Review Question - QID 102646

This patient with a history of intermittent epigastric pain with acutely worsened pain and abdominal exam concerning for peritonitis likely has a perforated peptic ulcer. A perforated peptic ulcer necessitates emergent surgical intervention.

Perforated peptic ulcer is a rare but serious complication of peptic ulcer disease (PUD). Perforated peptic ulcers present in someone with a history of PU) or gastroesophageal reflux disease (GERD) with peritoneal signs on physical exam. Exam findings suggestive of peritonitis include guarding, abdominal rigidity, and rebound tenderness. If a perforated peptic ulcer is suspected, an abdominal or chest radiograph should be obtained. If pneumoperitoneum (peritoneal free air) is present on abdominal or chest radiograph, perforation has likely occurred, and the patient should be brought to the operating room for emergent laparotomy with surgical repair of the rupture.

Ramakrishnan et al. review PUD. They note that bleeding is the most common indication for surgery in PUD, although proton pump inhibitors and endoscopic therapy can control most bleeds. Perforation and gastric outlet obstruction are also rare, but very serious complications.

Moller et al., in the PULP trial, found that a perioperative care protocol based on the Surviving Sepsis Guidelines (resuscitation goals defined as: central venous pressure of > 8 mmHg, central venous oxygen saturation of > 70%, MAP > 65mmHg and a urine output of >0.5mls/kg/hr) following surgical treatment for perforated peptic ulcer disease, reduced 30-day mortality by more than 1/3.

Figure A shows a chest radiograph demonstrating free air under the diaphragm. Note the appearance that air takes under the diaphragm, observed just over the liver in this radiograph.

Incorrect Answers:
Answer 1: Abdominal ultrasound would not be appropriate. This patient has a presentation concerning for a perforated peptic ulcer and requires emergent surgical intervention.

Answer 2: CT scan of the abdomen and pelvis with contrast may be appropriate to further evaluate some patients with abdominal tenderness in the absence of peritoneal signs. This patient has a presentation concerning for a perforated peptic ulcer and requires emergent surgical intervention.

Answer 3: Endoscopy may be appropriate for patients with non-ruptured peptic ulcer disease causing bleeding. However, it is not indicated for patients with perforated peptic ulcer disease and emergent surgical intervention is required.

Answer 5: Testing of stool for occult blood is sometimes performed for patients in whom peptic ulcer disease is suspected. However, this patient has a presentation concerning for a perforated peptic ulcer and requires emergent surgical intervention.

Bullet Summary:
Patients with free air under the diaphragm identified on a chest or abdominal radiograph require emergent surgical intervention.