Perforated and bleeding peptic ulcer: WSES guidelines

Abstract

Background: Peptic ulcer disease is common with a lifetime prevalence in the general population of 5-10% and an incidence of 0.1-0.3% per year. Despite a sharp reduction in incidence and rates of hospital admission and mortality over the past 30 years, complications are still encountered in 10-20% of these patients. Peptic ulcer disease remains a significant healthcare problem, which can consume considerable financial resources. Management may involve various subspecialties including surgeons, gastroenterologists, and radiologists. Successful management of patients with complicated peptic ulcer (CPU) involves prompt recognition, resuscitation when required, appropriate antibiotic therapy, and timely surgical/radiological treatment. Methods: The present guidelines have been developed according to the GRADE methodology. To create these guidelines, a panel of experts was designed and charged by the board of the WSES to perform a systematic review of the available literature and to provide evidence-based statements with immediate practical application. All the statements were presented and discussed during the 5th WSES Congress, and for each statement, a consensus among the WSES panel of experts was reached. Conclusions: The population considered in these guidelines is adult patients with suspected complicated peptic ulcer disease. These guidelines present evidence-based international consensus statements on the management of complicated peptic ulcer from a collaboration of a panel of experts and are intended to improve the knowledge and the awareness of physicians around the world on this specific topic. We divided our work into the two main topics, bleeding and perforated peptic ulcer, and structured it into six main topics that cover the entire management process of patients with complicated peptic ulcer, from diagnosis at ED arrival to post-discharge antimicrobial therapy, to provide an up-to-date, easy-to-use tool that can help physicians and surgeons during the decision-making process.

The modified Boey score (mBoey) for outcome prediction in patients with perforated peptic ulcer complicated by diffuse peritonitis: a retrospective study

“…The Boey score is the most commonly and easily implemented among different scoring systems, and accurately predicts perioperative morbidity and mortality preoperatively in PPU patients [33]. However, the positive predictive value of 94% reported earlier has not been replicated in subsequent studies [1].…”

“…With increasing age of patients, the duration of the perforation, as well as the presence of severe concomitant diseases, the morbidity and mortality rates increase [33]. The use of prognostic systems makes it possible to identify high-risk surgical patients with perforated peptic ulcer, but currently there is no 'ideal' score and, according to the literature, clinical prediction rules are not routinely used in PPU patients in everyday clinical practice [18].…”

Optimal treatment and complications for the perforated upper gastrointestinal tract

“…Most of the patients with suspected PPU received immediate surgery as an initial treatment [3,9]. Recently, the possibility of non-operative management has been assessed in the WSES and JSGE guidelines for PPU [11,12]. The WSES recommended against a routinely use of non-operative management, but non-operative management could be considered in extremely selected cases where perforation has sealed as con rmed on water-soluble contrast (weak recommendation based on lowquality evidence, 2C) [11].…”

“…Recently, the possibility of non-operative management has been assessed in the WSES and JSGE guidelines for PPU [11,12]. The WSES recommended against a routinely use of non-operative management, but non-operative management could be considered in extremely selected cases where perforation has sealed as con rmed on water-soluble contrast (weak recommendation based on lowquality evidence, 2C) [11]. The JSGE proposed that mild localized peritonitis could be an indication of nonoperative treatment for PPU.…”

“…The aforementioned panel of experts was assembled and charged by the board of the WSES with the purpose of answering clinical questions (CQs) pertaining to six main topics that thoroughly explain this pathology. These topics are diagnosis, resuscitation, nonoperative management, surgery, angiography-angioembolization, antimicrobial therapy [11]. In Japan, the Japanese Society of Gastroenterology (JSGE) has developed the evidence-based clinical practice guidelines for PU.…”