What is Peptic Ulcer Perforated?
Peptic ulcer disease refers to a condition where there’s damage to the lining of your upper digestive tract, causing sores that dig past the surface layer into the deeper layers. These ulcers mostly happen in the stomach and upper part of the small intestine (called the duodenum), but they can sometimes occur in other areas, like the esophagus or a special section of small intestine known as the Meckel diverticulum.
In most cases, peptic ulcers start without any symptoms, but eventually, they may cause discomfort ranging from mild indigestion to serious problems such as bleeding in your digestive system, the creation of holes (perforation) in the walls of your stomach or intestine, and blockages that prevent food from passing through your digestive tract (also known as gastric outlet obstruction). Peptic ulcers can form in the duodenum or the stomach.
This article gives a quick overview of peptic ulcer disease, especially focusing on the complicated issue of perforated peptic ulcers – a potential emergency condition that requires immediate medical attention.
What Causes Peptic Ulcer Perforated?
People used to think that peptic ulcers, or sores that develop in the lining of the stomach, were caused by things like having too much stomach acid, eating certain foods, or being too stressed. These days, however, it’s more commonly believed that a type of bacteria known as Helicobacter pylori and the use of certain pain relievers known as nonsteroidal anti-inflammatory drugs (NSAIDs) – which includes low-dose aspirin – are more likely to lead to peptic ulcers.
Other things such as smoking and consuming alcohol might also play a part in causing peptic ulcers. There are a few other underlying conditions and lifestyle factors that can increase someone’s risk of developing peptic ulcers as well. These include having a lower socioeconomic status, which might be associated with poorer hygiene and less healthy eating habits, atrophic gastritis (inflammation that causes the stomach lining to thin), being anxious or stressed, using steroids, and having certain conditions like Zollinger-Ellison syndrome, multiple endocrine neoplasia (MEN) syndrome, and hyperparathyroidism.
There are also a few factors that are more likely to be associated with gastric ulcers specifically. These include a slow emptying stomach (gastric stasis), lack of blood flow to the stomach lining (gastric mucosa ischemia), and a condition known as duodeno-gastric reflux, where the contents of the duodenum (the first part of the small intestine) flow back into the stomach.
Risk Factors and Frequency for Peptic Ulcer Perforated
Peptic Ulcer Disease (PUD) is a condition that is becoming less common, with current estimates suggesting that 5-10% of people will suffer from it over their lifetime. This disease is less often seen in developed countries. There has been a decrease in both the overall rate of PUD and its complications, but these complications still cause nearly 150,000 hospital stays each year in the United States.
- The chance of developing complications from PUD, such as bleeding, perforation, and obstruction, is decreasing.
- Upper GI bleeding is the most common complication from PUD.
- The second most common complication is perforation.
- Every year, between 19 to 57 out of every 100,000 people may have upper GI bleeding due to a peptic ulcer.
- The annual incidence of ulcer perforation is between 4 and 14 cases per 100,000 people.
People who are older than 60 are at a greater risk, with 60% of PUD patients being over this age. Infections with a bacteria called Helicobacter pylori and the usage of certain drugs, known as nonsteroidal anti-inflammatory drugs (or NSAIDs), are known factors that can increase the risk of bleeding ulcers and peptic ulcer perforation.
Signs and Symptoms of Peptic Ulcer Perforated
Peptic ulcer disease can sometimes cause no symptoms in about 70% of people. However, for those with a ruptured peptic ulcer, symptoms are usually obvious. Getting a thorough health history from specific groups, such as very young or old people, those with a weakened immune system, or those with consciousness impairment, can be challenging. When a reliable account is given, it may reveal additional symptoms that were present before the ulcer ruptured.
The main symptom for peptic ulcer sufferers is indigestion or upper belly pain. This discomfort may be general or it could be focused on the upper right or left area or epigastrium (the upper middle part of the abdomen). Food can sometimes worsen stomach ulcers, while a duodenal ulcer might not cause pain until 2-5 hours after eating. If the ulcer is bleeding, patients may experience nausea, vomit blood, or have black stools. Some patients might notice fresh blood or maroon-colored stool if there is a rapid blood loss from the upper gastrointestinal (GI) tract.
Pain in the upper abdomen is usually sudden and severe when a peptic ulcer perforates (breaks open). The pain starts locally but soon spreads across the abdomen. Patients might feel light-headed or faint because of low blood pressure from blood loss or a severe systemic inflammatory response (SIRS)/sepsis. The abdominal pain might ease slightly after a few hours, but it worsens with movement. If medical attention is delayed and the perforation doesn’t close off on its own, bloating may increase and the signs of SIRS/sepsis become more noticeable.
Everyone complaining of abdominal pain should receive a full physical exam. For those with a perforated peptic ulcer, the abdomen may be tender all over and progress to a hardened and rigid state. A rectal examination might show a positive guaiac stool test, indicating the presence of hidden blood in the stool. Patients often have a faster heart rate and may have low blood pressure. Fever and changes in mental state could occur if there’s been a delay in receiving medical care.
Testing for Peptic Ulcer Perforated
If your doctor thinks you might have a perforated peptic ulcer, a condition where a hole develops in the wall of your stomach or intestine, they will need to assess you quickly. This is necessary because the condition can get worse and become life-threatening with time. Even though the diagnosis can be made based on your symptoms and a physical check-up, your doctor will want to perform other tests to confirm the presence of the ulcer and rule out other possible causes of your symptoms.
You will have to undergo various lab tests and imaging studies. The lab tests include a complete blood count (CBC), chemistry panel, liver function tests, and tests to check your blood clotting profile and levels of an enzyme called lipase. The lipase test is important as high levels of lipase in your blood can indicate pancreatitis, an inflammation of your pancreas. Your doctor may also want to check your blood type as well as screen it.
If you show signs of the systemic inflammatory response syndrome (SIRS), a condition your body may go through when it responds to an infection, your doctor will need to test your blood culture and lactic acid levels. Lactic acid levels in your blood can provide information on whether there is lack of blood flow to parts of your body. A urine test may also be carried out if you have similar pain or problems related to urination.
Your doctor will perform imaging tests when you are stable. Simple imaging tests like an abdominal X-ray or a chest X-ray might be able to show the presence of free air which can suggest a hole in your stomach or intestine. However, a more detailed imaging test, a computed tomography (CT) scan of your abdomen and pelvis, can provide the most accurate results. Although a special type of drugs known as contrast substances are often given during a CT scan to better highlight the areas inside your body, your doctor might decide not to use them. But if your abdominal pain/peritonitis (inflammation of your peritoneum, a tissue that lines the inside of your abdomen) has unknown causes, an intravenous contrast might be used during your CT scan.
Treatment Options for Peptic Ulcer Perforated
Perforated peptic ulcers can be life-threatening, with a high risk of death around 30%. The best way to treat them usually involves quickly getting to the surgery room and managing any associated infection, which is also known as sepsis.
If a patient arrives at the hospital with symptoms of severe inflammation within the body (peritonitis), a surgical consultation is needed fast. Often before a full diagnosis is given. Medical treatment involves rehydrating the patient, managing pain with medicine and using antibiotics to fight potential infection. Certain antibiotics that are common against this type of illness may be used, especially in patients showing warning signs like extreme body temperature, increased heart rate, difficulty breathing, or abnormal white blood cell count, which we often see with infections.
Once it’s clear that a peptic ulcer has perforated, a tube is placed down the throat into the stomach (nasogastric tube), medicine to reduce stomach acid (IV proton pump inhibitor) is given, more antibiotics get used, and the surgical team evaluates the situation. Now is where a decision is made if surgery is necessary.
About half of deaths related to perforated peptic ulcers occur due to sepsis. Therefore, the use of antibiotics (specifically, ones that cover certain bacteria) is crucial. To ensure these antibiotics are effective, they must be able to fight a broad range of bacteria. Often the chosen antibiotic is either a combined beta-lactam/beta-lactamase inhibitor, or a pairing of a third-generation cephalosporin and metronidazole.
Intravenous proton pump inhibitors can help stop bleeding and heal ulcers, although we’re not sure how effective they are for perforated ulcers. However, the use of this medicine creates a better environment within the stomach for platelets (a part of the blood that helps in clotting) to gather and stop bleeding. Therefore its use is encouraged.
The best method of treatment for a perforated peptic ulcer is often to operate as soon as possible because the risk of death goes up the longer the surgery is delayed. Typical treatment involves washing out the abdominal cavity with saline, stitching up the ulcer, and placing a piece of fatty tissue over the stitched ulcer (known as a Roseo-Graham patch). A tube is placed to help drain fluid out of the abdomen and is typically removed after 3 to 5 days. This accident can be performed with an open surgery (larger incision) or laparoscopically (small incisions) – studies haven’t shown a significant difference in outcomes between the two methods.
A few patients can sometimes avoid surgery and manage their condition with medical treatment alone. This choice is made by the surgical team usually on patients who are younger, present early to the hospital, have mild or localized symptoms, and are generally stable. In these cases, the patient is managed with fluids, antibiotics, use of a nasogastric tube, constant monitoring of urine output and electrolytes. This is known as the Hermen-Taylor regimen. These patients typically need to follow up with an upper stomach examination (gastroscopy) after 12 weeks.
What else can Peptic Ulcer Perforated be?
When doctors diagnose a patient, they consider various conditions that might be causing the symptoms. Here are some of the conditions they might think about:
- Abdominal aortic aneurysm (AAA)
- Acute coronary syndrome
- Aortic dissection
- Appendicitis
- Boerhaave syndrome
- Cholecystitis
- Cholelithiasis
- Choledocholithiasis
- Diverticulitis
- Duodenitis
- Esophagitis
- Foreign body ingestion
- Gastritis
- Hepatitis
- Hernia
- Mesenteric ischemia
- Neoplasm
- Nephrolithiasis
- Pyelonephritis
- Small bowel obstruction
- Ureterolithiasis
- Volvulus
Surgical Treatment of Peptic Ulcer Perforated
Gastric ulcers, or sores in the lining of the stomach, can sometimes develop into cancer. Therefore, doctors often recommend a biopsy, a procedure where a small sample is taken from the ulcer or the edges of a hole in the stomach (called a perforation), to test for cancerous cells. If the biopsy shows the presence of these cells, a condition known as neoplasia, the next step is to determine the severity and spread of the disease.
This process, known as staging and grading, often involves the use of endoscopy (a procedure which involves inserting a thin tube into your body to create images) and different types of imaging like X-rays, ultrasounds, or MRIs. After the staging and grading, doctors can make recommendations for treatment which may involve surgery to remove the affected area, chemotherapy (which uses drugs to kill cancer cells), or a combination of both.
What to expect with Peptic Ulcer Perforated
The death rate for perforated peptic ulcers, which are basically tears or holes in the stomach’s lining, is ten times higher than that of acute appendicitis or cholecystitis, inflammation of the gallbladder. Even though bleeding is more likely to happen than perforation in a ratio of 6:1, the death rate is five times higher when there is a perforation compared to when there’s just bleeding.
Approximately, 24 out of 100 people may die within 30 days of suffering a perforated peptic ulcer. The prognosis, or outlook, tends to be worse for older adults/ those over 65 or people with other existing medical conditions. The same applies to individuals who present their symptoms late or show symptoms of shock at their first medical consultation; they too have a higher death rate.
Possible Complications When Diagnosed with Peptic Ulcer Perforated
Complications arising from untreated peptic ulcer perforation can be quite serious and may eventually result in death. Immediate complications can include:
- Hypovolemia or low blood volume
- Shock, which is a critical condition that can threaten your life
- Sepsis, a severe infection that spreads through the bloodstream
- Formation of a gastrocolic fistula, which is an abnormal connection between the stomach and the colon
Preventing Peptic Ulcer Perforated
People suffering from peptic ulcers, which are sores on the lining of the stomach, must be informed about the possibility of the ulcer breaking through, or perforating, the stomach wall. This can lead to severe complications. Following medication instructions accurately is vital in ensuring that the ulcer heals properly.
They should make an effort to stop smoking since this can worsen the condition. Similarly, they should try to stay away from things that can intensify the ulcer. These include certain medicines known as nonsteroidal anti-inflammatory drugs (NSAIDs), which are commonly used for pain like ibuprofen, alcohol and drinks with caffeine such as coffee and some sodas.
