• Acute onset of severe upper abdominal pain
• Immediate chemical peritonitis from gastroduodenal secretions followed by bacterial peritonitis in 12-24 hours
• Free air on abdominal x-ray
• The patient may or may not have had preceding chronic symptoms of peptic ulcer disease
• Perforation complicates peptic ulcer about half as often as hemorrhage
• Most perforated ulcers are located anteriorly
• 15% mortality rate correlates with increased age, female sex, and gastric perforations
• The diagnosis is overlooked in about 5% of patients
• In < 10% of cases, acute bleeding from a posterior "kissing" ulcer complicates the anterior perforation
• Severity of illness and occurrence of death are directly related to the interval between perforation and surgical closure
• Perforation usually elicits a sudden, severe upper abdominal pain
• The patient appears severely distressed, lying quietly with the knees drawn up and breathing shallowly to minimize abdominal motion
• Fever is absent at the start but spikes within 12-24 hours
• Rebound tenderness and abdominal rigidity
• Reduced or absent bowel sounds
• Free air in the abdomen with abdominal distention and diffuse tympany
• A mild leukocytosis in the range of 12,000/µL in the early stages followed by rise to 20,000/µL within 12-24 hours
• Mild rise in the serum amylase caused by absorption of the enzyme from duodenal secretions within the peritoneal cavity
• Infection with Helicobacter pylori
• Abdominal x-rays: Reveal free subdiaphragmatic air in 85% of patients
• If no free air is demonstrated and the clinical picture suggests perforated ulcer, an emergency upper GI contrast radiographic series should be performed
• Pain may be localized to the right lower quadrant if gastroduodenal contents collect in the right lateral peritoneal gutter
• Atypical perforations occur in patients already hospitalized for some unrelated illness, and the significance of the new symptom of abdominal pain is not appreciated
• Free air in the abdomen in a patient with sudden upper abdominal pain should clinch the diagnosis
• Diagnosis and treatment should be simultaneous
• Whenever a perforated ulcer is considered, an NG tube should be inserted to reduce further contamination of the peritoneal cavity
• CBC, electrolytes, lipase and amylase
• IV antibiotics (eg, cefazolin, cefoxitin)
• Fluid resuscitation precedes diagnostic measures
• X-rays as soon as the clinical status will permit
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