Peptic ulcers is a common upper gastrointestinal condition. These are open sores that form in the stomach or first part of the small intestine. Peptic ulcer disease (PUD) affects over 10% of the American population. It has become less common in recent years but complications from peptic ulcers continues at the same rate. One of these complications is a perforated peptic ulcer. It is a serious complication and can even be life-threatening if it is left untreated.
What is a perforated peptic ulcer?
A perforated peptic ulcer is where the open sore (ulcer) in the stomach or intestine becomes torn. These ulcers may extend deep into the wall of the stomach or intestine but with a perforation it pierces through the entire wall. Perforations of a peptic ulcer is not a common complication but is possible in severe cases. Without prompt treatment it can lead to further complications. However, not all perforated ulcers may require surgery. Sometimes the perforation can seal off on its own.
Peptic ulcer disease refers to both gastric ulcers (stomach) and duodenal ulcers (small intestine). A perforation presents with an acute abdomen. Patients are usually rushed to the emergency room and are often writhing in pain. Investigations like an x-ray, abdominal ultrasound or CT scan is necessary to confirm whether there is a perforation and if leaking of air and digestive juices into the abdominal cavity is occurring. This will determine whether surgery is necessary as non-surgical management is also possible for some cases.
Causes of Perforated Peptic Ulcers
The gastric acid and powerful digestive enzymes within the stomach can easily digest the stomach wall. However, the stomach has mechanisms to prevent this from happening. The same applies to the first part of the small intestine, the duodenum, which continues from the stomach. A mucus barrier separates the acid and enzymes from making contact with the wall and alkaline secretions like bile neutralizes the acid to make it less corrosive to living tissue.
The protective mechanisms can sometimes become disrupted as is the case with H.pylori infection and the use of certain drugs like non-steroidal anti-inflammatory drugs (NSAIDs). Apart from the bacterium penetrating the gastrointestinal wall, it also allows stomach acid to make contact with the wall. Sometimes the stomach acid production increases substantially which may overwhelm the protective barrier that is normally present. In these instances the stomach and intestinal wall becomes inflamed and eventually eroded to form ulcers (open sores).
Ulcers can vary in severity in terms of the number of ulcers, size and depth. When the erosion penetrates through entire wall of the stomach or intestine, it is referred to as a perforation. These torn ulcers can allow for the acid and enzymes to spill into the abdominal cavity where it can lead to inflammation and even an infection. The latter arises when bacteria in the gut gain entry into the otherwise sterile peritoneal cavity. However, this spillage does not always occur in every case of a perforated peptic ulcer.
There are other possible causes of stomach and intestinal perforations even without a peptic ulcer. Similarly a severe non-perforated peptic ulcer can increase the risk of these other causes leading to a perforation.
Signs and Symptoms
A perforated peptic ulcer where the gastrointestinal contents spill into the abdominal cavity typically causes severe upper abdominal pain. This pain may sometimes subside after a few hours only to recur once peritonitis sets in. Usually movement and deep breathing exacerbates the pain. There is major abdominal guarding and shallow breathing to prevent any further worsening of the pain. Other symptoms may include a rapid heart rate, low blood pressure and sweating. Abdominal distension is not always present in acute cases.
Since the perforation may wall off on its own and the gastrointestinal contents may not leak out into the abdominal cavity, these acute symptoms may not be present. However, there are still severe peptic ulcer symptoms including pain, nausea, regurgitation and sometimes excessive belching. There is often a history of weight loss and a lack of appetite, along with long term use of antacids. Eating and hunger can both aggravate the pain.
Diagnosis for Ulcer Perforation
An erect x-ray is usually done to identify a perforation. The presence of air or large amounts of fluid is usually indicative of a perforation where the gastrointestinal content (acid and enzymes as well as air) usually confirms a diagnosis of perforation. However, no air may be detected in as many as 30% of cases. An abdominal ultrasound or computed tomography (CT) scan may also be done.
If there is uncertainty then a peritoneal diagnostic tap may be done to confirm the presence of blood, fluid or pus in the abdominal cavity. When there is a strong indication of a leaking perforation despite the lack of conclusive evidence with other diagnostic investigations then a laparoscopy may be done to confirm the diagnosis and possibly repair the perforation once it is isolated. A history of long-standing and severe peptic ulcers also assists with the diagnosis.
Treatment for Peptic Ulcer Perforation
The treatment for peptic ulcer perforation depends on the severity of the condition. Painkillers, sometimes even morphine, may be administered for pain management. Oral medication should be avoided. Surgery is the only way to repair a perforation however it may not always be necessary. The perforation can physiologically seal on its own. However, delaying surgery for a perforated peptic ulcer beyond 12 hours is associated with poor outcomes.
The perforation may be corrected with laparoscopic or open surgery. It can be done to investigate further when other diagnostic investigations do not confirm the presence of a perforation or whether leakage into the abdominal cavity has occurred. As with any surgery there is the risk of complications, including wound infection, abdominal abscess and perforation among others. It is important to manage peptic ulcers after surgery. This may include H.pylori eradication treatment among other interventions to avoid another perforation.
Complications like peritonitis need to be promptly managed with antibiotics or it can complicate further to bacteremia or sepsis with possibly fatal outcomes.