A perforated duodenal ulcer can lead to severe complications, as it allows bacteria from the intestine to escape into and infect the lining of the abdomen. The infection can lead to sepsis, which can be fatal.

It is rare for duodenal ulcers to perforate, but the condition can be life threatening.

The most common underlying cause of duodenal perforation is peptic ulcer disease (PUD). PUD affects 4 million people globally, and around 5% of people with PUD experience perforation.

This article examines duodenal perforation and the associated symptoms, causes, and risk factors. It also looks at diagnosis, treatment, possible complications, and the outlook for people with the condition.

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Duodenal ulcers are a type of peptic ulcer that occurs in the upper area of the small intestine, known as the duodenum. The ulcers are part of PUD, which affects part of the duodenum and the stomach.

Certain substances may cause injury to the gastroduodenal mucosa, a protective barrier that prevents gastric juices from digesting a person’s organs. This may lead to perforation, which involves the lining of the duodenum splitting open.

There are two types of duodenal perforation: Free and contained.

If free perforation occurs, bowel contents leak freely through the perforation into the abdominal cavity, which leads to an infection known as peritonitis.

In contained perforation, the ulcer creates a hole, but organs such as the pancreas block the area and prevent the bowel contents from leaking freely into the abdomen.

Symptoms of duodenal perforation include:

The most common causes of duodenal perforation are the frequent use of nonsteroidal anti-inflammatory drugs (NSAIDs) and an overgrowth of the Helicobacter pylori (H. pylori) bacteria in the digestive tract.


Long-term use of NSAIDs can irritate and damage the lining of the digestive system and increase a person’s risk of developing peptic ulcers.

Around 25% of people who use NSAIDs chronically develop PUD, and of those, 2–4% of them will experience perforation or bleeding.

H. pylori

This type of bacteria infects the small bowel and stomach and is one of the most common infections worldwide.

It can irritate the lining of the digestive tract, which can lead to the development of peptic ulcers and increase the risk of perforation. The prevalence of the bacteria in people with duodenal ulcers ranges from 50–80%.

Other causes

Other causes include:

A doctor may order various tests to diagnose duodenal perforation and rule out other diagnoses.

These can include:

Chest X-rays and CT scans can help doctors identify free air, or gas, under the diaphragm, which may indicate a perforated peptic ulcer. A CT scan can also help doctors exclude acute pancreatitis as the cause of a person’s symptoms.

Laboratory tests to analyze a person’s blood and urine can help doctors rule out other diagnoses. Doctors may analyze a person’s white cell count and creatinine levels.

The condition can be fatal if a person does not receive treatment for a duodenal perforation. Initial treatment may involve:

Doctors will evaluate a person to determine how to best treat their condition. Nonsurgical treatment options include using medication to treat H. pylori to assist in healing the ulcer and reduce the risk of recurrence. This may involve medication such as amoxicillin or metronidazole with clarithromycin, a PPI medication, and omeprazole.

After initial treatment, doctors may closely monitor a person’s condition and administer intravenous antibiotics and nasogastric suction. Nasogastric suction involves the removal of gasses, liquids, and solids from the stomach and intestine via a small tube that doctors insert through the nose.

A doctor may need to treat a duodenal perforation with surgery. The most common surgery types include Graham patch surgery and Cellan-Jones repair surgery.

Graham patch surgery involves a doctor plugging the perforation with a free omental plug. A surgeon forms an omental plug from the omentum, a layer of tissue on the surface of the intraperitoneal organs.

Cellan-Jones repair surgery involves surgeons closing the perforation with sutures and then covering the repair with a flap that the omentum forms.

Complications may arise from the duodenal perforation or from surgery to treat the condition.

A common complication of the perforation is sepsis. Between 30% and 35% of people who enter the operating theatre with a perforated peptic ulcer have sepsis, accounting for 40–50% of fatalities in people with the condition.

Around 30% of patients with perforated peptic ulcers experience postoperative complications. These can include:

Various factors can influence the outlook for a person with duodenal perforation. The outlook is typically poorer if the time between the perforation and treatment is greater than 24 hours.

Other factors that may result in a poor outcome include whether the person:

The mortality rates of duodenal perforation range between 8% and 25%. There is an increased risk of septic shock for patients who receive surgical treatment.

More than a quarter of people who undergo surgery for perforation develop septic shock within a month. There is a mortality rate of 50–60% within this group.

Any person who experiences sudden abdominal pain that worsens steadily should contact a doctor as soon as possible or contact emergency medical services if the pain occurs outside of regular doctor’s hours.

Duodenal ulcers are a type of peptic ulcer in the duodenum, an area of the small intestine. Factors such as chronic use of NSAIDs or the bacteria H. pylori may irritate the protective lining of the intestine and cause the ulcer to perforate, or split open.

A perforation can lead to severe and fatal complications, as the contents of the bowel can leak into the abdominal cavity. This can lead to peritonitis and sepsis.

It is important that anyone with symptoms such as sudden and severe abdominal pain contacts a doctor as soon as possible. A period longer than 24 hours between perforation and treatment can result in a poorer outcome.

Treatment can involve medication, monitoring, or surgery to repair the perforation. The mortality rate for people with duodenal perforation is 8–25%.