Acute perforated duodenal ulcer

This report is based on a personal experience with nineteen patients who were operated upon for acute perforation of a duodenal ulcer. Closure of the perforation and posterior gastroenterostomy was done in all and in twelve the appendix was removed. Drainage was used in only two cases. There was one death. This patient who was admitted in a state of shock five hours after perforation and operated upon at once died twenty-four hours later. The youngest, and only female in the group, was a girl of eighteen years. This is not a selected group but one which contains all cases of acute perforated duodenal ulcer which have come under my care in the past fifteen years.Many perforated duodenal ulcers become sealed temporarily to the undersurface of the liver, thereby preventing for a time widespread contamination of the peritoneum.Acute perforation is the result of an acute ulcerative process in either a recent or an old ulcer. The perforation is caused by erosion (acid) and not by rupture from increased pressure.The operation of choice should be closure of the perforation and posterior gastroenterostomy. The closure is made by three or four through-and-through cotton sutures re-enforced by several nearby fat tabs. Do not infold; do not use a purse-string suture.Except in the presence of advanced peritonitis, gastroenterostomy is advisable because (1) perforation does not cure the ulcer. Simple closure is followed by recurrence of ulcer in 40 to 60 per cent of the patients and in others the stomach may have motor difficulty from fixation of the pylorus to the undersurface of the liver. Gastroenterostomy is the best safeguard against recurrence and motor dysfunction of the stomach. (2) It protects the sutured area of perforation against tension and leakage. (3) It does not increase the operative risk.When the appendix is readily accessible, it should be removed. Spinal anesthesia is recommended except in the presence of shock. Drainage is rarely indicated.