American Journal of Emergency Medicine 34 (2016) 15561560

Contents lists available at ScienceDirect

American Journal of Emergency Medicine

journal homepage: www.elsevier.com/locate/ajem

Original Contribution

Outcome of nonsurgical intervention in patients with perforated

peptic ulcers
Ping-Lien Lay, MD a,b, Hsin-Hung Huang, MD a, Wei-Kuo Chang, MD, PhD a, Tsai-Yuan Hsieh, MD, PhD a,
Tien-Yu Huang, MD, PhD a, Hsuan-Hwai Lin, MD, PhD a,
a
Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
b
Department of Internal Medicine, Kaohsiung, Armed Forces General Hospital, Kaohsiung, Taiwan

a r t i c l e i n f o a b s t r a c t

Article history: Background: Although surgical intervention is the favorable treatment modality for perforated peptic ulcer, non-
Received 20 April 2016 surgical treatment is another option. The aim of this study is to analyze the results of conservative treatment for
Received in revised form 15 May 2016 perforated peptic ulcer.
Accepted 17 May 2016 Methods: Between 2003 and 2014, 403 patients were admitted to our hospital for perforated peptic ulcer, and 383
patients underwent surgery, whereas 20 were allocated to conservative treatment. The results of nonsurgical in-
tervention in these patients were analyzed retrospectively.
Results: The overall mortality rate of conservative treatment was 40%. Eleven patients remained hospitalized less
than 2 weeks; among them, patients with a high (IV) American Society of Anesthesiologists class at admission
had higher mortality than those with a low (b IV) American Society of Anesthesiologists class (83.3% vs 0%, P =
.015). However, when patients remained hospitalized longer than 2 weeks, the mortality rates did not differ be-
tween patients with the low and high American Society of Anesthesiologists classes. Eight patients presented
with a high American Society of Anesthesiologists class, of which 3 received early enteral feeding, and all of
them survived. In contrast, the survival of patients without early enteral feeding was 0%, suggesting that early en-
teral feeding improved survival of patients with the high American Society of Anesthesiologists class (P = .018).
Conclusions: A higher American Society of Anesthesiologists class correlated with mortality in patients undergo-
ing conservative treatment during the rst 2 weeks of hospitalization. Early enteral feeding might improve the
outcome of conservative treatment in patients with high American Society of Anesthesiologists class.
2016 Elsevier Inc. All rights reserved.

1. Introduction
In the past century, peptic ulcer disease was a common health prob-
lem. Since histamine-2 receptor (H-2) blockers and proton pump inhib-
itors (PPIs) were introduced in the 1970s [1,2], these antisecretory
drugs have played an important role in the treatment of peptic ulcer dis-
ease, according to the principle of no acid, no ulcer [3]. In addition,
Marshall and Warren [4] and discovered Helicobacter pylori (H. pylori)
in 1982 and proved the crucial involvement of this pathogen in the de-
velopment of peptic ulcers. Furthermore, the eradication of H. pylori re-
duces the recurrence of peptic ulcer [5]. Because of the aforementioned
ndings and advancements, the incidence of uncomplicated peptic
This study was supported by the Research Fund of Tri-Service General Hospital (TSGH-
C103-067).
Corresponding author at: Division of gastroenterology, Tri-Service General Hospital,
No.325, Sec 2, Cheng-Gong Rd., Neihu, Taipei 114, Taiwan. Tel.: + 886 287927409;
fax: +886 287927139.
E-mail address: redstone120@gmail.com (H.-H. Lin).
ulcer has declined [6,7]. However, the incidence of perforated peptic
ulcer (PPU) has remained unchanged in the past decades [79]. It may
be that the increased use of nonsteroidal anti-inammatory drugs or as-
pirin in elderly patients increased the risk of PPU [10,11].
Perforated peptic ulcer is an emergent condition, and surgical inter-
vention is the preferred therapeutic treatment modality [12,13]. At rst,
broad-spectrum antibiotics should be administered intravenously, and
then simple closure, omental patch repair, or laparoscopic treatment is
performed in most patients, followed by antisecretory treatment and
H. pylori eradication, if indicated [1315]. The mortality rate ranges be-
tween 4% and 30% [7]. When patients are unsuitable for surgical repair,
nonsurgical treatment involving fasting, nasogastric tube suction, intra-
venous broad-spectrum antibiotics, and antisecretory therapy is anoth-
er option for PPU [1620]. In 1946, Taylor [20] rst reported the results
of conservative treatment for PPU, which yielded promising results,
with 11% mortality rate after conservative treatment for perforated du-
odenal ulcers. In addition, in 1989, Crofts et al [21] reported a random-
ized trial in which similar outcomes were reported for nonsurgical
treatment and emergency surgery, and the mortality rate was 5% in
both groups. Gul et al [17] reported an overall mortality rate of 3% in

http://dx.doi.org/10.1016/j.ajem.2016.05.045
0735-6757/ 2016 Elsevier Inc. All rights reserved.
 P.-L. Lay et al. / American Journal of Emergency Medicine 34 (2016) 15561560 1557

patients with perforated duodenal ulcer managed conservatively. How-

ever, these results are not widely accepted. In 1971, Cohen et al [22] re-
ported their experience in the management of 852 patients with PPU, in
which 87 patients received conservative treatment only, and their mor-
tality rate was 100%, which was signicantly higher than the 9% in the
operative treatment group in the same study. The reason for this huge
difference in mortality rates between conservative and operative treat-
ments in previous studies may be selection bias, and in such studies,
only patients with a low risk were recruited. Further, in those studies,
patients managed conservatively would be switched to surgical treat-
ment immediately if the former treatment was unsuccessful.
In 1987, Boey et al [13,23] reported that the major medical illness,
preoperative shock, and prolonged perforation (over 24 hours) are
risk factors for patients with perforated duodenal ulcer and can predict
the outcome of surgical treatment accurately. Kocer et al also showed
that old age, delayed surgery, presence of shock, high American Society
of Anesthesiologists (ASA) class, and denitive surgery are poor prog-
nostic factors for patients undergoing emergency surgery for PPU [7].
Larkin et al [24] performed a retrospective study of patients undergoing
conservative treatment and reported that the mortality rates of patients
with perforated duodenal ulcers were lower in the group with ASA clas-
ses I-III than in the group with ASA classes IV-V (0% vs 52.9%). The above
reports suggest that prognostic factors are crucial for the outcome of
both surgical and nonsurgical treatment of patients with PPU. Fig. 1. Plain abdominal radiograph showing the enteral feeding.
In this study, we aimed to retrospectively analyze the results of con-
servative treatment in patients undergoing nonsurgical treatment for 3. Results
PPU in a teaching hospital. The clinical characteristics of our patients
were rst examined, and subsequently, we analyzed the putative prog- 3.1. The clinical features of PPU in patients who did not undergo surgical
nostic factors and determined whether these factors were important for intervention
the entire course of conservative treatment.
During 2003-2014, 403 patients were admitted to the Tri-Service
General Hospital for PPU. Three hundred eighty-three patients
2. Materials and methods underwent surgery, whereas 20 patients (median age, 74 years; range,
31-99) received conservative treatment because they were unsuitable
2.1. Patients or unwilling to undergo surgery. Five patients were men, and 15 were
women. Fourteen patients had shock index (heart rate/systolic blood
In this retrospective study, medical records of patients who present- pressure) b1 at admission. Median ASA class was III (range, I-V). Median
ed to Tri-Service General Hospital with PPU, during a 10-year period be- APACHE II score was 10.5 (range, 5-46). Median duration of hospital
tween January 2003 and February 2014, were reviewed. The diagnosis stay was 14 days (range, 1-78). Of 20 patients, 8 died of sepsis with
of PPU was based on radiological (chest radiography or computed to- multiple-organ dysfunction, and the overall mortality rate of conserva-
mography scans), endoscopic, or operative ndings. This study focused tive treatment was 40%. Patients were divided into 2 groups according
on patients who did not undergo surgical intervention for PPU. Patient to the duration of hospital stay ( or b15 days), and 9 patients remained
age, sex, ASA class, Acute Physiology and Chronic Health Evaluation II hospitalized longer than 2 weeks (Table 1). There was no difference in
(APACHE II) score, clinical presentation, management mode, mortality, age, ASA class, and APACHE II score between these 2 groups. There
and duration of hospital stay of these patients were analyzed. Nonsurgi- was no signicant difference in the percentage of patients with clinical
cal treatment of these patients with PPU consisted of fasting, nasogastric improvement after conservative treatment for 12 hours between
tube suction, intravenous uids, intravenous broad-spectrum antibi- these 2 groups. Female sex predominated in both groups. The propor-
otics, and antisecretory therapy with PPIs. Some patients underwent en- tion of shock index 1 or higher at admission was higher in patients
doscopic placement of enteral feeding tubes, which bypassed the with lengths of hospital stays shorter than 2 weeks than in patients
perforated site [2527] and received early enteral feeding before the with lengths of hospital stay longer than 2 weeks (45.5% vs 11.1%);
PPU healed (Fig. 1). Patients undergoing conservative treatment however, the difference in these values was not signicant (P = .16).
were categorized into 2 groups according to the duration of hospital Similarly, mortality rates were higher in patients with shorter hospital
stay ( or b 15 days). The mortality rate of these patients in the 2 groups
was calculated. The study was approved by the institutional review Table 1
board of Tri-Service General Hospital. Clinical characteristics of patients with PPU according to the duration of hospital stay

Hospital stay Hospital stay P

b15 d 15 d
2.2. Statistical analysis No. 11 9
Median age (range) 74 (48-99) 74 (31-97) .94
All data were presented as median and range for continuous vari- Gender (male/female) 2/9 3/6 .62
Shock index 1 at admission, no. (%) 5 (45.5) 1 (11.1) .16
ables or number and percentage for categorical variables. Statistical
Median ASA class (range) III (II-V) III (I-IV) .19
analysis was performed using SPSS statistics software, version 18 (IBM Median APACHE II score (range) 14 (5-46) 10 (7-23) .37
Co, Somers, New York). Continuous variables were compared using With clinical improvement in 12 h, no. (%) 5 (45.5) 3 (33.3) .67
Mann-Whitney U tests, and categorical variables were compared using Mortality, no. (%) 6 (54.5) 2 (22.2) .19
Fisher exact test. All reported P were 2-tailed, and P b .05 was consid- Median hospital stay (range) 8 (1-14) 34 (15-78) b.001

ered signicant. Abbreviations: Shock index, heart rate (min)/systolic blood pressure (mm Hg).
1558 P.-L. Lay et al. / American Journal of Emergency Medicine 34 (2016) 15561560

stays than in patients with longer hospital stays (54.5% vs 22.2%), but Table 3
the difference was not signicant (P = .19). Outcome of patients with poor prognostic factors after early enteral feeding

Survival (%) P
3.2. Factors related to survival rate of patients with different durations of ASA class IV-V
hospital stays With early enteral feeding 3/3 (100) .018
Without early enteral feeding 0/5 (0)
In patients with hospital stays shorter than 2 weeks (Table 2), the APACHE II score 10
With early enteral feeding 3/3 (100) .045
survival rate was signicantly higher in patients who had a shock Without early enteral feeding 2/9 (22.2)
index less than 1 at admission compared with those with a shock Lack of clinical improvement after 12 h
index of 1 or higher at admission (83.3% vs 0%, P = .015). Patients With early enteral feeding 3/3 (100) .045
who experienced clinical improvement after 12 hours of starting con- Without early enteral feeding 2/9 (22.2)
servative treatment had a higher survival rate compared with patients
without clinical improvement after 12 hours (100% vs 0%, P = .002).
Similarly, the survival rate was signicantly higher in patients with improved survival of patients with a high ASA class or high APACHE II
ASA class I-III than that of patients with ASA class IV-V (83.3% vs 0%, score. Among patients who lacked clinical improvement after 12
P = .015). Furthermore, the survival rate was signicantly higher in pa- hours of starting conservative treatment, the survival rate was higher
tients with APACHE II score less than10 than in patients with APACHE II for patients with early enteral feeding than that for patients without
score of 10 or higher (100% vs 14.3%, P = .015). early enteral feeding (100% vs 22.2%, P = .045).
In patients with hospital stay longer than 2 weeks (Table 2), there
was no signicant difference in the survival rate between patients 4. Discussion
with shock index less than 1 and 1 or higher at admission (75% vs
100%, P = 1.0). The survival rate was not signicantly different between Perforated peptic ulcer is not a rare complication of peptic ulcer [3],
the patients with and without clinical improvement after 12 hours of and an emergent surgical repair is the preferred intervention for PPU
starting conservative treatment (66.7% vs 83.3%, P = 1.0). There was [12,13]. Conservative treatment is another option for PPU [1621]
also no statistically signicant difference in the survival rates between based on the observation that perforations may be gradually sealed by
patients with ASA score I-III and those with ASA score IV-V (66.7% vs the surrounding viscera [15,28]. However, conservative treatment has
100%, P = .5). In addition, there was no signicant difference in survival not been widely accepted. Therefore, the surgical intervention is the
rates between patients with APACHE II score less than 10 and those with preferred choice for these patients currently [12,13], and nonsurgical
APACHE scores of 10 or higher (75% vs 80%, P = 1.0). treatment is preserved for these patients unsuitable or unwilling to un-
dergo operation [15]. Previous retrospective studies have revealed that
3.3. Early enteral feeding might improve the outcome of patients with high most patients with PPU underwent surgery and that only 2% to 10% of
ASA class or APACHE II score these patients did not undergo surgical intervention [9,19,22,29]. In
our study, 4.9% patients with PPU underwent only nonsurgical treat-
Three patients underwent endoscopic placement of an enteral feed- ment during the study period.
ing tube and received early enteral feeding. They all presented with a In 1967, a retrospective study reviewed 402 patients with PPU and
high ASA class or high APACHE II score upon admission and did not showed that the mortality rates associated with nonsurgical and surgi-
present clinical improvement within 12 hours of starting conservative cal treatment for PPU were 72.5% and 7.5%, respectively [29]. Similarly,
treatment. Among the patients with ASA class IV-V, the survival rate in 1971, Cohen et al [22] also reported that the nonsurgical mortality
of patients with and without early enteral feeding was 100% and 0%, re- was signicant higher than the operative mortality (100% vs 9%). Both
spectively (P = .018; Table 3). Similarly, among the patients with retrospective studies suggested that nonsurgical intervention was asso-
APACHE II score of 10 or higher, the survival of patients with and with- ciated with a high mortality rate. However, antisecretory agents, such as
out early enteral feeding was 100% and 22.2%, respectively (P = .045; H-2 blockers and PPIs, were not introduced until the 1970s [1,2]. There-
Table 3). These results suggested that the early enteral feeding fore, no effective antisecretory agent was available during the study pe-
riod of the above studies. Bucher et al [19] retrospectively reviewed
patients with PPU between 1978 and 2004, and the mortality rate of
conservative treatment was 30%, which was much lower than those re-
Table 2
The correlation of survival rate with the shock index, ASA class, and APACHE II score in pa-
ported in previous retrospective studies. In a subgroup analysis, they
tients with a short duration of hospital stays found that the patients who received H-2 blockers as antisecretory
drugs had higher mortality rates than those who received PPIs (64% vs
Survival (%) P
11%, P = .008), suggesting that advances in antisecretory therapy im-
Hospital stay b15 d proved the outcome of conservative treatment for PPU [19]. In our
Shock index 1 at admission 0/5 (0) .015
study, all patients received PPIs, indicating that these antisecretory
Shock index b1 at admission 5/6 (83.3)
With clinical improvement after 12 h 5/5 (100) .002 drugs were routinely applied to the patients with PPU at our hospital.
Lack of clinical improvement after 12 h 0/6 (0) In 1989, Crofts et al [21] reported a prospective randomized trial that
ASA class I-III 5/6 (83.3) .015 compared the results of conservative treatment for PPU with that of
ASA class IV-V 0/5 (0) emergent surgical intervention. In this study, patients who were allocat-
APACHE II score 10 1/7 (14.3) .015
ed to receive conservative treatment underwent surgery when their
APACHE II score b10 4/4 (100)
Hospital stay 15 d clinical symptoms and signs did not improve after 12 hours. Notably,
Shock index 1 at admission 1/1 (100) 1.0 the mortality rates of nonsurgical and emergent surgical treatment
Shock index b1 at admission 6/8 (75) were both 5% [21]. Gul et al [17] also conducted a prospective study to
With clinical improvement after 12 h 2/3 (66.7) 1.0
dene the role of conservative treatment for perforated duodenal ul-
Lack of clinical improvement after 12 h 5/6 (83.3)
ASA class I-III 4/6 (66.7) .5 cers. As in previous study, conservative treatment would be switched
ASA class IV-V 3/3 (100) to surgical treatment when there was no clinical improvement after
APACHE II score 10 4/5 (80) 1.0 12 to 16 hours of treatment with conservative treatment. The overall
APACHE II score b10 3/4 (75) mortality rate of conservative treatment was 3% in this study [17].
Abbreviations: Shock index, heart rate (min)/systolic blood pressure (mm Hg). Two prospective studies described above showed a low mortality rate
 P.-L. Lay et al. / American Journal of Emergency Medicine 34 (2016) 15561560
after conservative treatment; however, in our study, the mortality
rate of conservative treatment was 40%, which was higher than that
reported in those prospective studies [17,20,21]. The reasons for such
difference may be that the patients who were recruited in those pro-
spective studies were carefully selected and closely monitored. For ex-
ample, the patients who were hemodynamically unstable or had been
perforated for more than 24 hours were excluded in those prospective
studies [17,21]. It has been proven that shock and delay in treatment
are associated with a high mortality in patients with PPU [23,30,31];
therefore, the exclusion of patients with poor prognostic factors may re-
sult in a better outcomes with conservative treatment.
As shown in Table 2, mortality rates were higher for the patients
with an unstable hemodynamic status, higher ASA class, or higher
APACHE II score during the rst 2 weeks of hospitalization, suggesting
that the poor condition at presentation of a patient with PPU is associat-
ed with poor outcome during the rst 2 weeks of conservative treat-
ment. Therefore, an unstable hemodynamic status, higher ASA class,
and higher APACHE II scores are poor predictive factors of patient
outcomes of conservative treatment. In addition, the lack of clinical
improvement after 12 hours of starting conservative treatment may
be also a poor predictive factor. In the above prospective studies, the
patients who did not have a clinical improvement after 12 hours with
conservative treatment were switched to surgical intervention immedi-
ately [17,21]; thus, only the patients without this poor predictive factor
remained in the group of conservative treatment. This may be another
reason for the low mortality rates after conservative treatment in
these prospective studies. In our study, survival rates were signicantly
higher for patients without this poor predictive factor than for patients
with the poor predictive factor during the rst 2 weeks of hospitaliza-
tion (Table 2). This result conrmed that the lack of clinical improve-
ment after 12 hours of starting conservative treatment is indeed a
poor predictive factor of patient outcomes. In contrast, the poor predic-
tive factors (such as unstable hemodynamic status, high ASA class, high
APACHE II score, and lack of clinical improvement in 12 hours) were not
associated with the mortality of patients with conservative treatment
after 2 weeks of hospitalization (Table 2). These results suggest that
the patients' condition at presentation with PPU is crucial for the surviv-
al during the rst 2 weeks, but it may not be so important for survival
when patients could remain hospitalized longer than 2 weeks with con-
servative treatment.
It has been shown that conservative treatment rather than
surgical intervention of PPU is associated with a longer hospital stay
[15,32,33]; thus, patients who underwent nonsurgical treatment had a
prolonged duration of fasting and parental nutrition period. Moreover,
parental nutrition is associated with an increased infection rate, im-
paired mucosal function, and increased hospital costs [3436]. In con-
trast, enteral nutrition was shown to reduce morbidity in critically ill
patients [34,35]. Therefore, early enteral nutrition should be considered
to improve the outcome of patients with PPU who undergo conservative
treatment. Our previous reports showed that postpyloric enteral feed-
ing could provide reliable enteral nutrition [25,26]. In this study, pa-
tients who had poor predictive factors had higher survival rates with
early enteral nutrition compared with those patients without early en-
teral nutrition (Table 3). This result suggests that early enteral feeding
should be considered when patients present poor predictive factors
and undergo nonsurgical treatment for PPU. However, this was a retro-
spective study, and the number of patients with early enteral feeding
was not large enough to make a denite conclusion. Therefore, a ran-
domized controlled trial is needed to address this issue.
In conclusion, the poor general condition of patients with PPU at pre-
sentation is a poor prognostic factor associated with mortality during
the rst 2 weeks of conservative treatment. Lack of clinical improve-
ment after 12 hours of conservative treatment is also a poor predictive
factor for mortality after nonsurgical treatment of PPU. However, the
roles of these factors are not crucial when the patients could survive
after conservative treatment for 2 weeks. Early enteral feeding may
1559
improve the outcome of patients with poor prognostic factors, but this
issue needs to be addressed in a further study.
References
[1] Henn RM, Isenberg JI, Maxwell V, et al. Inhibition of gastric acid secretion by cimet-
idine in patients with duodenal ulcer. N Engl J Med 1975;293:3715. http://dx.doi.
org/10.1056/NEJM197508212930802.
[2] Fellenius E, Berglindh T, Sachs G, et al. Substituted benzimidazoles inhibit gastric
acid secretion by blocking (H+ + K+)ATPase. Nature 1981;290:15961 [http://
www.nature.com/nature/journal/v290/n5802/abs/290159a0.html].
[3] Malfertheiner P, Chan FK, McColl KE. Peptic ulcer disease. Lancet 2009;374:144961.
http://dx.doi.org/10.1016/S0140-6736(09)60938-7.
[4] Marshall BJ, Warren JR. Unidentied curved bacilli on gastric epithelium in active chronic
gastritis. Lancet 1983;1:12735. http://dx.doi.org/10.1016/S0140-6736(83)92719-8.
[5] Hentschel E, Brandstatter G, Dragosics B, et al. Effect of ranitidine and amoxicillin
plus metronidazole on the eradication of helicobacter pylori and the recurrence of
duodenal ulcer. N Engl J Med 1993;328:30812. http://dx.doi.org/10.1056/
NEJM199302043280503.
[6] Cai S, Garcia Rodriguez LA, Masso-Gonzalez EL, et al. Uncomplicated peptic ulcer in
the UK: trends from 1997 to 2005. Aliment Pharmacol Ther 2009;30:103948.
http://dx.doi.org/10.1111/j.1365-2036.2009.04131.x.
[7] Kocer B, Surmeli S, Solak C, et al. Factors affecting mortality and morbidity in pa-
tients with peptic ulcer perforation. J Gastroenterol Hepatol 2007;22:56570.
http://dx.doi.org/10.1111/j.1440-1746.2006.04500.x.
[8] Svanes C. Trends in perforated peptic ulcer: incidence, etiology, treatment, and prog-
nosis. World J Surg 2000;24:27783 [http://www.ncbi.nlm. nih.gov/pubmed/
10658061].
[9] Svanes C, Salvesen H, Stangeland L, et al. Perforated peptic ulcer over 56 years. Time
trends in patients and disease characteristics. Gut 1993;34:166671 [http://www.
ncbi.nlm.nih.gov/pubmed/8282252].
[10] Higham J, Kang JY, Majeed A. Recent trends in admissions and mortality due to pep-
tic ulcer in England: increasing frequency of haemorrhage among older subjects. Gut
2002;50:4604 [http://www.ncbi.nlm.nih.gov/pubmed/11889062].
[11] Gisbert JP, Legido J, Garcia-Sanz I, et al. Helicobacter pylori and perforated peptic
ulcer prevalence of the infection and role of non-steroidal anti-inammatory
drugs. Dig Liver Dis 2004;36:11620. http://dx.doi.org/10.1016/j.dld.2003.10.011.
[12] Behrman SW. Management of complicated peptic ulcer disease. Arch Surg 2005;
140:2018. http://dx.doi.org/10.1001/archsurg.140.2.201.
[13] Lohsiriwat V, Prapasrivorakul S, Lohsiriwat D. Perforated peptic ulcer: clinical pre-
sentation, surgical outcomes, and the accuracy of the Boey scoring system in
predicting postoperative morbidity and mortality. World J Surg 2009;33:805.
http://dx.doi.org/10.1007/s00268-008-9796-1.
[14] Moller MH, Adamsen S, Wojdemann M, et al. Perforated peptic ulcer: how to im-
prove outcome? Scand J Gastroenterol 2009;44:1522. http://dx.doi.org/10.1080/
00365520802307997.
[15] Bertleff MJ, Lange JF. Perforated peptic ulcer disease: a review of history and treat-
ment. Dig Surg 2010;27:1619. http://dx.doi.org/10.1159/000264653.
[16] Visick AH. Conservative treatment of acute perforated peptic ulcer. Br Med J 1946;2:
9414 [http://www.ncbi.nlm.nih.gov/pubmed/20341242].
[17] Gul YA, Shine MF, Lennon F. Non-operative management of perforated duodenal
ulcer. Ir J Med Sci 1999;168:2546 [http://www.ncbi.nlm.nih.gov/pubmed/
10624365].
[18] Brinkman JM, Oddens JR, Van Royen BJ, et al. Non-operative treatment for perforated
gastro-duodenal peptic ulcer in Duchenne muscular dystrophy: a case report. BMC
Surg 2004;4:1. http://dx.doi.org/10.1186/1471-2482-4-1.
[19] Bucher P, Oulhaci W, Morel P, et al. Results of conservative treatment for perforated
gastroduodenal ulcers in patients not eligible for surgical repair. Swiss Med Wkly
2007;137:33740 http://dx.doi.org/2007/23/smw-11796.
[20] Taylor H. Perforated peptic ulcer; treated without operation. Lancet 1946;2:4414.
http://dx.doi.org/10.1016/S0140-6736(46)90971-3.
[21] Crofts TJ, Park KG, Steele RJ, et al. A randomized trial of nonoperative treatment for
perforated peptic ulcer. N Engl J Med 1989;320:9703. http://dx.doi.org/10.1056/
NEJM198904133201504.
[22] Cohen MM. Treatment and mortality of perforated peptic ulcer: a survey of 852
cases. Can Med Assoc J 1971;105:2639 [http://www.ncbi.nlm.nih.gov/pubmed/
5563345].
[23] Boey J, Choi SK, Poon A, et al. Risk stratication in perforated duodenal ulcers. A pro-
spective validation of predictive factors. Ann Surg 1987;205:226 [http://www.ncbi.
nlm.nih.gov/pubmed/3800459].
[24] Larkin JO, Bourke MG, Muhammed A, et al. Mortality in perforated duodenal ulcer
depends upon pre-operative risk: a retrospective 10-year study. Ir J Med Sci 2010;
179:5459. http://dx.doi.org/10.1007/s11845-010-0515-1.
[25] Chang WK, McClave SA, Chao YC. Simplify the technique of nasoenteric feeding tube
placement with a modied suture tie. J Clin Gastroenterol 2005;39:479 [http://
www.ncbi.nlm.nih.gov/pubmed/15599210].
[26] Lin HH, Hsieh TY, Chu HC, et al. Transpyloric tube feeding for 506 consecutive pa-
tients with delayed gastric emptying. J Intern Med Taiwan 2006;17:5260 [http://
www.tsim.org.tw/journal/jour17-2/07.PDF].
[27] Ginsberg GG, Kochman ML, Norton ID, et al. Clinical gastrointestinal endoscopy. 2nd
ed. Elsevier Health Sciences; 2011.
[28] Donovan AJ, Berne TV, Donovan JA. Perforated duodenal ulcer: an alternative thera-
peutic plan. Arch Surg 1998;133:116671 [http://www.ncbi.nlm.nih.gov/pubmed/
9820345].
1560 P.-L. Lay et al. / American Journal of Emergency Medicine 34 (2016) 15561560
[29] Devitt JE, Taylor GA. Perforated peptic ulcer. Can Med Assoc J 1967;96:51923
[http://www.ncbi.nlm.nih.gov/pubmed/6019350].
[30] Saber A, Gad MA, Ellabban GM. Perforated duodenal ulcer in high risk patients: is
percutaneous drainage justied? N Am J Med Sci 2012;4:359. http://dx.doi.org/
10.4103/1947-2714.92902.
[31] Prabhu V, Shivani A. An overview of history, pathogenesis and treatment of perforat-
ed peptic ulcer disease with evaluation of prognostic scoring in adults. Ann Med
Health Sci Res 2014;4:229. http://dx.doi.org/10.4103/2141-9248.126604.
[32] Fujii Y, Asato M, Taniguchi N, et al. Sonographic diagnosis and successful nonopera-
tive management of sealed perforated duodenal ulcer. J Clin Ultrasound 2003;31:
558. http://dx.doi.org/10.1002/jcu.10125.
[33] Zittel TT, Jehle EC, Becker HD. Surgical management of peptic ulcer disease
todayindication, technique and outcome. Langenbecks Arch Surg 2000;385:
8496 [http://www.ncbi.nlm.nih.gov/pubmed/10796046].
[34] Nicholas JM, Cornelius MW, Tchorz KM, et al. A two institution experience with 226
endoscopically placed jejunal feeding tubes in critically ill surgical patients. Am J
Surg 2003;186:58390. http://dx.doi.org/10.1016/j.amjsurg.2003.09.005.
[35] Marik PE, Zaloga GP. Early enteral nutrition in acutely ill patients: a systematic re-
view. Crit Care Med 2001;29:226470 [http://www.ncbi.nlm.nih.gov/pubmed/
11801821].
[36] Braun J, Bein T, Wiese CH, et al. Enteral feeding tubes for critically ill patients.
Anaesthesist 2011;60:35265. http://dx.doi.org/10.1007/s00101-010-1800-0.
Reproduced with permission of the copyright owner. Further reproduction prohibited without
permission.