Nonoperative management for perforated peptic ulcer: who can benefit?

BACKGROUND: Although nonoperative management for perforated peptic ulcer (PPU) has been used for several decades, the indication is still unclear. A clinicoradiological score was sought to predict who can benefit from it.

METHODS: A clinicoradiological protocol for the assessment of patients presenting with PPU was used. A logistic regression model was applied to identify determinant variables and construct a clinical score that would identify patients who can be successfully treated with nonoperative management.

RESULTS: Of 241 consecutive patients with PPU, 107 successfully received nonoperative management, and 134 required surgery. In multivariable analysis, the following four variables correlated with surgery and were given one point each toward the clinical score: age ≥70 years, fluid collection detection by ultrasound, contrast extravasation detection by water-soluble contrast examination, and Acute Physiology and Chronic Health Evaluation II (APACHE II) score ≥8. Eighty-five percent of patients with a score of 1 or less were successfully treated with nonoperative management, whereas 23 of 29 patients with a score of 3 or more required surgery. The area under the receiver operating characteristic curve was 0.804 (95% confidence interval = 0.717-0.891).

CONCLUSION: By combining clinical, radiological parameters, and APACHE II score, the clinical score allowed early identification of PPU patients who can benefit from nonoperative management.