What are the WSES guidelines for the diagnosis and treatment of perforated peptic ulcer?

Updated: Apr 26, 2021
  • Author: BS Anand, MD; Chief Editor: Philip O Katz, MD, FACP, FACG  more...
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Perforated peptic ulcer clinical practice guidelines were released in January 2020 by the World Society of Emergency Surgery. [68]

The recommended biochemical and imaging investigations in the diagnosis of perforated peptic ulcer are as follows:

  • Suspected gastroduodenal perforation: Routine laboratory studies and arterial blood gas analysis

  • Acute abdomen from suspected perforated peptic ulcer: CT scanning

  • Acute abdomen from suspected perforated peptic ulcer: Chest and abdominal radiography as initial diagnostic assessment in the event CT scanning is not immediately available

  • Acute abdomen from suspected perforated peptic ulcer if free air is not seen on imaging and perforation remains a concern: Imaging with water-soluble contrast (oral or via nasogastric tube)

The recommended targets for resuscitation in unstable patients with a perforated peptic ulcer are as follows:

  • Rapid resuscitation to reduce mortality

  • Restoration of physiological parameters with a mean arterial pressure 65 mm Hg or higher, urine output of 0.5 mL/kg/h or greater, and lactate normalization

  • Use of hemodynamic monitoring (invasive or noninvasive) to optimize fluid/vasopressor therapy, with an individualized resuscitation strategy

Surgical indications and appropriate timing of surgery in patients with perforated peptic ulcer are as follows:

  • In association with significant pneumoperitoneum, extraluminal contrast extravasation, or signs of peritonitis: Operative treatment strongly recommended

  • Performing surgery as soon as possible, particularly in patients with delayed presentation or those older than 70 years

The recommended surgical approach (laparoscopic vs open) for perforated peptic ulcer is as follows:

  • Stable patients: Laparoscopic approach, unless equipment and skilled personnel are not available, in which case an open approach is recommended

  • Unstable patients: Open surgery

The recommended antimicrobial and antifungal therapy strategies in perforated peptic ulcer are as follows:

  • Administration of broad-spectrum antibiotics

  • Microbiological sample collection for analysis for bacterial and fungal pathogens in all patients undergoing surgery, with postanalysis antibiotic therapy adjustment as needed

  • Antifungal agents not suggested as standard empiric therapy; may be appropriate in high-risk patients, such as those who are immunocompromised, have comorbidities, or are of advanced age

The recommended antimicrobial regimen and duration of therapy in perforated peptic ulcer are as follows:

  • Initiation of empiric broad-spectrum antibiotics as soon as possible, targeting gram-negative, gram-positive, and anaerobic bacteria

  • Short course of 3-5 days or until inflammatory markers normalize

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