After increasing steeply at the beginning of the twentieth century, ulcer perforation incidence during the last decades has declined in the young and in men and it has risen among the elderly and in women. Lethality is higher in the elderly and is higher after gastric than after duodenal perforation. The delay before surgical treatment is a strong determinant for lethality, complication rates and hospital costs. History of dyspepsia may or may not be forthcoming but one can always relate pain to particular time as the onset is sudden and pain is acute. Pain is intense and initially it is in the epigastrium and right hypocondrium at the duodenum point and soon it spreads in the upper abdomen. Clinical features are often suggestive of peritonitis and the site of pain and tenderness often clinches the diagnosis. Additional features are history of dyspepsia, analgesic intake or cortisone ingestion. An upright chest radiograph demonstrates gas under the diaphragm in about 60–70% percent of cases and those patients who are too ill to stand may be benefited by lateral cubitus view or across the table view. While perforated peptic ulcers are generally considered an indication for surgery, conservative treatment has been suggested under special circumstances (e.g. a prohibitive anaesthesiological risk or the absence of peritoneal signs). An alternative method practical now is simple closure by laparoscopy. Regardless of the method used to treat perforated peptic ulcer disease it is essential to eradicate H. Pylori in positive patients, since it has been shown that eradication of H. Pylori after simple closure of a perforated peptic ulcer reduces the incidence of residual and recurrent ulcers. It is important to rule out malignancy in a perforated gastric ulcer. Four-quadrant biopsy is taken before closure of the duodenal fistula. Low output fistula does not need any active treatment and it settles down in few days. High out fistula, where duodenal sutures have given way should be taken up for surgery early after resuscitation and correcting the fluid and electrolyte balance. Gastro-jejunostomy with or without vagotomy or Billroth II is the treatment of choice perforation.
