presentation of a patient with a perforated peptic ulcer
- Patients usually describe a prodrome of gnawing localized pain in the epigastric region prior to perforation.
- With acute perforation, the epigastric pain becomes diffuse as a result of release of acidic fluid in the peritoneal cavity and the resulting release of vasoactive mediators, and is often associated with fever, tachycardia, tachypnea, and hypotension.
- Patients with a perforated posterior duodenal ulcer will often present with upper GI bleeding secondary to erosion into the gastroduodenal artery. On examination, the patient with peptic ulcer perforation lies immobile.
- Bowel sounds are typically absent, and the abdomen is diffusely tender and rigid.
- The white blood cell count is elevated, and, in 70% of cases, free intraperitoneal air is found on upright abdominal radiographs.
- Although computed tomography (CT) scan is the most sensitive radiologic test for free intraperitoneal air, it is rarely indicated because patients with perforated peptic ulcers usually present with classic signs and symptoms, and CT scanning only serves to delay an operation.
