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WSES · 2020

Perforated Peptic Ulcer — Risk Stratification, Operative Decision & Approach

Source: Perforated and bleeding peptic ulcer: WSES guidelines, World Journal of Emergency Surgery, 2020
Guideline: Strong Guideline: Conditional Guideline: Not recommended ClinicoQ pathway suggestion (not from the cited guideline)

Diagnosis

Diagnostic criteria Suspected based on sudden-onset, severe, constant epigastric pain with peritoneal signs (rigidity, guarding, diminished bowel sounds). Upright abdominal X-ray shows pneumoperitoneum in about 80% of cases; if free air is not seen but suspicion remains, CT abdomen is highly sensitive for perforation.
⚠ Alarm features (investigate before diagnosing)
Initial workup
TestWhen to order
Upright chest/abdominal X-ray Initial test in suspected perforation — shows free air (pneumoperitoneum) in ~80% of cases.
CT abdomen When free air is not seen on X-ray but clinical suspicion remains — highly sensitive for perforation.
Boey, PULP, or ASA score calculation In all patients, to risk-stratify and predict outcomes (Weak recommendation, 2C). Note: the Boey score shows notable variability in accuracy across studies; the newer PULP score and ASA score have been shown to predict mortality at least as well as, and in some studies better than, the Boey score — though PULP is harder to apply and hasn't been validated outside its original center. Hypoalbuminemia remains the single strongest predictor of mortality across studies.
Water-soluble contrast study In stable patients being considered for non-operative management, to confirm the perforation is sealed.

Decision Points

❓ Is the patient hemodynamically stable with normal vital signs?
No — shock or instability → Resuscitate + urgent operative repair
Yes — stable → Assess for non-operative management candidacy
❓ Is the patient a candidate for non-operative management (sealed perforation on water-soluble contrast study, no signs of ongoing leak/peritonitis)?
Yes — sealed perforation, stable, minimal peritonitis → Non-operative management (selected patients)
No — free leak, peritonitis, or unstable → Operative repair — approach selection
❓ For a stable patient needing operative repair: is appropriate laparoscopic skill and equipment available?
Yes — laparoscopic skills and equipment available → Laparoscopic repair
No — laparoscopic skills/equipment not available → Open repair

Treatment

Resuscitate + urgent operative repair

1 IV fluid resuscitation, broad-spectrum antibiotics, NG decompression, then urgent surgery Strong (Guideline recommendation)
Dose
Broad-spectrum antibiotics covering Gram-negative and anaerobic organisms
Duration
Surgery as soon as the patient is resuscitated enough to tolerate it — without unnecessary delay
Evidence level
Moderate
Avoid if
-
If no response
In unstable patients, the guideline recommends open surgery specifically (Strong, 1D) — a laparoscopic approach is not used regardless of skill/equipment availability

Assess for non-operative management candidacy

1 Obtain a water-soluble contrast study to check whether the perforation has sealed Guideline recommendation — this assessment determines whether the patient is a candidate for non-operative management or needs operative repair
Dose
-
Duration
-
Evidence level
Low
Avoid if
-
If no response ClinicoQ pathway
See the nom_candidacy decision point above for the next step based on the contrast study result

Non-operative management (selected patients)

1 NG decompression, IV fluids, broad-spectrum antibiotics, serial abdominal exams, PPI therapy Conditional (Guideline recommendation) — appropriate only in carefully selected stable patients with a sealed perforation
Dose
IV PPI + broad-spectrum antibiotics
Duration
Close monitoring; factors associated with NOM failure include larger pneumoperitoneum, heart rate >94 bpm, and abdominal distension — reassess frequently
Evidence level
Low-Moderate
Avoid if
Any sign of clinical deterioration, ongoing leak, or peritonitis on reassessment
If no response ClinicoQ pathway
Convert to operative repair if clinical deterioration or failure to improve

Operative repair — approach selection

1 Determine whether appropriate laparoscopic skill and equipment are available Guideline recommendation — this determines the choice between laparoscopic and open repair for a stable patient (see the approach_selection decision point above)
Dose
-
Duration
-
Evidence level
Moderate
Avoid if
-
If no response ClinicoQ pathway
-

Laparoscopic repair

1 Laparoscopic simple closure (with or without omental patch) Weak (Guideline recommendation, 2B) — the guideline's criterion for choosing laparoscopic over open is patient stability plus availability of laparoscopic skills/equipment, not the Boey score or perforation size specifically
Dose
- surgical procedure; simple closure alone has shown comparable outcomes to closure plus omental patch in several comparative studies
Duration
As soon as possible after diagnosis
Evidence level
Moderate
Avoid if
Higher conversion risk has been observed in the literature with a high Boey score (2-3), large perforation (>=10mm, especially >=25mm which carries a higher leak rate with the omental patch technique), or inability to localize the perforation site — these are useful clinical considerations for anticipating conversion, but are not themselves the guideline's stated criterion for choosing the approach
If no response ClinicoQ pathway
Convert to open repair if safe laparoscopic closure is not feasible

Open repair

1 Open surgical repair (simple closure +/- omental patch, with peritoneal lavage) Weak (Guideline recommendation, 2B) — recommended when laparoscopic skills/equipment are unavailable, and Strong (1D) for hemodynamically unstable patients regardless of skill/equipment availability
Dose
- surgical procedure
Duration
As soon as possible after diagnosis/resuscitation
Evidence level
Moderate
Avoid if
-
If no response
-

✕ Treatments the guideline advises against

Non-operative management as the default approach for most patients: Guideline states this approach is not appropriate for the large majority of patients with perforated peptic ulcer — it is reserved for carefully selected, stable patients with a confirmed sealed perforation.
Routine addition of an omental patch to simple suture closure: Multiple comparative studies found no consistent additional benefit (leak rate, complications, hospital stay) over simple closure alone — though practice varies and some surgeons still add it routinely. The guideline makes no recommendation for or against the omental patch specifically (Weak, 2C).
Endoscopic treatment (clipping, fibrin glue sealing, or stenting) as a standard approach: Guideline suggests avoiding these (Weak, 2C) — case series exist but these are not recognized as standard approaches and need further validation.
⚠️ Correction note: the criterion for choosing a laparoscopic vs. open surgical approach was revised to match the guideline's actual recommendation — patient hemodynamic stability plus availability of laparoscopic skills/equipment, not the Boey score or perforation size (which were previously, and incorrectly, used as the gating criterion here; those factors come from a different question in the guideline about the sutureless-repair literature, not the open-vs-laparoscopic question). A caveat about the Boey score's variable accuracy relative to PULP/ASA scores was also added. This is an educational summary of current international clinical practice guidelines and does not replace individualized clinical judgment. Final treatment decisions remain the responsibility of the treating physician.