Perforation of the stomach or duodenal lining

Approximately 5 to 10 percent of patients with peptic ulcers suffer a perforation of the stomach or duodenum, and about 15 percent of them die from the condition. This rate is higher in men than in women.

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Two types of perforation have been observed. Free perforation occurs when duodenal or gastric contents spill into the abdominal cavity and contaminate the peritoneum (the membrane lining the abdominal cavity and organs). Contained perforation occurs when the ulcer produces a hole in the duodenum or stomach, but the folds in the peritoneum or other adjacent organs prevent digestive juices from leaking out.

Perforations are most likely in elderly patients on chronic therapy with nonsteroidal anti-inflammatory drugs and they are more common in stomach than in duodenal ulcers. Initial symptoms of perforated duodenal or gastric ulcers include severe abdominal pain, worse in the upper middle portion of the abdomen, often accompanied by nausea and vomiting. Typically, the patient is acutely and severely ill. The finding of free air on an X-ray taken from an upright position or with the patient lying on one side is noted in approximately 70 percent of cases.

Perforation is a contraindication for endoscopy, because the procedure may worsen spillage of gastric contents or disrupt a sealed perforation. Urgent surgical therapy is recommended in patients with uncontained, free perforated ulcers, because spontaneous sealing is rare. In addition, gastric adenocarcinoma cannot be ruled out, and there is a greater potential for bacterial colonization. Aggressive surgical intervention helps to decrease the high mortality associated with perforating gastric ulcers.