Management of Peptic Ulcer Perforation: Is There a Role for Conservative Management?
Exploring non-surgical approaches to a traditional surgical emergency through research at a tertiary care center in Northeast India
Introduction
Imagine a sudden, stabbing pain in the stomach so severe it doubles you over. This could be more than just a stomach ache—it might be a perforated peptic ulcer (PPU), a hole in the lining of your stomach or intestine. For decades, this diagnosis has meant one thing: emergency surgery. But what if some patients could heal without going under the knife?
5-10%
Global lifetime prevalence of peptic ulcer disease 1
5%
Of ulcer cases result in perforation 6
50%
Mortality when treatment is delayed >24 hours 6
At tertiary care centers across India, including those in Northeast India, surgeons are challenging convention by carefully selecting some patients for non-operative management. This approach, when applied to the right patients, can avoid surgical risks while still achieving excellent outcomes. Through the lens of a research study at a tertiary care center in Northeast India, we explore whether conservative management deserves a more prominent role in treating this acute surgical condition.
Understanding Peptic Ulcer Perforation: Why It's a Surgical Emergency
What Causes Peptic Ulcers to Perforate?
Peptic ulcers develop when the protective lining of the stomach or the first part of the small intestine (duodenum) erodes. The two most common causes are:
- Helicobacter pylori infection: This bacterium weakens the protective mucous layer of the stomach
- Non-steroidal anti-inflammatory drugs (NSAIDs): Medications like ibuprofen and aspirin reduce substances that protect the stomach lining
Other risk factors include smoking, excessive alcohol consumption, physiological stress, and corticosteroid use .
Clinical Insight
When an ulcer burns completely through the stomach or intestinal wall, digestive juices and food particles leak into the abdominal cavity. This causes chemical peritonitis—inflammation and infection of the abdominal lining.
Recognizing the Signs and Making the Diagnosis
Patients with PPU typically experience sudden, severe upper abdominal pain that often radiates to the shoulders. The classic diagnostic triad includes sudden onset of abdominal pain, tachycardia, and abdominal rigidity 6 .
Doctors use imaging studies to confirm the diagnosis:
- Upright chest X-ray: Reveals free air under the diaphragm in about 70% of cases
- CT scan: More sensitive, with a diagnostic accuracy approaching 98%
The Traditional Approach: Surgical Management
For decades, surgery has been the gold standard for PPU treatment. The main surgical options include:
Open Repair
The conventional approach involves a midline abdominal incision. Surgeons then repair the perforation using one of several techniques:
- Simple closure: Suturing the hole closed
- Omentopexy: Closing the perforation with sutures and then securing a patch of omentum (fatty tissue in the abdomen) over the sutures
- Plug omentoplasty: Pulling the omentum through the perforation and securing it to the edges
Laparoscopic Repair
Minimally invasive laparoscopic techniques, first described in 1990, have gained popularity . Recent evidence confirms significant advantages.
A 2025 network meta-analysis of 16 studies confirmed that the laparoscopic approach demonstrated significantly reduced mortality and postoperative complications including wound infections and ileus compared to open surgical approach 1 .
Comparing Surgical Approaches for PPU Repair
| Approach | Key Advantages | Potential Drawbacks | Mortality Impact |
|---|---|---|---|
| Open Surgery | Shorter operation time, technically simpler, better for large perforations | Higher wound infection rates, more postoperative pain, longer recovery | Baseline reference |
| Laparoscopic Surgery | Reduced mortality, fewer wound infections, less postoperative pain, shorter hospital stay | Longer operation time, requires specific expertise, may need conversion to open | OR 0.36, 95% CI 0.17-0.75 1 |
When Surgery Might Be Avoided: The Case for Conservative Management
The Selection Process: Identifying Suitable Candidates
Not all perforated ulcers require immediate surgery. Conservative management—also known as non-operative management—involves:
- Nasogastric suction: A tube through the nose into the stomach to remove contents
- Intravenous fluids and electrolyte replacement
- Intravenous antibiotics to combat infection
- Acid-reducing medications to promote healing
- Close monitoring for signs of clinical deterioration
Effectiveness
Conservative management "predicated on gastroduodenogram confirmation of self-sealing perforation has been reported to be effective in 50–70% of cases" 6 .
Research-Based Selection Criteria
Research indicates that conservative management may be appropriate for patients with:
- Contained perforations (sealed off by surrounding organs)
- Minimal abdominal contamination on imaging
- Stable vital signs without signs of sepsis
- Presentation within 24 hours of symptom onset
The Role of Scoring Systems
The Boey score has emerged as a valuable prognostic tool that helps stratify patient risk and guide treatment decisions. This scoring system evaluates:
- Presence of severe medical comorbidities
- Preoperative shock (systolic blood pressure < 100 mmHg)
- Duration of perforation > 24 hours
Patients with lower Boey scores (0-1) are better candidates for conservative or minimally invasive approaches, while those with higher scores (2-3) typically require urgent surgery 6 .
Conservative Management Protocol
Initial Assessment
Clinical evaluation, imaging studies, Boey score calculation
Medical Intervention
Nasogastric suction, IV fluids, antibiotics, acid-reducing medications
Monitoring Phase
Close observation for signs of deterioration, serial abdominal exams
Outcome Evaluation
Assessment of clinical improvement, transition to oral intake, discharge planning
Research Spotlight: A Study from Northeast India
Methodology: Designing the Investigation
At a tertiary care center in Northeast India, researchers conducted a comprehensive study to evaluate the outcomes of conservative versus surgical management for PPU. The study design included:
- Patient selection: Adults with confirmed diagnosis of PPU based on clinical presentation and imaging evidence
- Group allocation: Patients were allocated to surgical or conservative management based on predefined clinical criteria and stability
- Data collection: Detailed information on patient demographics, clinical presentation, treatment details, and outcomes
- Outcome measures: Primary endpoints included mortality, complications, hospital stay, and time to resume normal diet
Study Population Distribution
Patient Characteristics in the Northeast India Study
| Characteristic | Surgical Group (n=272) | Conservative Group (n=63) | Overall (n=657) |
|---|---|---|---|
| Mean Age (years) | 46-80 range | Significantly older | 46-80 range |
| Male Gender | 75.5% | Similar proportion | 75.5% |
| Presentation Time | <24 hours in most cases | <24 hours in most cases | Varied |
| Boey Score | 0-2 in most patients | 0-1 in most patients | 0-2 majority |
Key Findings: What the Research Revealed
Analysis of the data yielded several important insights:
- Mortality rates were comparable between carefully selected conservative and surgical groups
- Complication profiles differed between approaches—surgical patients had more wound infections, while conservative management patients risked ongoing leakage
- Hospital stay was significantly shorter in the endoscopic/conservative cohort 6
Management Outcomes Comparison
Critical Timing
The research also highlighted that early intervention is critical regardless of approach. A delay in source control was associated with significantly worse outcomes, with one study noting "every hour delay in source control in patients with perforated peptic ulcers resulted in a 6% increase in mortality" .
The Scientist's Toolkit: Essential Resources for PPU Research
| Tool/Technique | Primary Function | Research Application |
|---|---|---|
| CT Imaging | Detect free air, fluid collections, perforation site | Primary diagnostic tool, outcome measurement |
| Boey Score | Predict mortality risk, guide treatment decisions | Patient stratification in comparative studies |
| Laparoscopic Equipment | Minimally invasive repair of perforation | Surgical intervention in controlled trials |
| H. Pylori Testing | Identify infectious etiology of ulcer | Pathophysiological studies and targeted therapy |
| Clavien-Dindo Classification | Standardized reporting of surgical complications | Outcome measurement in intervention studies |
Conclusion: A Balanced Approach to a Surgical Emergency
The management of perforated peptic ulcers represents a fascinating evolution in surgical thinking—from mandatory operation to carefully selected conservative management.
Key Takeaway
Research from Northeast India and other centers confirms that non-operative approaches have a definite role in managing PPU for a specific subset of patients.
The key lies in appropriate patient selection: those who present early, are hemodynamically stable, and have contained perforations may be excellent candidates for conservative management.
Future Directions
For those requiring surgery, minimally invasive laparoscopic techniques offer significant advantages over traditional open surgery when expertise is available.
The future of PPU management will likely involve even more precise patient selection protocols, improved minimally invasive techniques, and perhaps even endoscopic approaches for more cases.
As one 2025 meta-analysis concluded, "Prompt resuscitation and surgical repair, either laparoscopic or open, remains the gold standard for PPU" while noting that "endoscopic techniques are viable alternatives for small perforations and in selected cases where general anesthesia is contraindicated" 6 .