Perforated and Bleeding Peptic Ulcer Clinical Practice Guidelines (2020)

World Society of Emergency Surgery

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

February 28, 2020

Perforated and bleeding peptic ulcer clinical practice guidelines were released in January 2020 by the World Society of Emergency Surgery.[1]

Perforated Peptic Ulcer

The recommended biochemical and imaging investigations in the diagnosis of perforated peptic ulcer are as follows:

  • Suspected gastroduodenal perforation: Routine laboratory studies and arterial blood gas analysis

  • Acute abdomen from suspected perforated peptic ulcer: CT scanning

  • Acute abdomen from suspected perforated peptic ulcer: Chest and abdominal radiography as initial diagnostic assessment in the event CT scanning is not immediately available

  • Acute abdomen from suspected perforated peptic ulcer if free air is not seen on imaging and perforation remains a concern: Imaging with water-soluble contrast (oral or via nasogastric tube)

The recommended targets for resuscitation in unstable patients with a perforated peptic ulcer are as follows:

  • Rapid resuscitation to reduce mortality

  • Restoration of physiological parameters with a mean arterial pressure 65 mm Hg or higher, urine output of 0.5 mL/kg/h or greater, and lactate normalization

  • Use of hemodynamic monitoring (invasive or noninvasive) to optimize fluid/vasopressor therapy, with an individualized resuscitation strategy

Surgical indications and appropriate timing of surgery in patients with perforated peptic ulcer are as follows:

  • In association with significant pneumoperitoneum, extraluminal contrast extravasation, or signs of peritonitis: Operative treatment strongly recommended

  • Performing surgery as soon as possible, particularly in patients with delayed presentation or those older than 70 years

The recommended surgical approach (laparoscopic vs open) for perforated peptic ulcer is as follows:

  • Stable patients: Laparoscopic approach, unless equipment and skilled personnel are not available, in which case an open approach is recommended

  • Unstable patients: Open surgery

The recommended antimicrobial and antifungal therapy strategies in perforated peptic ulcer are as follows:

  • Administration of broad-spectrum antibiotics

  • Microbiological sample collection for analysis for bacterial and fungal pathogens in all patients undergoing surgery, with postanalysis antibiotic therapy adjustment as needed

  • Antifungal agents not suggested as standard empiric therapy; may be appropriate in high-risk patients, such as those who are immunocompromised, have comorbidities, or are of advanced age

The recommended antimicrobial regimen and duration of therapy in perforated peptic ulcer are as follows:

  • Initiation of empiric broad-spectrum antibiotics as soon as possible, targeting gram-negative, gram-positive, and anaerobic bacteria

  • Short course of 3-5 days or until inflammatory markers normalize

Bleeding Peptic Ulcer

The recommended biochemical and imaging/procedural investigations in the diagnosis of suspected bleeding peptic ulcer are as follows:

  • Blood-typing; hemoglobin, hematocrit, and electrolyte values; and coagulation assessment

  • Performing endoscopy as soon as possible, particularly in high-risk patients (Management decisions can be guided based on the damage noted from recent hemorrhage during endoscopy, as this can help predict further bleeding risk.)

The recommended parameters for evaluation at emergency department referral and the criteria for defining an unstable patient are as follows:

  • Rapid, careful medical/surgical evaluation to prevent further bleeding and reduce mortality

  • Upon emergency department referral, evaluation of signs, symptoms, and laboratory findings to assess stability versus instability

  • Evaluation according to Rockall and Glasgow-Blatchford scoring systems to assess disease severity and guide therapy

The recommended nonoperative and endoscopic strategies in patients with bleeding peptic ulcer are as follows:

  • Nonoperative management as first-line management after endoscopy

  • Endoscopic treatment to achieve hemostasis and to help prevent rebleeding, the need for surgery, and mortality

  • Administration of pre-endoscopy erythromycin

  • Initiation of proton-pump inhibitor therapy as soon as possible

  • Post successful endoscopic hemostasis, high-dose proton-pump inhibitor therapy as a continuous infusion for the first 72 hours

  • Proton-pump inhibitor therapy for 6-8 weeks following endoscopic treatment (Long-term proton-pump inhibitor therapy is not recommended except in patients with ongoing NSAID use.)

Indications for surgical treatment and the appropriate approach for surgery in patients with bleeding peptic ulcer are as follows:

  • Surgical hemostasis, or, if equipment and qualified personnel are available, angiographic embolization, after failure of repeated endoscopy

  • Refractory bleeding peptic ulcer: Surgical intervention with open surgery

  • Intraoperative endoscopy to facilitate localization of the bleeding site

Indications for antimicrobial therapy and for Helicobacter pylori testing in patients with bleeding peptic ulcer are as follows:

  • Empirical antimicrobial therapy not recommended

  • H pylori testing in all patients

  • If positive for H pylori, eradication therapy recommended

  • First-line eradication therapy: Standard triple therapy (ie, amoxicillin, clarithromycin, proton-pump inhibitor)

  • First-line therapy if high clarithromycin resistance detected: Ten-day sequential therapy with four drugs (ie, amoxicillin, clarithromycin, metronidazole, proton-pump inhibitor)

  • Second-line therapy if first-line failed: Ten-day levofloxacin-amoxicillin triple therapy

  • Start standard triple therapy after 72-96 hours of intravenous proton-pump inhibitor, for 14-day duration

For more information go to Peptic Ulcer Disease and Surgical Treatment of Perforated Peptic Ulcer.

For more Clinical Practice Guidelines, go to Guidelines.

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