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  • • 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

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Epidemiology

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  • • 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

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Symptoms and Signs

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  • • 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

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Laboratory Findings

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  • • 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

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Imaging Findings

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  • 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

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  • • 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

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Rule Out

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  • • Acute pancreatitis and acute cholecystitis

    • The simultaneous onset of pain and free air in the abdomen in the absence of trauma usually means perforated peptic ulcer

    • -Free perforation of colonic diverticulitis and acute appendicitis are other rare causes

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  • • 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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When to Admit

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  • • Nearly all cases of free perforation require surgical intervention and necessitate admission

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Surgery

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  • • All free perforations should be repaired by secure closure of the hole ...

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