Table 13 clinical pathway for patients with gastroduodenal perforation is illustrated

Clinical signs and symptoms

• Severe, sudden-onset epigastric pain, which can become generalized

• Abdominal tenderness

• Fever

• Abdominal distension, tenderness, and rigidity with masked liver dullness and absent bowel sounds

Laboratory markers

• White blood cell count

• Leucocyte left shift (> 75%)

• C-reactive protein

Imaging

• CT

• Plain abdominal x-ray

• US

Diagnosis

• Laparoscopic/open simple or double-layer suture with or without an omental patch is a safe and effective procedure to address small perforated ulcers (standard procedure).

• Distal gastrectomy (large perforations near the pylorus; suspicion of malignancy).

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Antibiotic therapy for 4 days (immunocompetent and stable patients) (more days if there are signs of ongoing sepsis).

Treatment

Amoxicillin/clavulanate 2.2 g every 8 h +/− gentamicin 5–7 mg/Kg every 24 h

Avoid Amoxicillin/clavulanate if local Enterobacteriaceae resistances > 20%.

Piperacillin/tazobactam 6 g/0.75 g LD then 4 g/0.5 g every 6 h or 16 g/2 g by continuous infusion +/− gentamicin 5–7 mg/Kg every 24 h (in critically ill patients)

Ceftriaxone 2 g every 24 h + metronidazole 500 mg every 8 h

Cefotaxime 2 g every 8 h + metronidazole 500 mg every 8 h

or

In patients with beta-lactam allergy

A fluoroquinolone-based regimen

Ciprofloxacin 400 mg every 8/12 h + metronidazole 500 mg every 8 h

or

An aminoglycoside-based regimen

Amikacin 15–20 mg/kg every 24 h + metronidazole 500 mg every 8 h

Antibiotic therapy