What are some of the common risk factors for peptic ulcer disease?

• Helicobacter pylori infection (in 90% of duodenal ulcer, DU)

• Alcohol abuse

• Non-steroidal anti-inflammatory drugs (NSAIDs)

• Steroids

• Old age

What pre-operative measures must be undertaken in the management of a patient with a perforated peptic ulcer?

• Intravenous fluid resuscitation

• Urinary catheterisation and hourly urine output monitoring

• Nasogastric intubation to decompress the stomach

• Central venous catheterisation (if the patient is haemodynamically unstable)

• Analgesia

• Intravenous proton pump inhibitors

• Intravenous antibiotics (e.g. Cefuroxime and Metronidazole)

• Blood investigations indicate a neutrophil leucocytosis (Pancreatitis must be excluded with an amylase)

• Erect CXR will reveal a pneumoperitoneum in only 80% of cases (Can also use a lateral decubitus film which is more sensitive)

Describe how you would repair a perforated DU

The aim is primarily to repair defect and to wash out the abdominal cavity.

Position This is supine the patient is prepared and draped as for a laparotomy.

Incision Upper midline through linea alba (see Chapter 24, Laparotomy).

Procedure The duodenum is isolated and the perforation identified. A patch of omentum is oversawn across the perforation using Vicryl sutures. The abdomen is irrigated with copious amounts of warm saline. A drain may be placed prior to closure.

Closure The abdomen is closed using mass closure technique as for a laparotomy.

What if there is a perforated gastric ulcer?

This will only be evident at operation and the treatment is the same as for DU. A biopsy of the ulcer should be taken for definitive pathological diagnosis prior to repair with an omental patch as there is a higher occurrence of malignant ulcer here.