Perforated Ulcers: Causes, Symptoms and Treatment

A perforated ulcer is a severe complication of peptic ulcers. It occurs when an open sore in the stomach or small intestine wears through the organ’s wall. This allows stomach acid and bacteria to leak into the abdominal cavity, causing infection and inflammation.

This article provides a comprehensive guide to perforated ulcers, including their causes, symptoms, diagnosis, and treatment options. Understanding these key aspects can help with early detection and timely medical intervention.

[signup]

Peptic Ulcers and Their Complications: Understanding the Risk of Perforation

Peptic ulcer disease (PUD) occurs when open sores develop in the lining of the stomach or upper small intestine due to prolonged exposure to stomach acid.

The two primary causes are Helicobacter pylori (H. pylori) infection and long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen and aspirin. H. pylori weakens the stomach’s protective barrier, while NSAIDs reduce mucus production, making the digestive lining more susceptible to acid damage.

One of the most severe and life-threatening complications is a perforated ulcer, where the ulcer completely erodes through the stomach or intestinal wall. This creates an opening that allows stomach acid, bacteria, and partially digested food to leak into the abdominal cavity, triggering a dangerous infection known as peritonitis.

Overview of Perforated Peptic Ulcers

Perforation is a serious complication of PUD and, in many cases, requires emergency surgery. However, select patients may be managed non-surgically under close medical supervision.

It is associated with significant morbidity and mortality, with reported 30-day mortality rates reaching 20% and 90-day mortality as high as 30%.

Despite advances in medical therapy for PUD, perforation remains a major surgical emergency requiring immediate intervention to prevent sepsis and multi-organ failure.

Causes of Perforated Peptic Ulcers

PPU results from factors that compromise the integrity of the gastrointestinal lining:

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): Chronic use increases the risk of ulcers and their complications.

H. pylori Infection: A major contributor to ulcer formation, increasing the likelihood of perforation if untreated.

Smoking and Alcohol: Both impair gastric mucosal defenses and delay ulcer healing.

Physiological Stress: Severe physiological stress, such as trauma or critical illness, can increase acid production and reduce stomach lining protection, contributing to ulcer formation.

Hypersecretion of Gastric Acid: Conditions like Zollinger-Ellison syndrome (ZES) lead to excessive gastric acid secretion, significantly increasing the risk of ulcer formation and subsequent perforation.

Recognizing Symptoms of a Perforated Peptic Ulcer

A perforated peptic ulcer often presents with sudden, severe abdominal pain, typically in the upper abdomen, which can quickly spread.

Additional symptoms may include:

Nausea and vomiting, sometimes with blood.

Dizziness or fainting, due to low blood pressure.

Rigid or tender abdomen, a sign of inflammation.

Rapid heartbeat (tachycardia) and fever, indicating infection.

Confusion or disorientation, especially in older adults or critically ill patients.

Symptoms vary based on severity and patient health. While sudden, severe upper abdominal pain is the hallmark symptom, older adults or immunocompromised patients may have milder pain but present with confusion or weakness due to sepsis.

Complications of a Perforated Ulcer

With early intervention, survival rates improve significantly. However, delayed treatment increases the risk of serious complications such as:

Hypovolemic shock

Gastrocolic fistula
Organ failure

Diagnosis of Perforated Peptic Ulcers

Diagnosing a perforated peptic ulcer requires urgent evaluation. Patients often present with sudden, severe abdominal pain that may spread.

A physical exam reveals abdominal rigidity, tenderness, and signs of peritonitis. Severe cases may show shock symptoms like low blood pressure and rapid heart rate.
Laboratory tests, including complete blood count, metabolic panel, liver function tests, and coagulation profile, help detect infection and complications. Elevated white blood cell counts indicate infection, while metabolic imbalances suggest systemic issues. Lactic acid levels assess tissue oxygenation and ischemia.
Imaging studies confirm the diagnosis. While abdominal X-rays may show free air under the diaphragm, CT scans provide a more accurate assessment of perforation, inflammation, and fluid buildup.

Treatment of Perforated Peptic Ulcers

Treatment focuses on stabilization, infection control, and surgical repair:

Intravenous (IV) fluids to maintain blood pressure and hydration.

Broad-spectrum antibiotics to prevent or treat infection.

Proton pump inhibitors (PPIs) reduce stomach acid and promote healing.

Nasogastric tube placement to decompress the stomach and minimize leakage.

Surgery is typically required to close the perforation, often using an omental (Graham) patch.

In select cases with small perforations, no widespread infection, and stable vitals, patients may be managed non-operatively with IV antibiotics, PPIs, and close monitoring.

Postoperative Complications

Surgical repair of PPU is associated with a high risk of complications, particularly in older patients and those presenting late. Examples of postoperative complications include:

Surgical Site Infection (SSI): SSI prolongs hospital stays and increases morbidity.

Pneumonia: May occur due to prolonged immobilization and post-anesthesia respiratory compromise.

Intra-abdominal Abscesses: Occur when the infection persists in the abdominal cavity, requiring drainage.

Wound Dehiscence: Breakdown of the surgical incision, potentially leading to evisceration.

Anastomotic Leak: A serious complication that can cause peritonitis and sepsis.

Paralytic Ileus: Temporary loss of bowel function, leading to obstruction and delayed recovery.

Mortality: Post-operative mortality has been associated with delayed presentation, older age, frailty, pre-existing medical conditions, and hemodynamic instability at the time of surgery.

Comprehensive postoperative management, including early mobilization, deep breathing exercises, and infection control measures, reduces the risk of postoperative complications.

Preventing a Perforated Ulcer

Understanding risk factors and symptoms helps patients seek timely medical care and take preventive steps to avoid complications.

Patients should be informed that peptic ulcers can lead to serious complications like perforation.

Taking medications as prescribed helps ulcers heal and reduces the risk of complications.

Avoiding NSAIDs, such as ibuprofen and aspirin, protects the stomach lining.

Quitting smoking lowers the chance of ulcers worsening or becoming perforated.
Avoiding acidic, spicy, or highly processed foods may help reduce ulcer irritation and symptoms.

Limiting alcohol and caffeine prevents irritation and further damage to the stomach.

This article is for educational purposes only and does not replace professional medical advice. If you experience symptoms of a peptic ulcer, consult a healthcare provider immediately.

[signup]

Key Takeaways

A perforated ulcer is a life-threatening complication of peptic ulcer disease that requires immediate medical intervention.

Common risk factors include H. pylori infection, prolonged NSAID use, smoking, excessive alcohol consumption, and high stomach acid production.

Symptoms such as sudden, severe abdominal pain, nausea, vomiting, fever, and a rigid abdomen may signal a medical emergency.

Diagnosis involves a physical examination, imaging tests like CT scans, and lab work to detect infection and complications.

Treatment typically includes IV fluids, antibiotics, acid-reducing medications, and, in most cases, surgical repair to close the perforation.

Preventive measures include managing underlying conditions, avoiding NSAIDs, quitting smoking, limiting alcohol and caffeine, and adhering to prescribed ulcer treatments.