A frail elderly patient is found to have an anterior perforation of a duodenal ulcer. He has a recent history of nonsteroidal anti-inflammatory drug (NSAID) use and no previous history of peptic ulcer disease. A large amount of bilious fluid is found in the abdomen. What should be the next step?

Although surgery is generally recommended for perforation, conservative measures can be considered in select cases. A patient who has a benign clinical presentation or one who is improving, might be considered for treatment with antibiotics and nasogastric decompression.Patients who have an acute abdomen and are hemodynamically unstable should not be observed. Board-like rigidity of the abdomen occur as a result of chemical peritonitis. These patients should have fluid and electrolyte repletion, and antibiotics followed by surgery.Choice of the operative procedure should be guided by the information obtained during the history, the presence of comorbid disease, and hemodynamic stability during the operation. A omental (Graham) patch will seal the ulcer, but it will not prevent recurrence.