Review Question - QID 103307

This patient most likely presents with a perforated peptic ulcer as demonstrated by the radiograph demonstrating free intraperitoneal air under the diaphragm. The most appropriate initial step in management is emergent surgical intervention.

Peptic ulcer disease (PUD) is most commonly due to infection with Helicobacter pylori, or excessive NSAID use. A peptic ulcer is an erosion of the mucosal lining of the stomach and often presents with abdominal pain and discomfort. Peptic ulcer disease (PUD) is very common, with a lifetime risk of 10% in the population. Complications of PUD include rupture of an ulcer which results in severe abdominal pain and peritoneal signs on physical exam. Patients with peptic ulcer rupture will typically have normal EKGs, cardiac enzymes, and amylase/lipase. On chest radiograph, free air under the diaphragm indicates a viscous rupture - most commonly from a perforated ulcer in a patient with severe abdominal pain and a history of PUD. A ruptured peptic ulcer is a true surgical emergency and warrants emergent surgical intervention and repair.

Kevitt et. al review the diagnosis and management of peptic ulcer disease. They discuss the pathophysiology and typical clinical presentation of PUD. They note that the progression of untreated PUD ultimately will result in perforation requiring emergent surgical intervention.

Figure A is a chest radiograph demonstrating free air under the diaphragm, suggestive of a perforation in the GI tract.
Illustration A is an endoscopic image of a perforated gastric ulcer. Illustration B is a graphic representation of a perforated gastric ulcer.

Incorrect Answers:
Answer 1: Abdominal CT scan with contrast is not necessary as this patient's history, exam, and radiograph are suggestive of perforated peptic ulcer. CT scan would delay emergent surgical intervention.

Answer 2: Abdominal ultrasound is not indicated in this patient due to the presence of a chest radiograph with free air indicating a perforated viscus that requires immediate surgical intervention.

Answer 3: Emergent endoscopy is indicated for patients with peptic ulcer disease that are unstable due to bleeding. However, this patient's presentation is suggestive of a perforated peptic ulcer which requires surgical intervention.

Answer 5: Intravenous proton pump inhibitor therapy is used in the management of patient's with PUD requiring admission. However, this patient's intraperitoneal free air warrants immediate surgical intervention.

Bullet Summary:
Patients with free intraperitoneal air on chest radiograph require emergent surgical intervention as the initial step in management.