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Introduction 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 ulcerationis falling

The number of perforated ulcers remains unchanged

Sustained incidence possibly due to increased NSAIDin elderly

80% of perforated duodenal ulcers are H. pyloripositive

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Investigations Erect plain chest radiograph

Serum amylase levels (amylase level may be elevated

but not as much as in pancreatitis) CT scan

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Management Preoperative preparations- resuscitation with fluids

and analgesia,nasogastric tube,antibiotics

Laparotomy- Upper midline incision(if the location is known) orsmall incision at umbilicus to localize the perforation

Laparoscopy

Truncal vagotomy/pyloroplasty (older method) Highly selective vagotomy(relatively safe)

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Perforation at duodenum close by several well-

placed sutures, then closing the ulcer in a transversedirection as with a pyloroplasty

Omental patch over the perforation to enhancechances of sealing the leak

Thorough peritoneal toilet with 0.9% saline

If unable to find perforation open the less sac

Remember that multiple perforations can occur

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Prepyloric ulcer behave as duodenal ulcers

All gastric ulcers require biopsy to exclude malignancy

Massive perforation-Billroth II gastrectomy

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Omental patch

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Laparoscopic closure ofperforated duodenal ulcer &

omental patching.

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Outcome Operative mortality depends on four major risk

factors:

Long period from perforation to admission

Increasing age

Coexisting medical disease

Hypovolaemia on admission