Patients with perforated peptic ulcers usually present with acute onset of abdominal pain. Patients frequently report that the pain started “as if someone flipped a switch.” However, elderly patients frequently present with a less robust onset of pain. Occasionally, patients will complain of left shoulder pain from diaphragmatic irritation and some will complain of nausea and vomiting. While some patients report a history of recent gastritis, frequent steroid or nonsteroidal anti-inflammatory drug use, or use of cocaine, perforation may be the first clinical sign that patients have underlying peptic ulcer disease. On radiographic imaging, pneumoperitoneum is present in greater that 80% of patients.

Nonoperative management of perforated ulcers has been described since the 1940s; however, its use and patient selection remains a major debate. Patients who present with pneumoperitoneum who have a water-soluble contrast gastroduodenogram showing no extravasation, no signs of septic shock, and abdominal examination findings confined to the upper abdomen may be considered for nonoperative treatment. Nonoperative treatment routinely includes nasogastric decompression, antibiotics to cover enteric pathogens, antibiotics to cover Helicobacter pylori if present, and proton pump inhibitors. However, approximately 30% of patients treated nonoperatively do not improve and require surgical intervention. Patients treated nonoperatively also have about a 30% longer inpatient length of stay. Nonoperative management also has an extremely high failure rate (around 70%) in the elderly, patients with comorbidities, patients with hemodynamic instability, perforations greater than 48 hours old, and in patients with impaired wound healing. This creates a dilemma because the patients that you would prefer to treat nonoperatively are the ones most likely to fail nonoperative therapy. Therefore, operative treatment is the preferred modality except in an extremely selective subset of patients.

The classic indication for use of a patch for perforated ulcer is in the unstable patient with shock, the presence of extensive peritonitis or abdominal abscess formation, or patients with severe comorbidities. While patch repair of perforated ulcer was described as a damage control technique, with the development of effective medical therapy for ulcer disease and the corresponding decrease in patients requiring surgical therapy for ulcer disease, more surgeons are utilizing patch repair in the acute setting. In addition, the average age of patients presenting with perforated duodenal ulcers is increasing, with the average age now between 65 and 75 years. With this older age at presentation, it is more likely that these patients will have comorbidities that lead the surgeon to opt for a less involved procedure in the acute phase.