Peptic Ulcer Surgery

A 52-year-old man with a 10-year history of duodenal ulcer disease presents to the emergency department with sudden-onset severe epigastric pain radiating to the back, followed by vomiting. On examination, he is in acute distress with a rigid, board-like abdomen and rebound tenderness. Vital signs show BP 95/55 mmHg, HR 118/min, RR 22/min. Upright chest X-ray reveals free air under the diaphragm. He is resuscitated with IV fluids and broad-spectrum antibiotics. After stabilization, what is the most appropriate surgical management?

A 48-year-old man with a 15-year history of gastric ulcer disease presents with persistent epigastric pain and early satiety despite 8 weeks of PPI therapy (omeprazole 40 mg daily). Upper endoscopy shows a 2 cm ulcer in the gastric antrum with clean base and no signs of malignancy. Serum gastrin is 45 pg/mL (normal <100), and H. pylori serology is negative. He has no NSAID use. After confirming compliance and ruling out malignancy, what is the most appropriate next step in management?

A 52-year-old man with a 10-year history of peptic ulcer disease presents to the emergency department with sudden onset epigastric pain and vomiting. On examination, he is in severe distress, blood pressure is 95/60 mmHg, heart rate 110/min, and the abdomen is rigid with guarding. Plain X-ray chest shows free air under the diaphragm. Upper endoscopy reveals a 1.5 cm perforation in the anterior wall of the duodenum. After resuscitation and broad-spectrum antibiotics, what is the most appropriate surgical management?

A 48-year-old man with a history of chronic peptic ulcer disease refractory to medical therapy (on omeprazole 40 mg daily for 2 years) presents with recurrent epigastric pain and melena. Endoscopy shows a 2 cm antral ulcer with a visible vessel. After two sessions of endoscopic hemostasis (injection and clip placement), he re-bleeds within 48 hours. His hemoglobin has dropped from 11 g/dL to 7.5 g/dL despite 4 units of packed red blood cells. What is the most appropriate surgical intervention?

A 52-year-old man presents to the emergency department with sudden-onset epigastric pain and hematemesis. He has a 10-year history of peptic ulcer disease managed medically. On examination, he is pale, blood pressure 95/60 mmHg, heart rate 110/min. Upper endoscopy reveals a large posterior gastric ulcer with a visible vessel. After successful endoscopic hemostasis, he remains stable for 48 hours but then develops sudden severe epigastric pain, fever (38.5°C), and peritoneal signs. Abdominal X-ray shows free air under the diaphragm. What is the most appropriate next step in management?