Synopsis
Recognise gastroduodenal perforation before physiological collapse, resuscitate and treat intra-abdominal infection while arranging urgent source control, then address ulcer aetiology and nutritional recovery after the emergency.
- A duodenal or gastric ulcer can perforate freely into the peritoneum or leak in a contained fashion into adjacent tissue, producing very different early examination findings.
- Pain classically starts abruptly in the epigastrium and becomes generalised, but older, frail, immunosuppressed and steroid-treated patients may have muted tenderness despite severe contamination.
- NSAIDs, aspirin, H. pylori, smoking, previous ulcer and delayed presentation increase probability; absence of previous dyspepsia does not protect against a first perforation.
Key red flags
Abrupt epigastric pain that spreads across the abdomen, with involuntary guarding, percussion tenderness or rigidity, should be treated as a perforated viscus until urgent assessment proves otherwise.
Investigation priorities
Locate perforation, assess contamination and identify an alternative surgical emergency.
Management branches
Sudden severe abdominal pain, peritonism, sepsis or imaging suggests a gastroduodenal leak.
- Keep nil by mouth, call senior general or upper-GI surgery and anaesthesia, obtain venous access, bloods and crossmatch, and begin monitored resuscitation with analgesia and antiemesis.
- Give broad-spectrum intravenous antimicrobial treatment using the current intra-abdominal sepsis protocol and arrange urgent contrast CT if stability permits without creating a source-control delay.
Key medicines
Broad-spectrum intravenous treatment for gastroduodenal perforationStart the current local complicated intra-abdominal infection regimen promptly; select agent and dose for allergy, renal function, sepsis severity, prior colonisation and local resistance, then review after source control and cultures.
Proton-pump inhibitor after perforated ulcerUse the named intravenous or oral product and dose in the surgical ulcer protocol, changing route as enteral function returns and defining duration from site, cause, repair and follow-up findings.