A Comparative Analysis of Generalized Peritonitis Secondary to Upper Gastrointestinal Perforation: Surgical Approaches, Antibiotic Management, and Patient Outcomes

Generalized peritonitis due to gastric or peptic ulcer perforation (PULP) carries substantial morbidity and mortality. This study is a Preferred Reporting Items for Systematic Reviews and Meta-Analyses-guided systematic review, conducted using PubMed, MEDLINE, Embase, Scopus, and Cochrane, from January 2020 to August 2025. Adults with generalized peritonitis from gastric/PULP reporting surgery, antibiotics, and outcomes were included. Two independent reviewers conducted the screening and data extraction, assessing the risk of bias (RoB) using the Newcastle-Ottawa Scale for observational studies and RoB2 for randomized controlled trials. A narrative synthesis was conducted due to clinical/methodological heterogeneity. Twenty-five studies met the criteria. The contemporary series showed variable 30-day or in-hospital mortality. The highest rates were observed when the time to surgery exceeded 12-24 hours, in cases of shock, among older patients, and for those with an American Society of Anesthesiologists classification of ≥III. Laparoscopic repair, when feasible, was consistently associated with shorter length of stay and fewer wound infections than open repair, with similar mortality; conversion was more likely with higher PULP scores. Omental patch repair predominated and showed lower complications than gastric resection, the latter reserved for large, malignant, or recurrent ulcers. Empiric broad-spectrum antibiotics were universally initiated, with variable stewardship/deescalation. Outcomes hinge on early resuscitation, rapid source control, and structured sepsis care. Laparoscopy reduces morbidity when expertise/resources are available; globally, the omental patch remains first-line. Standardized antibiotic pathways and risk-based triage may reduce variation, but timely access and critical care capacity are decisive.