Nonoperative Management of a Perforated Peptic Ulcer in the Setting of Decompensated Alcoholic Cirrhosis

Perforation of peptic ulcers is typically considered a surgical emergency, but management must account for patient comorbidities. Surgical management of perforated ulcers in the setting of decompensated cirrhosis can be complicated by coagulopathy and delayed wound healing, leading to increased morbidity and mortality. This case outlines the nonoperative management of a perforated peptic ulcer in a 47-year-old male with decompensated alcoholic cirrhosis. Computed tomography scan revealed pneumoperitoneum, and further imaging showed a large perforated ulcer of the superior fornix of the duodenal bulb. Due to the patient’s high preoperative risk, a nonoperative approach was chosen by his multidisciplinary care team. Initial management included nil per os with nasogastric tube decompression, antibiotics, and therapeutic paracentesis. Due to the patient’s declining hemoglobin, an urgent esophagogastroduodenoscopy was performed, and the hemorrhage was treated with epinephrine injection and clipping, followed by placement of a percutaneous pigtail catheter adjacent to the site of perforation. An upper gastrointestinal series completed 11 days later showed no leak from the site of perforation. The patient tolerated dietary advancement and continued to improve until discharge on hospital day 36. In this case, a nonoperative approach yielded resolution of the patient’s bleeding perforated ulcer and resulted in a favorable outcome for our patient.