A perforated peptic ulcer is a full-thickness breach of the stomach or duodenum that spills gastroduodenal content into the peritoneal cavity, and it presents as sudden severe epigastric pain. According to the WSES guidelines on perforated and bleeding peptic ulcer, the answer is rapid resuscitation to defined physiological targets, a CT scan, and operative treatment as soon as possible when there is significant pneumoperitoneum, contrast extravasation or peritonitis. The station tests whether you can resuscitate and get a patient to theatre without delay.

Key takeaways

  • The WSES guidelines recommend CT imaging in patients with an acute abdomen from suspected perforated peptic ulcer, with chest and abdominal radiographs as the initial assessment only when CT is not promptly available
  • Free air on plain radiography is present in a highly variable 30% to 85% of perforations, so a negative film does not exclude a perforated peptic ulcer
  • WSES recommends restoring a mean arterial pressure of 65 mmHg or more, a urine output of 0.5 ml/kg/hr or more, and normalisation of lactate in unstable patients
  • WSES recommends operative treatment for significant pneumoperitoneum, extraluminal contrast extravasation or signs of peritonitis, and surgery as soon as possible, especially in delayed presentation and in patients over 70
  • In the Danish cohort WSES cites, each hour of surgical delay in the first 24 hours after admission was associated with an adjusted 2.4% decreased probability of survival compared with the previous hour
  • WSES suggests primary repair for a perforation smaller than 2 cm, a laparoscopic approach in stable patients, open surgery in unstable patients, and a short antibiotic course of 3 to 5 days

How do I recognise a perforated peptic ulcer?

Recognise a perforated peptic ulcer from sudden-onset severe abdominal pain in a patient who is still, rigid and unwilling to move, often with a history of non-steroidal anti-inflammatory drugs, steroids, smoking or previous ulcer disease.

Do not rely on peritonism to make the diagnosis. The WSES guidelines note that localised or generalised peritonitis is typical of perforated peptic ulcer but may be present in only two-thirds of patients.

Examination findings are least reliable where they matter most. WSES states that physical findings may be equivocal and peritonitis may be minimal or absent, particularly where a perforation has contained or sealed.

Be most suspicious in older, frail and immunosuppressed patients, in whom a perforated peptic ulcer can present with hypotension and confusion rather than with a rigid abdomen.

What is my immediate A to E management of a suspected perforated peptic ulcer?

The immediate management of a suspected perforated peptic ulcer is A to E resuscitation with high-flow oxygen if hypoxic, two large-bore cannulae, fluid resuscitation, analgesia, blood cultures and early broad-spectrum antibiotics.

WSES recommends rapid resuscitation in unstable patients with perforated peptic ulcer to reduce mortality, and names the targets: a mean arterial pressure of 65 mmHg or more, a urine output of 0.5 ml/kg/hr or more, and lactate normalisation.

Alongside that, make the patient nil by mouth, pass a nasogastric tube and a urinary catheter, start a proton pump inhibitor, correct coagulopathy, and book the theatre conversation while the fluids are still running.

WSES also recommends prompt evaluation and early recognition of perforated peptic ulcer associated sepsis to prevent further organ failure, and suggests SOFA and qSOFA to assess severity.

Which investigations do I order in a perforated peptic ulcer?

In a suspected perforated peptic ulcer, WSES recommends routine laboratory studies and arterial blood gas analysis, and recommends a CT scan as the imaging investigation in patients with an acute abdomen.

WSES recommends an erect chest or abdominal radiograph as the initial routine assessment only where a CT scan is not promptly available. Erect and left lateral decubitus films have similar accuracy, and the decubitus film is better tolerated in peritonitis.

Know the limitation. WSES states that free air on plain radiography is present in a highly variable 30% to 85% of perforations, which is why a clear film cannot exclude a perforated peptic ulcer.

When free air is not seen and suspicion persists, WSES suggests imaging with the addition of water-soluble contrast, either orally or via a nasogastric tube. Send bloods including lactate, amylase, a coagulation screen and a group and save.

When does a perforated peptic ulcer need an operation?

A perforated peptic ulcer needs an operation when there is significant pneumoperitoneum, extraluminal contrast extravasation or signs of peritonitis, which is exactly how the WSES recommendation is worded.

WSES recommends performing surgery as soon as possible, especially in patients with delayed presentation and patients older than 70 years, and it grades that recommendation on moderate-quality evidence.

The number to quote is the gradient rather than a deadline. In the Danish cohort WSES cites, each hour of surgical delay over the first 24 hours after admission carried an adjusted 2.4% decreased probability of survival compared with the previous hour.

WSES suggests against the routine use of non-operative management in perforated peptic ulcer, and confines it to extremely selected cases where the perforation has sealed as confirmed on a water-soluble contrast study.

What operation is done for a perforated peptic ulcer?

For a perforated peptic ulcer smaller than 2 cm, WSES suggests primary repair, and makes no recommendation on whether an omental patch adds further protection to that repair.

For a perforation larger than 2 cm, WSES suggests a tailored approach based on the ulcer's location. Large gastric ulcers raise the suspicion of malignancy and it suggests resection with frozen section where possible, and considering resection for large duodenal ulcers.

On access, WSES suggests a laparoscopic approach in stable patients with perforated peptic ulcer, with open surgery recommended in the absence of appropriate laparoscopic skills and equipment, and recommends open surgery in unstable patients.

In septic shock with severe physiological derangement, WSES suggests a damage control strategy. It also suggests avoiding endoscopic treatments such as clipping, fibrin glue sealing or stenting in perforated peptic ulcer.

What antibiotics does a perforated peptic ulcer need?

A perforated peptic ulcer needs broad-spectrum antibiotics, and WSES recommends starting an empirical regimen against a mixture of Gram-negative, Gram-positive and anaerobic bacteria as soon as possible, ideally after peritoneal fluid has been collected.

WSES recommends collecting samples for microbiological analysis for both bacteria and fungi in all patients undergoing surgery, with subsequent adjustment of the antibiotic therapy to the results.

On duration, WSES suggests a short course of 3 to 5 days, or until inflammatory markers normalise, once source control is adequate. It suggests against routine empirical antifungal therapy, reserving it for patients at high risk of fungal infection.

How do I risk-stratify a patient with a perforated peptic ulcer?

Risk-stratify a patient with a perforated peptic ulcer with a formal score. WSES suggests adopting scoring systems including the Boey, PULP and ASA scores for risk stratification and to predict outcomes.

WSES notes that the Boey score is the most used, that its accuracy varied widely across validation studies, and that the PULP and ASA scores predicted mortality equally well and better than Boey.

The single strongest predictor WSES names is hypoalbuminaemia. The systematic review it cites also associated older age, comorbidity, use of NSAIDs or steroids, shock on admission, preoperative metabolic acidosis, tachycardia, acute renal failure, a high ASA score and preoperative delay over 24 hours with poor prognosis.

Who do I escalate a perforated peptic ulcer to, and when?

Escalate a perforated peptic ulcer to the surgical registrar the moment it is suspected, and to the consultant and the anaesthetic team once CT confirms it, because the operating list is the destination.

Escalate to critical care early for a patient in shock, with a raised lactate, with organ dysfunction or with a high predicted mortality, because postoperative level 2 or 3 care usually needs booking before theatre, not after.

Escalate the frailty conversation too. In a very frail patient with a perforated peptic ulcer, a ceiling of treatment discussion with the consultant, the patient and the family is part of the management, not a substitute for it.

What is the interviewer listening for in a perforated peptic ulcer scenario?

The interviewer in a perforated peptic ulcer scenario is listening for parallel resuscitation and escalation, CT rather than a plain film as the modern answer, and an understanding that delay kills.

  • Resuscitation targets named: mean arterial pressure of 65 mmHg or more, urine output of 0.5 ml/kg/hr or more, lactate normalisation
  • CT named as the investigation, with the plain film reserved for where CT is not promptly available
  • The limitation of free air on plain film stated, at 30% to 85%
  • Antibiotics, proton pump inhibitor, nasogastric tube, catheter and theatre booking all happening at once
  • Primary repair under 2 cm, laparoscopic if stable, open if unstable, damage control in septic shock

What are the common mistakes in a perforated peptic ulcer answer?

The commonest mistake in a perforated peptic ulcer answer is waiting for a plain film to show free air, when WSES puts CT first and the plain film misses a large proportion of perforations.

The second is offering conservative management too readily. WSES suggests against routine non-operative management and restricts it to extremely selected cases where the perforation has sealed on a contrast study.

The third is sequencing rather than parallelising. Resuscitation, imaging, antibiotics, consent and the theatre booking in a perforated peptic ulcer happen together, and saying so is what separates a core trainee answer from a foundation one.

How this comes up at the CST interview

A perforated peptic ulcer usually arrives as an emergency department referral: sudden severe epigastric pain in a patient on non-steroidal anti-inflammatory drugs, tachycardic, with a rigid abdomen.

The panel then pushes on the frail patient who may not survive an operation, on what you would do if the CT scanner were busy, or on how you would consent a patient who is drowsy from sepsis.

The coresurgeryinterview question bank carries scored acute abdomen scenarios of this shape among its 299 questions, with AI-marked spoken practice for the resuscitation sequence: /Question-Bank/Sample-Questions.