Overview
Definition:
Primary closure of a perforated duodenal ulcer, typically using an omental patch (Graham patch), is a surgical technique aimed at sealing the perforation and preventing further leakage of gastric contents into the peritoneal cavity
This procedure addresses a life-threatening complication of peptic ulcer disease.
Epidemiology:
Perforated duodenal ulcers are a common surgical emergency, with an incidence ranging from 10-20 cases per 100,000 population annually
They are more prevalent in males and individuals with a history of NSAID use, Helicobacter pylori infection, or smoking
Morbidity and mortality rates are significant, underscoring the need for prompt diagnosis and treatment.
Clinical Significance:
Perforation leads to peritonitis, a serious condition characterized by rapid fluid and electrolyte shifts, septic shock, and multi-organ failure
Effective surgical management, including prompt closure and source control, is critical for patient survival and reducing long-term complications
Understanding the Graham patch technique is vital for surgical residents preparing for DNB and NEET SS examinations.
Clinical Presentation
Symptoms:
Sudden onset of severe, diffuse abdominal pain, often described as epigastric initially and then spreading throughout the abdomen
Nausea and vomiting may be present
Patients often appear acutely ill and may present with signs of shock
Absence of bowel sounds (ileus) is common.
Signs:
Generalized tenderness and guarding of the abdomen, often with rebound tenderness and rigidity (peritoneal signs)
Vital signs may show tachycardia, hypotension, fever, and tachypnea
Patients may lie still with knees flexed to minimize abdominal pain.
Diagnostic Criteria:
Diagnosis is primarily based on clinical suspicion confirmed by imaging
Diagnostic criteria include sudden onset of severe abdominal pain, diffuse peritonitis on physical examination, and radiographic evidence of free air under the diaphragm (pneumoperitoneum) on erect chest X-ray or abdominal CT scan.
Diagnostic Approach
History Taking:
Detailed history of pain onset, character, and radiation
Past history of peptic ulcer disease, NSAID use, H
pylori infection, smoking, and alcohol consumption
Recent ingestion of corrosive substances or trauma
Assess for any preceding symptoms like dyspepsia or epigastric pain.
Physical Examination:
Thorough abdominal examination assessing for tenderness, guarding, rigidity, and rebound tenderness
Auscultation for bowel sounds
Assessment of vital signs for hemodynamic stability
Rectal examination to rule out blood.
Investigations:
Plain erect chest X-ray to detect pneumoperitoneum (most common initial investigation)
Abdominal ultrasound may show free fluid but is less sensitive for free air
CT scan of the abdomen is highly sensitive for detecting free air, fluid collections, and identifying the site of perforation
Laboratory investigations include complete blood count (CBC) to assess for leukocytosis and anemia, serum electrolytes, renal function tests, liver function tests, and arterial blood gas (ABG) if septic shock is suspected
Blood and stool cultures as indicated.
Differential Diagnosis:
Other causes of acute abdomen: acute pancreatitis, acute cholecystitis, appendicitis, bowel obstruction, mesenteric ischemia, ruptured ectopic pregnancy, myocardial infarction (referred pain).
Management
Initial Management:
Immediate resuscitation with intravenous fluids and broad-spectrum antibiotics
Nasogastric tube insertion for gastric decompression
Analgesia
Strict NPO status
Urgent surgical consultation.
Surgical Management:
The gold standard is laparotomy or diagnostic laparoscopy
Graham patch closure is the most common technique for simple perforations
This involves excising the undermined edges of the perforation and oversewing it with a purse-string suture, then reinforcing it with a patch of omentum
In cases of very large or multiple perforations, or if the patient is unstable, a subtotal gastrectomy with gastrojejunostomy may be considered
Definitive ulcer treatment (e.g., H
pylori eradication, PPI therapy) is initiated postoperatively.
Supportive Care:
Postoperative monitoring of vital signs, fluid balance, and urine output
Pain management
Early mobilization
Gradual reintroduction of oral intake
Nutritional support as needed
Close monitoring for signs of infection or anastomotic leak.
Complications
Early Complications:
Intra-abdominal abscess formation, wound infection, anastomotic leak (if gastrectomy is performed), pneumonia, deep vein thrombosis (DVT), pulmonary embolism (PE), continued peritoneal contamination, re-perforation.
Late Complications:
Adhesions leading to bowel obstruction, recurrent ulceration (stomal ulcer, marginal ulcer), dumping syndrome (if partial gastrectomy performed), incisional hernia.
Prevention Strategies:
Adequate antibiotic coverage, meticulous surgical technique, secure closure of the perforation with good omental coverage, judicious use of drains, early mobilization, and prophylactic anticoagulation for DVT prevention
Adherence to ulcer management protocols postoperatively to prevent recurrence.
Prognosis
Factors Affecting Prognosis:
Time from perforation to surgery is the most critical factor
delayed surgery significantly increases mortality
Patient's overall health status, presence of comorbidities, extent of peritonitis, and development of sepsis and multi-organ failure
Severity of the initial ulcer disease.
Outcomes:
With prompt diagnosis and surgical intervention, the mortality rate for perforated duodenal ulcers can be reduced significantly
Most patients recover well after Graham patch closure and appropriate medical management
However, complications can lead to prolonged hospitalization and increased morbidity.
Follow Up:
Postoperative follow-up includes assessment for wound healing, pain management, and monitoring for any signs of complications
Long-term follow-up should focus on H
pylori eradication confirmation, continuous PPI therapy, and management of risk factors like NSAID use and smoking to prevent ulcer recurrence.
Key Points
Exam Focus:
The Graham patch technique is the cornerstone of surgical management for uncomplicated perforated duodenal ulcers
Key aspects for exams include indications, contraindications, steps of the procedure, and common complications
Recognition of pneumoperitoneum on imaging is crucial.
Clinical Pearls:
Always suspect perforated duodenal ulcer in patients with sudden, severe epigastric pain
Resuscitation is paramount before surgery
For unstable patients or those with large/multiple perforations, consider more definitive surgery like gastrectomy
Prophylactic antibiotics are essential.
Common Mistakes:
Delaying surgical intervention
Inadequate resuscitation
Missing pneumoperitoneum on plain X-rays
Incomplete closure of the perforation or inadequate omental coverage
Failure to consider H
pylori eradication postoperatively
Not adequately managing the underlying ulcer disease.