Treatment Options for Perforated Duodenal Ulcer

Perforated duodenal ulcer is a common acute abdominal condition characterized by severe symptoms and variable clinical presentations. The treatment approach generally falls into two categories: surgical and non-surgical. Here's a detailed overview of the available treatment strategies:

Surgical Treatment

Simple Perforation Repair

For patients with perforated duodenal ulcers that are not suspected to be malignant, simple perforation repair may be appropriate under certain conditions. This approach is typically considered when the perforation has been present for more than eight hours and there is significant intra-abdominal infection with purulent exudate. It is especially suitable for older patients or those with comorbidities who cannot tolerate prolonged surgery. In such cases, a straightforward closure of the perforation with sutures may be performed without attempting a more extensive procedure.

Radicical Resection Procedures

In most other scenarios, a more definitive surgical approach is preferred. This involves complete removal of both the ulcer and the perforation in a single procedure. This option is suitable for patients whose perforation duration is less than eight hours, or even longer if peritoneal contamination is not extensive. A common surgical technique used is partial gastrectomy with Billroth II anastomosis, which effectively addresses both the ulcer and perforation while reducing the risk of recurrence.

Non-Surgical (Conservative) Treatment

When Is Conservative Management Appropriate?

Conservative treatment may be considered for patients with favorable clinical characteristics. These include those with small, fasting-state perforations, minimal abdominal signs, and localized peritonitis that has stabilized after more than 24 hours. Additionally, patients who have undergone upper gastrointestinal imaging with water-soluble contrast (such as gastrografin) that confirms the perforation has sealed may be candidates for non-operative management—provided they do not have complications like bleeding or pyloric obstruction.

Key Components of Non-Operative Care

Non-surgical management involves several critical elements to ensure successful outcomes. These include continuous gastric decompression through nasogastric tube placement, maintenance of fluid and electrolyte balance, and nutritional support. Antibiotic therapy is essential to control and prevent infection, while proton pump inhibitors (PPIs) administered intravenously help suppress gastric acid secretion, promoting ulcer healing and reducing the risk of further complications.