ANTIBIOTICS. (2.9) are only indicated in late cases with peritonitis.

ANAESTHESIA. (1) General anaesthesia with good relaxation. (2) If this is contraindicated because of lung disease, do an intercostal block (A 6.7), from T6 to T11.

Premedicate him with intravenous morphine, and palpate his abdomen when this has taken effect. If his rigidity is generalized, morphine will make little difference if he has a perforation, but if he has appendicitis, rigidity will now be localized to his right iliac fossa.

INCISION. Make a midline or upper right paramedian incision (9.2). The escape of gas as you incise his peritoneum confirms the diagnosis.

Initial examination will probably show a pool of exudate under his liver, with food and fluid everywhere, and an inflamed peritoneum. The fluid may be odourless and colourless with yellowish flecks, or bile-stained[md]if it is pure bile, he has biliary peritonitis. If you see patches of fat necrosis, he has acute pancreatitis. If there is no fluid or little fluid, push a swab on a holder beside his ascending colon towards his caecum. If you withdraw it soaked with fluid, this suggests a perforation. Draw his stomach and transverse colon downwards: you may see flecks of fibrin, and perhaps pieces of food.

To expose his stomach and duodenum place a self- retaining retractor in the wound. Place a moist abdominal pack on the greater curvature of his stomach. Draw this downwards, and ask your assistant to hold it; at the same time ask him to hold the patient's liver upwards with a deep retractor. Put an abdominal pack between the retractor and his liver to protect it. If necessary, get the help of a second assistant.

Suck away any fluid, looking carefully to see where it is coming from.

Search for a small (1 to 10 mm or more) circular hole on the anterior surface of his duodenum, looking as if it has just been drilled out. Feel it. The tissues around it will be oedematous, thickened, scarred, and friable. If his duodenum is normal, look at his stomach, especially its lesser curve. If the hole is small, there may be more to feel than to see. Sometimes, a gastric ulcer is sealed off by adhesions to the liver. Remember that a gastric ulcer may be malignant: consider biopsy.

If his stomach is adherent to his liver, separate it.

Open his lesser sac through his lesser omentum. Feel the posterior surface of his stomach. An ulcer high up posteriorly may be difficult to find. Feel carefully.

If his stomach and duodenum are normal, feel gently downwards towards his appendix. If there is a mass or it is obviously inflamed, close the midline incision and make a gridiron one. Two smaller incisions are better than one huge one.

Fig. 11-2 CLOSING A PERFORATED PEPTIC ULCER. A, the stomach retracted and a perforation on the anterior of the duodenum exposed. B, the perforation being closed with several interrupted sutures of 2/0 catgut on an atraumatic needle. C, a fold of omentum being sewn over the hole. Kindly contributed by Gerald Hankins.

To close the perforation, use 2/0 chromic catgut on an atraumatic needle to bring its edges together with 1 to 3 deep stitches. If the tissue is so rigid that the stitches cut out, you may be able to reduce the size of the hole with loose sutures, or by using a purse string suture. Always sew omentum over the perforation, by bringing up a fold of greater omentum. A hole so plugged is unlikely to leak.

Wash out his peritoneal cavity. This is absolutely critical, and may be more important than closing the hole. Tip a litre of warm saline into his peritoneal cavity, spread it well, and then suck it out again. Repeat this several times, and try to wash out every possible recess in his upper abdomen. Mop the upper surface of his liver. Instil tetracycline 1 g in a litre of of saline and leave it in. This may be unnecessary if you operate within 6 hours of the perforation.

FURTHER PROCEDURES. If: (1) his general condition is good, and you are operating early (within 6 to 8 hours of a duodenal, or particularly a gastric perforation), and (2) he has severe ulcer disease (uncontrollable symptoms, or a previous bleed or perforation), and (3) you are experienced, consider doing a vagotomy and gastroenterostomy (11-4). Otherwise, proceed to close his abdomen.

CLOSURE. Close his abdomen securely with non-absorbable sutures in a single layer (9.8), because it is particularly likely to burst (9.13). Don't insert drains.

POSTOPERATIVELY. Nurse him sitting up in a high Fowler's position. He will breathe more easily, he will be less likely to have chest complications, and any exudate will gravitate downwards. Continue with nasogastic suction and intravenous fluids, as in Sections 9.9 and A 15.5. Replace gastric aspirate with 0.9% saline. If he is likely to get lung complications (9.11), chest physiotherapy is vital.

DIFFICULTIES [s7]WITH A PERFORATED PEPTIC UCER If a patient who is VOMITING for any reason suddenly feels a severe pain in his epigastrium and behind his lower sternum, or spreading between his shoulders, suspect that he has a RUPTURED OESOPHAGUS, and see Section 25.16.

If his ulcer is BURROWING INTO HIS LIVER, separate his stomach or his duodenum from his liver by pinching between them with your finger and thumb. If this is difficult, or it is leaking into his peritoneal cavity, cut around it, and leave its base fixed to his liver. If you have been able to separate it from his liver, deal with it as usual. If you are experienced and he is fit, partial gastrectomy (not described here) is appropriate.

CAUTION ! Don't put your finger through his ulcer into his liver, it will bleed severely.

If he runs a FEVER in the second week, suspect that he has a subphrenic abscess (6.4).

If you continue to obtain MUCH GASTRIC ASPIRATE, he probably has pyloric stenosis aggravated by the suture. If it continues for more than 10 days, and you are competent to do so, do a gastroenterostomy and truncal vagotomy (a gastroentrostomy alone has a high incidence of anastomotic ulcers, except in women over 50).