A Randomized Trial of Nonoperative Treatment for Perforated Peptic Ulcer

Abstract

To determine whether surgery could be avoided in some patients with perforated peptic ulcer, we conducted a prospective randomized trial comparing the outcome of nonoperative treatment with that of emergency surgery in patients with a clinical diagnosis of perforated peptic ulcer. Of the 83 patients entered in the study over a 13-month period, 40 were randomly assigned to conservative treatment, which consisted of resuscitation with intravenous fluids, institution of nasogastric suction, and intravenous administration of antibiotics (cefuroxime, ampicillin, and metronidazole) and ranitidine. Eleven of these patients (28 percent) had no clinical improvement after 12 hours and required an operation. Two of the 11 had a perforated gastric carcinoma, and 1 had a perforated sigmoid carcinoma. The other 43 patients were assigned to immediate laparotomy and repair of the perforation. One of these patients was found to have a perforated gastric carcinoma. The overall mortality rates in the two groups were similar (two deaths in each, 5 percent), and did not differ significantly in the morbidity (infection, cardiac failure, or renal failure) rates (40 percent in the surgical group and 50 percent in the nonsurgical group). The hospital stay was 35 percent longer in the group treated conservatively. Patients over 70 years old were less likely to respond to conservative treatment than younger patients (P less than 0.05). We conclude that in patients with perforated peptic ulcer, an initial period of nonoperative treatment with careful observation may be safely allowed except in patients over 70 years old, and that the use of such an observation period can obviate the need for emergency surgery in more than 70 percent of patients.

Evidence-based clinical practice guidelines for peptic ulcer disease 2015

“…Crofts et al [148] reported patients below 70 years old were significantly less likely to transfer to surgical therapy than older patients. Many studies reported that age of indication for conservative therapy was less than 70 years.…”

“…Comment: Even when surgery is not indicated based on the above statements, follow-up CT is needed for patient observation [148]. If the patient's state is not improved at follow-up, the surgery is indicated.…”

Management of Peptic Ulcer Perforation is there A Role for Conservative Management? A Research Study at a Tertiary Care Center in North East India

“…A fibrin clot appears quickly on and around the perforation. This is the initiation of definitive closure of perforation with the help of adhesions between perforated ulcer and adjacent organs [12][13][14][15] .…”

“…In the Exeter series, 33% of those over 70s had perforation for longer than 24 hours. Conservative treatment is not advised with a history longer than 12 hours [24] . In our study 50% of the patients presented within first 24 hours and another 41% of patients presented within 24-72 hours of onset of symptoms.…”

“…However, non-operative treatment has been shown to be safe and effective in selected patients [9] . It is known that perforated ulcers frequently seal spontaneously by the adherence of the omentum of organs adjacent to the ulcer and operation can be avoided in selected patients [10] .…”