A 45-year-old man presents with sudden-onset severe diffuse abdominal pain. On examination he has board-like rigidity and absent bowel sounds. Erect chest X-ray reveals free gas under the right hemidiaphragm. He has a 2-year history of peptic ulcer disease inadequately treated with over-the-counter antacids. After initial resuscitation, what is the definitive management?

• A Emergency laparotomy with omental patch repair (Graham patch) ✓
• B Conservative management with nasogastric suction and IV antibiotics
• C Urgent upper GI endoscopy to identify and clip the perforation
• D Immediate laparotomy with truncal vagotomy and antrectomy

Explanation

A perforated peptic ulcer with pneumoperitoneum requires emergency surgery following resuscitation. The Graham omental patch repair, performed open or laparoscopically, is the procedure of choice: it is quick, safe, and combined with postoperative H. pylori eradication and PPIs achieves excellent long-term outcomes. Conservative (Taylor's) management is considered only in very selected, haemodynamically stable patients where the perforation appears sealed on water-soluble contrast study. Endoscopic clipping of frank perforations is not standard practice. Definitive ulcer surgery (vagotomy + antrectomy) is rarely performed in the emergency setting today.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.