Perforated peptic ulcer in a township hospital with no general anaesthesia

Resuscitation and source control decisions must run in parallel, because delay to surgery is the main modifiable determinant of mortality in perforated peptic ulcer.

First 60 minutes.

• Two large-bore cannulae; take blood for group and save, full blood count, urea, creatinine, electrolytes, and glucose. Do not wait for results before starting fluid.
• Rapid crystalloid resuscitation: an initial 1 L of Ringer's lactate or 0.9% sodium chloride over 15–20 minutes, then reassess pulse, blood pressure, capillary refill and urine output. She is likely 3–4 L down from two days of peritonitis; expect to give 2–3 L in the first hour if tolerated, watching for pulmonary oedema.
• Nasogastric tube to decompress the stomach, urinary catheter to monitor output, and oxygen by mask.
• Analgesia - titrated intravenous opioid - and an antiemetic. Withholding analgesia does not improve diagnostic accuracy here; the diagnosis is already established radiologically.
• Antibiotics within the first hour: a third-generation cephalosporin plus metronidazole (for example ceftriaxone 2 g plus metronidazole 500 mg intravenously), or co-amoxiclav if available. Anaerobe cover is essential.
• Correct obvious electrolyte disturbance, especially hypokalaemia, once urine output is established.
• Start a proton pump inhibitor intravenously.

Document the resuscitation response: if she remains hypotensive after 2 L, she is a poor candidate for a long road transfer and the case for local surgery strengthens. Speak to the regional surgeon by phone now, before committing to a plan.

Local surgery under spinal anaesthesia. A perforated duodenal ulcer can be repaired through an upper midline incision under spinal anaesthesia, provided the surgeon is competent and resuscitation has been started. Advantages: source control within 1–2 hours; avoids a 5-hour road journey in a hypovolaemic patient with peritonitis; avoids the risk that the ambulance is delayed further by flooding. Disadvantages: spinal anaesthesia causes sympathetic blockade and can precipitate profound hypotension in a patient who is already volume-depleted; the theatre is shared; there is no blood bank if a vessel is injured; and the anaesthetist's ability to manage a high block or respiratory compromise is limited.

Transfer. Advantages: a definitive surgeon, general anaesthesia, intensive care, and blood. Disadvantages: at least 5 hours of untreated peritonitis, an ambulance that may not leave on time, deterioration en route with no airway support, and the real possibility of arriving after further delay.

Recommendation. If resuscitation produces a measurable response (pulse falling, blood pressure rising, urine output established) and the anaesthetist is confident, operate locally under spinal anaesthesia. The delay to definitive care is the dominant risk; a 5-hour transfer in a patient with established generalised peritonitis carries a high mortality even with a better-equipped destination. If she remains in refractory shock after adequate fluid, operate anyway - she will not survive the journey - but involve the regional surgeon by phone for intraoperative advice.

Consent must be taken from the patient if competent, otherwise from the husband or eldest child, and must cover the possibility of conversion, a difficult abdomen, and the absence of blood products. Document the discussion with the family, including their preference and your reasons for overriding it.

Operative plan.

• Confirm the diagnosis and inspect the entire anterior and posterior duodenum, stomach and pylorus; a second perforation is uncommon but a missed posterior ulcer or gastric malignancy changes management.
• Take a wedge/edge biopsy only if the ulcer looks malignant or atypical; otherwise omit, as biopsy of a chronic ulcer can narrow the lumen.
• Close the perforation with three or four interrupted 2-0 absorbable sutures, taking healthy tissue, and buttress with a pedicled omental patch (Graham patch). Avoid excessive tension, which causes recurrence of the leak.
• Do not perform a definitive acid-reducing procedure in this contaminated, unstable setting.
• Peritoneal lavage with 3–5 L of warm saline until the effluent is clear; suction thoroughly, especially in the subhepatic and subphrenic spaces and the pelvis.
• Leave a drain near the repair. Close the midline with mass closure; the skin may be left open or loosely approximated given contamination.

Postoperative plan.

• Oxygen, hourly observations for the first 12 hours then 2-hourly, strict fluid balance, and daily electrolytes.
• Continue ceftriaxone and metronidazole for 5–7 days, switching to oral when eating.
• Keep nil by mouth with a nasogastric tube until bowel function returns; start a proton pump inhibitor (or high-dose H2 blocker) intravenously and continue oral therapy for 8 weeks.
• Sit up, chest physiotherapy and early mobilisation - aspiration and chest infection are common causes of death in this group.
• Watch for a persistent drain of bilious fluid, fever, or failure to improve, which suggest a leak; there is no CT available, so re-operation is a clinical decision.
• Arrange H. pylori testing when stable and eradicate if positive; document the need for follow-up endoscopy if the ulcer was atypical.