Treatment of Perforated Peptic Ulcer When the Perforation Has Sealed — Stable Patient with No Peritonitis or Sepsis
This protocol addresses a narrowly defined and carefully selected subset of patients with perforated peptic ulcer: those in whom the perforation has confirmed sealed on imaging, with no evidence of ongoing leak, peritoneal contamination, or systemic instability.
Clinical Scenario
The patient presents with a perforated peptic ulcer where water-soluble contrast study confirms the perforation is sealed, with:
- No contrast extravasation on imaging
- No clinical signs of peritonitis
- No sepsis
- Normal vital signs — haemodynamically stable
This constellation of findings defines an extremely selected group where clinical decision-making differs from the typical presentation. The evidence base for management in this scenario is limited, and recommendations carry important caveats.
Treatment Approach
Even in this carefully selected, seemingly stable presentation, the evidence-based approach centres on operative intervention. The full protocol specifies the operative strategy and the conditions under which alternatives may be weighed.
Complete regimen, criteria, and decision pathway available in the full protocol →
References
- In patients with perforated peptic ulcer we suggest against a routinely use of non-operative management; non-operative management (NOM) could be considered in extremely selected cases where perforation has sealed as confirmed on water-soluble contrast study (weak recommendation based on low-quality evidences, 2C).
- On the other hand, NOM could be considered if no contrast extravasation is present and the patient does not have signs of peritonitis or sepsis.
- In patients with perforated peptic ulcer with significant pneumoperitoneum or extraluminal contrast extravasation or signs of peritonitis, we recommend operative treatment (Strong recommendation based on low-quality evidences, 1C).
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