Risk stratification and nonoperative management of duodenal perforation: the role of the POMPP score and CT imaging in a retrospective cohort

Background Duodenal perforation is a heterogeneous and potentially life-threatening surgical emergency, with increasingly complex etiologies and management strategies in recent years. In previous studies and guidelines comparing nonoperative management (NOM) and surgical treatment, gastric and duodenal perforations have often been investigated together as upper gastrointestinal perforations, whereas evidence focusing specifically on duodenal perforation remains limited. This study aimed to identify risk factors for severe complications in duodenal perforation, to compare the predictive performance of different risk scoring systems, to explore differences among perforation sites within the duodenum, and to evaluate conditions under which NOM may be considered. Methods A retrospective study was conducted on patients diagnosed with duodenal perforation between January 2021 and May 2025. Clinical characteristics were compared among patients with different outcomes, treatment strategies, and perforation locations. Representative cases were also described. Results Age, POMPP score, sex, albumin, D-dimer, urea, C-reactive protein, creatinine and hemoglobin were associated with the occurrence of severe complications (Clavien–Dindo classification ≥ IV). The POMPP score demonstrated superior predictive performance compared with the Boey score. When comparing patients managed with NOM and those undergoing surgery, significant differences were observed only in CT findings, specifically extensive extraluminal air and suprapelvic fluid collections, whereas other clinical characteristics and clinical outcomes were comparable between the two groups. In addition, patients with perforations at the D2/D3 segments required longer durations of somatostatin use, acid-suppressive therapy, antibiotic treatment, and hospital stay than those with D1 perforations. Conclusion The management of duodenal perforation should be individualized based on patient risk factors, perforation characteristics, and disease progression. Hypoalbuminemia, advanced age, female sex, anemia, and elevated C-reactive protein, creatinine, urea, and D-dimer levels are associated with a higher risk of severe complications. The POMPP shows promise as a reliable tool for identifying low-risk patients. Compared with D1 perforations, D2/D3 perforations require longer treatment durations. In clinically stable, low-risk patients, the absence of extensive extraluminal air or suprapelvic fluid collections on CT may support the selection of NOM.