Treatment of perforated peptic ulcer includes -a) i.v. fluidsb) Drainage of paracolic gutterc) Immediate surgeryd) Antacidse) i.v. pantoprazole
Management of Peptic ulcer perforation

Nasogastric tube: whenever a perforated ulcer is suspected, the first step is to pass a nasogastric tube and empty the stomach to reduce further contamination of the peritoneal cavity.
Intravenous crystalloid: The patient is resuscitated aggressively by administration of intravenous crystalloid. Intravenous broad-spectrum antibiotics

Surgery:
Surgery is mostly indicated, although occasionally nonsurgical treatment can be used in stable patients without peritonitis, and in whom radiologic studies document a sealed perforation.
Surgery whether laparoscopy or laparotomy involves two components:
i) Thorough peritoneal toilet

to remove all the fluid and food debris
 drain is not indicated

ii) Management of perforation
For duodenal ulcer perforation

The most frequently performed operation for a perforated duodenal ulcer is simple closure with an omental onlay reinforcement or patch.
This is combined with postoperative H. pylori eradication (antibiotics + antisecretory agents)
Insertion of a nasoenteric or jejunal feeding tube should be considered


For gastric ulcer perforation

All perforated gastric ulcers are best treated by distal gastric resection with or without a truncal vagotomy (Truncal vagotomy can be added for type II & III gastric ulcers. Type I and IV gastric ulcers do not need acid reducing procedures as they are associated with hyposecretion). Ulcer is removed along with gastric resection as it carries a risk of malignancy (cf: duodenal ulcer has no risk of cancer). If ulcer is left behind, biopsy is always done.

- Other procedures used for gastric ulcers are
-     patch closure with biopsy - wedge excision and closure
Conservative Management:
Conservative management may be tried in stable patients without peritonitis, and in whom radiologic studies document a sealed perforation.
In conservative management, the patient is observed closely and treated with

nasogastric suction,
IV fluids
intravenous acid secretion suppression, and
intravenous broad-spectrum antibiotics.
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