G a s t ro d u o d e n a l P e r f o r a t i o n

Raminder Nirula, MD, MPH

KEYWORDS
 Gastroduodenal  Perforation  Ulcer-reducing surgery

KEY POINTS
 The most common cause of gastroduodenal perforation is peptic ulcer disease.
 Nonoperative management can be considered in patients with minimal symptoms who
are younger than 70 years.
 Abdominal washout, ulcer biopsy, and omental patch are appropriate in most
circumstances.
 Acid-reducing surgery is indicated in patients who have a history of failed medical therapy.

The cause and management of gastroduodenal perforation has changed as a result of

increasing use of nonsteroidal antiinflammatories and improved pharmacologic treat-
ment of acid hypersecretion, as well as the recognition and treatment of Helicobacter
pylori (Fig. 1). As a result of the reduction in ulcer recurrence with medical therapy, the
surgical approach to patients with gastroduodenal perforation has also changed over
the last 3 decades, with ulcer-reducing surgery being performed infrequently.1,2

CAUSE
 The most common cause of gastroduodenal perforation is ulcer disease
 Ulcer disease may be secondary to acid hypersecretion, H pylori infection, or
from medications (steroids, nonsteroidal antiinflammatories)
 Other causes include trauma, neoplasm, foreign body ingestion, or iatrogenic
(endoscopic procedures).
 Blunt trauma resulting in gastroduodenal perforation is rare, comprising only
5% of blunt hollow viscous injuries.
 Malignant perforations may be secondary to necrotic tumor in the stomach or
duodenum that perforates or from an obstructing tumor, leading to proximal
dilation and perforation.
 Foreign bodies may cause perforation from direct injury to the stomach or
duodenum or as a result of luminal obstruction.1

Department of Surgery, University of Utah, 50 North Medical Drive, Salt Lake City, UT 84132,
USA
E-mail address: r.nirula@hsc.utah.edu

Surg Clin N Am 94 (2014) 31–34

http://dx.doi.org/10.1016/j.suc.2013.10.002 surgical.theclinics.com
0039-6109/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
32 Nirula

Fig. 1. Treatment of perforated gastroduodenal ulcer. Exams, examinations; NG, nasogas-

tric; PPI, proton pump inhibitor.

PRESENTATION
 Sudden onset of severe epigastric and right upper quadrant abdominal pain in
patients with a history of gastroesophageal reflux is common among those
with peptic ulcer disease perforations.
 Peritonitis may be minimal in the case of contained leaks.
 Mental status changes and septic shock (fever, hypotension, tachycardia) may
be observed in diffuse leakage of the perforation.

DIAGNOSIS
 Leukocytosis, metabolic acidosis, and hyperamylasemia may be present but are
not sensitive.
 Upright chest radiograph may show free air.
 Computed tomography (CT) with enteral contrast shows free air, free fluid,
mesenteric fat stranding, and bowel wall thickening and may localize the site
of perforation. Early CT scans after traumatic injury may be falsely negative in
up to 12% of cases.3

MANAGEMENT
Nonoperative Management
Approximately half of the perforations spontaneously seal, which raises the question
as to whether these patients can be managed nonoperatively. The difficulty is identi-
fying those patients who have sealed without compromising the outcomes for those
who have not sealed while one observes them for signs of clinical deterioration.4 Fac-
tors mandating surgical management include shock and generalized peritonitis. Risk
factors that have been associated with failure of nonoperative management include
age greater than 70 years, symptoms of greater than 24 hours, and lack of improve-
ment after 12 hours of conservative therapy. Conservative therapy includes showing
that there is no free extravasation of contrast and that the leak is confined either by
CT or gastroduodenography. Once this information is verified, a nasogastric tube
 Gastroduodenal Perforation 33

for decompression is required. The patient should receive antimicrobial therapy

directed at aerobic gram-positive cocci such as ampicillin/sulbactam, as well as a
proton pump inhibitor.5 Should the patient fail to improve or worsen (fever, shock,
worsening peritonitis), prompt surgical intervention is required.

Operative Management
Patients who have free perforation, shock, generalized peritonitis, or progressive
symptoms should undergo surgery. The decision to perform an acid-reducing opera-
tion is made based on the patient’s history. Those patients who have perforated
despite antacid therapy and H pylori eradication or who require ulcerogenic medica-
tions such as steroids should undergo an acid-reducing operation. For those who
have not received adequate medical therapy, ulcer biopsy for gastric ulcers, omental
patch, and abdominal washout followed by medical therapy provide acceptably low
ulcer recurrence rates, of less then 10%.6–8
In patients who have failed medical therapy and are hemodynamically stable, there
are several antacid operations, each with its merits: truncal vagotomy with pyloro-
plasty, truncal vagotomy with antrectomy, and either a Bilroth I or Bilroth II reconstruc-
tion, or highly selective vagotomy. These operations should generally be reserved for
ulcers that are related to acid hypersecretion, which include prepyloric ulcers or
gastric ulcers within the body that occur in conjunction with duodenal ulcers. The
choice of which operation to perform needs to take into account the location of the
perforation and the ability to achieve closure along with the risk for ulcer recurrence
balanced by the risk of complications related to the operation. Vagotomy and antrec-
tomy carries the lowest risk for ulcer recurrence, at approximately 2%, whereas vagot-
omy and pyloroplasty carries a recurrence rate of 5%, and 10% to 20% for highly
selective vagotomy.9,10
Closure of gastric perforations can typically be easily performed, because of the
mobility and redundancy of the stomach, which can then be reinforced with an
omental patch. Duodenal perforations frequently cannot be primarily closed unless
they are small without causing duodenal narrowing. Therefore, an omental or jejunal
serosal patch may be necessary. If the integrity of the repair is in question, the right
upper quadrant should be drained in anticipation of a duodenal fistula and a gastro-
stomy tube for drainage, and a jejunal feeding tube should be placed. In patients
who are hemodynamically normal, this procedure may be performed laparoscopically.
If the perforation is proximal and an antacid operation is being performed, then, the
ulcer may be resected if the remaining duodenal stump is not indurated, and the
resection can be performed without injury to the ampulla.

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