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Perforated Peptic Ulcer

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Textbook of Emergency General Surgery

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Abstract

Perforated peptic ulcer (PPU) presents with a clinical triad of sudden severe epigastric pain, tachycardia, and abdominal rigidity. An erect chest X-ray is an important diagnostic test. Computerized tomography (CT) scan is indicated when PPU is suspected, but chest X-ray is normal. Compliance with sepsis bundle is an integral component of resuscitation. PPU is a surgical emergency, and source control warrants closure of perforation. Open and laparoscopic omental patch suture repair (OPR) techniques (Graham’s patch or Cellan-Jones repair) and falciformopexy are safe, feasible, and comparable. Laparoscopic OPR may expedite the post-operative recovery; however, it requires proficiency in intra-corporeal suturing. Non-operative management (NOM) and endoscopic clipping or stenting are reported to be safe in selected patients. The principles of NOM are six R’s: radiologically undetected leak; repeated clinical examination; repeated blood investigations; respiratory and renal support; resources for monitoring; and readiness to operate. Gastric resections are warranted in patients with suspected malignancy or a giant ulcer size. There is minimal data to suggest that gastric resection improves clinical outcomes in patients with a giant ulcer. Vagotomy can be considered obsolete. Proton pump inhibitors, smoking cessation, and Helicobacter pylori eradication are the cornerstone for preventing recurrence. Scoring systems can assist in predicting mortality.

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Authors and Affiliations

  1. Ministry of Health Holdings, Singapore, Singapore

    Delphina Yeo Boon Xue & Ramkumar Mohan

  2. Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore

    Vishal G. Shelat

  3. Lee Kong Chian School of Medicine, Nanyang Technology University, Singapore, Singapore

    Vishal G. Shelat

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  1. General, Emergency and Trauma Surgery Dept., Pisa University Hospital, Pisa, Italy

    Federico Coccolini

  2. General and Emergency Surgery Dept., Bufalini Hospital, Cesena, Italy

    Fausto Catena

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Xue, D.Y.B., Mohan, R., Shelat, V.G. (2023). Perforated Peptic Ulcer. In: Coccolini, F., Catena, F. (eds) Textbook of Emergency General Surgery. Springer, Cham. https://doi.org/10.1007/978-3-031-22599-4_72

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