Perforated peptic ulcer

Question 1

Typical features

Answer 1

Question 2

Stages

Answer 2

The clinical syndrome has 3 stages:

1. prostration
2. reaction (after 2–6 h)—symptoms may improve initially
3. peritonitis (after further 4 h)—severe pain

Question 3

Diagnosis

Answer 3

Chest X-ray:

• may show free air under diaphragm (in 75%)—need to sit upright for 15 mins prior.

Limited gastrografin meal can confirm diagnosis.

CT scan is accurate.

Question 4

Management

Answer 4

Drip and suction (immediate nasogastric tube)

Immediate laparotomy after resuscitation

Conservative Rx may be possible (e.g. later presentation and gastrografin swallow indicates sealing of perforation)