1. Dr Ahmad abanamy hospital Dr Nuaman danawar general& gastrointestinal surgeon

2. Perforated peptic ulcer 50 years ago perforated peptic ulcer was a disease of young men Today it is a problem seen mainly in elderly women Overall incidence for admission with peptic ulceration is falling The number of perforated ulcers remains unchanged Sustained incidence possibly due to increased NSAID in elderly 80% of perforated duodenal ulcers are H. pylori positive

3. Clinical features Most occur in patients with pre-existing dyspepsia 10% have no previous symptoms Classic presentation is with: – Sudden onset epigastric pain – Rapid generalisation of pain – Examination shows peritonitis with absent bowel sounds 10% have an associated episode of melaena 10% have no demonstrable gas on an erect chest x-ray If diagnostic doubt then water soluble contrast enema may confirm perforation Can be associated with elevated serum amylase but not to same level as in pancreatitis

4. Free air Under RT hemi diaphragm

5. Management Most patients require surgery after appropriate resuscitation Conservative management may be considered if significant co-morbidity More likely to fail if perforation is of a gastric ulcer Laparoscopic techniques have recently been described

6. Preoperative preparation Fluid resuscitation with CVP or Swan Ganz monitoring Analgesia Antibiotics Nasogastric intubation

7. Operation Oversew of ulcer first performed by Dean in 1894 Usually performed through an upper midline incision Oversew perforation with omental patch Use 2/0 synthetic absorbable. Take 1 cm bites either side of ulcer Picture provided by Vitoon Chinswangwatanakul, Siriraj Hospital, Bangkok, Thailand Thorough wash out and irrigation of peritoneal cavity with 0.9% saline If unable to find perforation open the less sac Remember that multiple perforations can occur If closure secure and adequate toilet then a drain is not required Pre-pyloric ulcer behave as duodenal ulcers All gastric ulcers require biopsy to exclude malignancy Definitive ulcer surgery probably not required 50% patients develop no ulcer recurrence Postoperatively patients should receive H. pylori eradication therapy Surgery increasingly performed laparoscopically Associated with no increased morbidity and reduced hospital stay

8. Outcome Operative mortality depends on four major risk factors – Long period from perforation to admission – Increasing age – Coexisting medical disease – Hypovolaemia on admission