Perforated Peptic Ulcer: When Initial Resuscitation Has Not Restored Haemodynamic Stability
In a subset of patients with perforated peptic ulcer, the initial resuscitative approach — however promptly applied — fails to achieve the physiological targets required for safe, definitive repair. This page describes the recognised next step once that failure is established.
Clinical scenario
The patient presents with, or deteriorates into, haemodynamic instability in the setting of a perforated peptic ulcer. Despite active management, physiological parameters remain outside acceptable thresholds, placing the patient in a category requiring a modified surgical strategy.
Why the initial approach was insufficient
The preceding step — rapid resuscitation with fluid and vasopressor therapy (guided by haemodynamic monitoring), broad-spectrum antibiotics, and prompt open surgery — did not achieve the required physiological restoration.
Specifically, one or more of the following goals was not met: mean arterial pressure ≥ 65 mmHg, urine output ≥ 0.5 ml/kg/h, and lactate normalisation.
Next-step approach
In patients with septic shock from a perforated peptic ulcer and signs of severe physiological derangement, the evidence supports a damage control surgical strategy — a structured, staged operative approach designed to limit physiological insult and defer definitive repair until stability is achieved.
The full protocol specifies the operative sequence, decision thresholds, and subsequent management steps.
References
- In unstable patients with perforated peptic ulcer, we recommend performing rapid resuscitation to reduce mortality (strong recommendation based on low quality evidences, 1C).
- In unstable patients with perforated peptic ulcer, we recommend open surgery (strong recommendation based on very low-quality of evidences, 1D).
- In patients with septic shock from a perforated peptic ulcer and signs of severe physiological derangement, we suggest a damage control strategy (Weak recommendation based on very low-quality of evidences, 2D).
View source ↗