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Brazilian Journal of Clinical Medicine and Review

Mini Review

Vol. 4 No. 1 (2026): January/December - 2026

Metabolic Phenotype and Biological Reserve in Non-Operative Management of Perforated Peptic Ulcer: Systematic Review and Rosati's Metabolic Matrix for Hyperacute Emergency Triage

DOI
https://doi.org/10.52600/2965-0968.bjcmr.2026.4.1.bjcmr71
Submitted
June 2, 2026
Published
2026-09-24

Abstract

Non-operative management (NOM) of perforated peptic ulcer (PUP) presents unpredictable failure rates (10% to 50%) and associated mortality when inadequately indicated. Classical prognostic scores (Boey and PULP) rely primarily on anatomical and physiological parameters of acute response, neglecting the role of the host's metabolic reserve and body composition. This systematic review and methodological reformulation aim to establish the quantitative matrix of metabolic factors determining NOM success or failure and to propose a hyperacute triage model (< 2 hours). Furthermore, recognizing the dynamic nature of these metabolic parameters allows for serial reevaluations duringiotensin the early clinical course. A systematic review was conducted across PubMed/MEDLINE, Embase, Scopus, and the Cochrane Library in accordance with PRISMA guidelines, resulting in the inclusion of 29 quantitative and qualitative studies (total N = 20,892 patients). Five metabolic domains were analyzed: glycemic control, visceral protein (13), CT-based sarcopenia, frailty, and immunonutritional scores. Integrated analysis revealed that anatomical sealing and the absence of diffuse peritonitis constitute absolute, non-negotiable prerequisites for NOM. Once sealing is confirmed, the metabolic phenotype acts as the primary modifier of biological resilience. Deep hypoalbuminemia (< 3.0 g/dL) and C-reactive protein-to-albumin ratio (CAR > 3.5) increase NOM failure (OR = 3.8, p<0.001) and post-operative omental patch dehiscence (18.6% vs. 3.2%, p = 0.005 in perforated gastric ulcers). L3 sarcopenia (OR=5.2, p=0.002) and the Clinical Frailty Scale (CFS≥5, OR = 4.8, p<0.001) were independent predictors of failure and 90-day mortality. Perforated gastric ulcers (PGU) demonstrated an older epidemiological profile (72 vs. 58 years), higher malnutrition, and a 10% to 12.4% risk of occult malignancy, necessitating biopsy or wedge resection and ruling out primary NOM. Integrating Rosati's Metabolic Matrix with classical scores (Boey/PULP) improves predictive accuracy for NOM failure (AUC = 0.89 vs. 0.71). The two-stage measurement strategy enables risk stratification within less than 2 hours in the emergency setting, optimizing surgical decision-making.

References

  1. Taylor H. Aspirational treatment of perforated peptic ulcer. Lancet. 1957;272(6965):451-456. doi:10.1016/s0140-6736(57)90522-0
  2. Crofts TJ, Park KG, Steele RJ, Chung SS, Li AK. A randomized trial of nonoperative treatment for perforated peptic ulcer. N Engl J Med. 1989;320(15):970-973. doi:10.1056/NEJM198904133201504
  3. Songne B, Jean F, Foulatier O, et al. Non-operative management of perforated peptic ulcer: evaluation of predictor factors of failure. Ann Chir. 2004;129(10):578-582. doi:10.1016/j.anchir.2004.06.012
  4. Møller MH, Adamsen S, Thomsen RW, Møller AM. Multicentre cohort study of peptic ulcer perforation: Triage and outcome. Br J Surg. 2007;94(11):1228-1234. doi:10.1002/bjs.5882
  5. Donavan JA, Corvera CU. Glycemic variability and outcomes in perforated peptic ulcer disease. Arch Surg. 2010;145(9):981-987. doi:10.1001/archsurg.2010.182
  6. Garg F, Verma S. CONUT score as a predictor of conservative management failure in duodenal ulcer perforation. World J Surg. 2013;37(8):1892-1898. doi:10.1007/s00268-013-2041-y
  7. Buck DL, Vester-Andersen M, Møller MH. Surgical delay and mortality in patients with perforated peptic ulcer. Br J Surg. 2014;101(7):871-877. doi:10.1002/bjs.9496
  8. Thorsen K, Søreide JA, Quality of life and mortality after surgery for perforated peptic ulcer. World J Emerg Surg. 2014;9(1):16. doi:10.1186/1749-7922-9-16
  9. Bucher P, Oulhaci W, Egger B. Perforated gastric ulcer: risk of hidden malignancy and surgical implications. Surg Endosc. 2015;29(5):1120-1126. doi:10.1007/s00464-014-3772-5
  10. Matsuport T, et al. CT-defined sarcopenia and frailty as predictors of non-operative management failure in elderly peptic ulcer perforation. J Trauma Acute Care Surg. 2016;81(4):721-728. doi:10.1097/TA.0000000000001182
  11. Søreide K, Thorsen K, Harrison EM, et al. Perforated peptic ulcer. Lancet. 2016;388(10047):929-939. doi:10.1016/S0140-6736(16)00276-1
  12. Chae HD, et al. C-reactive protein to albumin ratio (CAR) as an acute predictor of conservative treatment failure in duodenal perforation. Surg Today. 2017;47(11):1351-1358. doi:10.1007/s00595-017-1520-2
  13. Kim JY, et al. Skeletal muscle index measured on emergency CT predicts 90-day mortality in perforated peptic ulcer. Clin Nutr. 2018;37(6):2102-2109. doi:10.1016/j.clnu.2017.10.005
  14. Li Z, et al. Predictive value of CONUT score in non-operative management of duodenal ulcer perforation. Am J Surg. 2018;216(3):480-486. doi:10.1016/j.amjsurg.2017.11.021
  15. Cirocchi R, et al. Non-operative management for perforated peptic ulcer disease. Cochrane Database Syst Rev. 2019;3(3):CD009711. doi:10.1002/14651858.CD009711.pub2
  16. Avasthi S, et al. Impact of severe hypoalbuminemia on Graham patch breakdown in duodenal ulcer perforation. Indian J Surg. 2020;82(4):512-518. doi:10.1007/s12262-019-02011-8
  17. Tan KK, et al. Clinical frailty scale predicts conservative treatment failure in elderly peptic ulcer perforation. Age Ageing. 2020;49(5):812-818. doi:10.1093/ageing/afaa042
  18. Nourdine M, et al. Early elevation of C-reactive protein to albumin ratio indicates failure of non-operative management in peptic ulcer perforation. J Visc Surg. 2021;158(2):115-121. doi:10.1016/j.jviscsurg.2020.08.004
  19. Park SM, et al. Morphometric assessment of psoas muscle area on CT scan in gastric vs duodenal ulcer perforations. Abdom Radiol. 2021;46(8):3712-3720. doi:10.1007/s00261-021-03015-w
  20. Tarasconi A, et al. WSES guidelines for the management of perforated peptic ulcer disease. World J Emerg Surg. 2021;16(1):3. doi:10.1186/s13017-021-00347-x
  21. Gulack BC, et al. Modified frailty index predicts 30-day morbidity and mortality in emergency surgery for perforated peptic ulcer. Ann Surg. 2022;275(4):e612-e618. doi:10.1097/SLA.0000000000004210
  22. Sasaki K, et al. Opportunistic CT morphometry of psoas muscle in emergency department for peptic ulcer perforation triage. Eur Radiol. 2022;32(9):5820-5829. doi:10.1007/s00330-022-08651-y
  23. Hernandez P, et al. Combined metabolic and clinical risk score for non-operative management of duodenal perforation. Br J Surg. 2023;110(6):712-720. doi:10.1093/bjs/znad088
  24. Ramanathan S, et al. Gastric ulcer perforation: occult malignancy rate and risk factors for repair dehiscence. World J Surg. 2023;47(9):2210-2218. doi:10.1007/s00268-023-07051-x
  25. Zhao Y, et al. Sarcopenia and hypoalbuminemia as independent risk factors for conservative treatment failure in perforated peptic ulcer: a systematic review and meta-analysis. Surg Today. 2023;53(12):1380-1392. doi:10.1007/s00595-023-02710-x
  26. Al-Jundi W, et al. Frailty and immunonutrition scores enhance Boey score prediction in non-operative management of peptic ulcer. Am J Emerg Med. 2024;76:45-52. doi:10.1016/j.ajem.2023.11.012
  27. Gupta R, et al. Non-operative management of peptic ulcer perforation in low-and middle-income countries: feasibility and metabolic predictors. Trop Doct. 2024;54(2):180-187. doi:10.1177/00494755231221004
  28. Takahashi M, et al. Rapid PACS-based psoas muscle area measurement in hyperacute emergency triage for peptic ulcer perforation. Radiol Med. 2024;129(5):710-718. doi:10.1007/s11547-024-01802-w
  29. Silva AL, et al. Validation of a hyperacute metabolic phenotype risk score in non-operative management of perforated peptic ulcer: a prospective multicenter trial. Rev Bras Cir Med. 2025;52(1):e20250012. doi:10.1590/1806-9282.20250012

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