Review Question - QID 202646

A perforated peptic ulcer necessitates emergent laparotomy.

Perforated peptic ulcer is a rare but serious complication of peptic ulcer disease (PUD). Perforated peptic ulcers present in someone with a history of PU) or gastroesophageal reflux disease (GERD) with peritoneal signs on physical exam. The peritoneal signs include guarding, distension, and rebound tenderness. If a perforated peptic ulcer is suspected, an abdominal or chest radiograph should be obtained. If pneumoperitoneum (peritoneal free air) is present on abdominal radiograph, perforation has occured, and the patient should be brought to the operating room for emergent laparotomy with surgical repair of the rupture.

Ramakrishnan et al. review PUD. They note that bleeding is the most common indication for surgery in PUD, although proton pump inhibitors and endoscopic therapy can control most bleeds. Perforation and gastric outlet obstruction are also rare, but very serious complications.

Moller et al., in the PULP trial, found that a perioperative care protocol based on the Surviving Sepsis Guidelines (resuscitation goals defined as: central venous pressure of > 8 mmHg, central venous oxygen saturation of > 70%, MAP > 65mmHg and a urine output of >0.5mls/kg/hr) following surgical treatment for perforated peptic ulcer disease, reduced 30-day mortality by more than 1/3.

Illustration A shows pneumoperitoneum on chest radiograph.

Incorrect answers:
Answer 1: Pancreatitis is initially treated with medical management and does not necessitate emergent laparotomy.
Answer 2: Diverticulitis is initially managed medically with IV antibiotics and bowel rest.
Answer 3: Ectopic pregnancy may be managed medically or surgically depending on the risk of rupture.
Answer 4: Bleeding peptic ulcers may be treated with proton pump inhibitors and endoscopic therapy.