Evaluation of a protocol for the non-operative management of perforated peptic ulcer

Background: The non-operative management of perforated peptic ulcer has pre viously been shown to be both safe and effective although it remains contro versial. A protocol for non-operative management was set up in this hospita l in 1989. Adherence to the guidelines in the protocol has been audited ove r a 6-year period with a review of outcome. Methods: The case-notes of patients with a diagnosis of perforated peptic u lcer were reviewed. Twelve guidelines from the protocol were selected for e valuation of compliance to the protocol. Results: Forty-nine patients underwent non-operative treatment initially. F ight patients failed to respond and underwent operation. Complications incl uded abscess formation (seven patients), renal failure (one), gastric ileus (one), chest infection (two), and cardiac failure and stroke (one). Four d eaths occurred in this group. Adherence to certain protocol guidelines was poor, notably those concerning prevention of thromboembolism, use of antibi otics, use of contrast examination to confirm the diagnosis and referral fo r follow-up endoscopy. Two gastric cancers were detected on subsequent endo scopy. Conclusion: This experience demonstrates that non-operative treatment can b e used successfully in a general hospital. Adherence to protocol guidelines was found to be variable and the protocol has therefore been simplified. T his study highlights the need for an accurate diagnosis and the importance of follow-up endoscopy.