Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 8 Sept 2026Clinical review pending
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Free perforation with peritonitis
A full-thickness ulcer releases air and gastroduodenal contents, causing chemical peritonitis, bacterial contamination, hypovolaemia and sepsis that worsen with every delay to source control.
Action: Keep nil by mouth, begin ABCDE resuscitation, insert gastric decompression with senior oversight, give IV broad-spectrum antibiotics, obtain urgent CT and proceed to emergency surgery when free leak or peritonitis is present.
Synopsis
Recognise gastroduodenal perforation, resuscitate sepsis, demonstrate the leak, select operative repair or rare sealed-perforation observation, and eradicate the ulcer cause after source control.
CT abdomen is the preferred imaging test because it detects free gas, fluid, the likely site and an alternative diagnosis more sensitively than an erect chest radiograph.
WSES advises against routine non-operative management; consider it only in an exceptionally selected stable patient whose perforation is sealed on water-soluble contrast and who has no sepsis or peritonitis.
Operate promptly when there is contrast leak, peritonitis, pneumoperitoneum with clinical deterioration or failed observation; delay increases mortality.
Key red flags
Sudden severe epigastric pain with rigid generalised guarding, shock or free intraperitoneal gas is perforation until proved otherwise.
Temporary pain improvement after initial chemical peritonitis does not mean the defect has sealed safely; physiology and contrast leak determine the plan.
Abrupt peritonism
Sudden severe epigastric pain rapidly generalises as gas and acidic contents contact the parietal peritoneum.
Septic physiology
Tachycardia, hypotension, confusion, oliguria and rising lactate mark systemic consequence and demand rapid source control.
Investigation priorities
01
Contrast CT abdomen and pelvisFirst step
Confirm perforation, locate the likely defect and quantify contamination.
Management branches
Free perforationMove from shock to source control
A 61-year-old NSAID user has sudden generalised pain, rigid guarding, lactate 4.1 mmol/L and CT showing free gas with contrast leaking from the anterior duodenal bulb. Initial pressure is 88/54 mmHg with pulse 118/min; there is no beta-lactam allergy and renal function permits the standard antibiotic dose.
Keep nil by mouth, call surgery and anaesthesia, establish IV access, resuscitate perfusion and decompress the stomach. In this DBTH-protocol example, start co-amoxiclav 1.2 g IV every eight hours, infused over 30–40 minutes, alongside urgent source-control planning.
After resuscitation, blood pressure is 116/72 mmHg, pulse 92/min, urine output exceeds 0.5 mL/kg/hour and lactate has fallen to 2.0 mmol/L. Active leak and generalised peritonitis still require urgent operation; his restored stability permits the experienced team to choose laparoscopy. Persistent instability would favour an open approach.
Exceptionally selected observationProve sealing and retain rescue
A stable patient presents early with localised pain, no sepsis, and CT shows a tiny perigastric air pocket without diffuse fluid.
Key medicines
Co-amoxiclav example for perforated-ulcer intra-abdominal infectionThis is the September 2025 DBTH adult complicated intra-abdominal infection example. Give co-amoxiclav 1.2 g IV every eight hours by infusion over 30–40 minutes; the selected product also permits slow injection over 3–4 minutes. Review at 48–72 hours and, when improving and absorbing, change to 625 mg orally every eight hours with a meal, completing five days according to response and source control. For age over 65 AND co-amoxiclav or cephalosporin exposure in the preceding two weeks, DBTH instead uses piperacillin/tazobactam 4.5 g IV every eight hours, infused over 30 minutes, followed by culture-led oral de-escalation.Co-amoxiclav is contraindicated with penicillin hypersensitivity, a previous severe immediate reaction to another beta-lactam, or prior co-amoxiclav-associated jaundice/hepatic dysfunction. After an initial IV 1,000/200 mg dose, reduce to 500/100 mg every 12 hours at CrCl 10–30 mL/min or every 24 hours below 10. The oral 500/125 mg tablet frequency is twice daily at CrCl 10–30 or once daily below 10, not the normal-function three-times-daily schedule. Piperacillin/tazobactam is contraindicated with penicillin hypersensitivity or a previous acute severe other beta-lactam reaction; its maximum is 4 g/0.5 g every eight hours at CrCl 20–40 and every 12 hours below 20. Send cultures and monitor renal/hepatic function and electrolytes. Reassess dosing as AKI changes; antibiotics support but cannot replace closure and washout.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 8 Sept 2026; clinical approval remains outstanding.