Perforated Peptic Ulcer

Perforated peptic ulcer presents with sudden-onset epigastric pain and peritonitis. Free air under the diaphragm on erect CXR confirms perforation in 70–80% of cases. The Boey score risk-stratifies operative mortality; emergency surgery is the…

Boey Score / Emergency Laparotomy

The pathway

1 · Rapid history

NSAID/steroid use: major risk factor for peptic ulceration
H. pylori status (if known)
Alcohol excess
Onset: sudden epigastric pain ('like a knife') with rapid peritoneal spread
Medical comorbidities: directly enters Boey score

2 · Erect CXR

Free air under diaphragm in 70–80% of perforations
Most sensitive when performed upright for 10 minutes before exposure
If negative but clinical suspicion high: proceed to CT

3 · CT abdomen/pelvis

If CXR negative: CT is highly sensitive for free air and identifies perforation site
Also assesses for abscess, alternative diagnoses, and operative planning
Do not delay surgery for CT if patient is haemodynamically unstable with clinical peritonitis

4 · Resuscitation

IV access × 2, bloods (FBC, U&E, CRP, LFTs, amylase, clotting, group & save)
IV fluid resuscitation (Hartmann's)
Urinary catheter + hourly output monitoring
NG tube (decompresses stomach, reduces soiling at laparotomy)
NBM immediately

5 · IV PPI and antibiotics

Omeprazole 40mg IV BD: reduces acid and aids healing
Co-amoxiclav 1.2g IV + metronidazole 500mg IV: broad spectrum peritonitis cover
Piperacillin-tazobactam if systemically septic or immunocompromised

6 · Boey score

Shock on admission (SBP <90): 1 point
Major medical comorbidity: 1 point
Perforation >24h: 1 point
Score 0: mortality <1%; Score 1: ~10%; Score 2: ~45%; Score 3: >100% quoted (high risk — senior discussion)

7 · Senior surgical and anaesthetic review

Alert the on-call surgical registrar/consultant immediately
Anaesthetic review for fitness for emergency surgery
ICU/HDU bed booking if Boey score ≥2
If Boey score 3 or unfit for surgery: consider conservative (Taylor's) management (strict NBM, NG, IV fluids, antibiotics)

8 · Surgery and post-op care

Laparoscopic repair (Graham patch omentoplasty): preferred if haemodynamically stable and skill available
Open laparotomy: if laparoscopy unavailable, widespread contamination, or haemodynamic instability
Post-op H. pylori eradication: triple therapy once eating (PPI + amoxicillin + clarithromycin × 7 days)
PPI long-term

Drugs

Drug	Dose	Route	Notes
Omeprazole	40mg	IV	BD administration. Switch to PO once tolerating diet.
Co-amoxiclav	1.2g	IV	TDS. Peritonitis cover. Review at 48h.
Metronidazole	500mg	IV	TDS for anaerobic cover in peritonitis.
Piperacillin-tazobactam	4.5g	IV	Q8h. Use if septic or failed first-line antibiotics.
Morphine	5–10mg	IV	Titrate to pain. Does not mask signs in already-confirmed peritonitis.

When to escalate

Haemodynamic instability despite resuscitation — emergency theatre,Clinical peritonitis — do not delay surgery awaiting imaging,Boey score ≥2 — HDU/ICU booking, senior consultant involvement,Age >70 with comorbidities — anaesthetic risk assessment, consider conservative management,Perforation >24h — higher mortality risk, senior surgical decision

Reference: British Society of Gastroenterology / OMGE 2010 / NICE Peptic Ulcer guidance

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