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.
- Contrast-enhanced CT is the most informative test in a patient stable enough for imaging, showing free gas, focal wall defect, fluid and alternative causes of an acute abdomen.
- Resuscitation and diagnosis must proceed in parallel with antibiotics and surgical decision-making because delay to control of an infected leak worsens outcome.
- Most free perforations require operative repair and peritoneal washout; laparoscopic or open access and the exact repair depend on physiology, site, size, tissue quality and expertise.
- Non-operative treatment is exceptional and belongs to close consultant-led observation of a stable patient with evidence that the leak has sealed and immediate access to surgery if deterioration occurs.
- Survival from the operation is not the endpoint: test and eradicate H. pylori, remove ulcerogenic exposure, ensure gastric pathology is not malignant, and rebuild nutrition and function.
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.
Tachypnoea, cool peripheries, confusion, oliguria, hypotension or raised lactate suggests sepsis and hypovolaemia. Tachycardia may be absent with beta-blockade, pacing or advanced frailty.
Persistent tachycardia, fever, pain, ileus, rising inflammatory markers or enteric drain output after repair may signal leak, abscess or missed pathology and requires urgent reassessment.
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.
- Assess operative risk and destination early, but prioritise timely theatre for free perforation or deterioration, with consultant-delivered surgery and planned postoperative critical care when risk is high.