Perforated peptic ulcer is a complication of peptic ulcer disease. It is associated with a high incidence of mortality and morbidity if there is a delay in the diagnosis. Clinical suspicion, history, and examination findings along with imaging studies are necessary for detecting this condition early.
Perforated peptic ulcer (PPU) is a comparatively rare complication of peptic ulcers and is associated with a mortality rate of up to 40%    . The incidence of PPU has decreased in the Western countries but it may be encountered more frequently amongst the elderly , and especially in females . Long-standing treatment with non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, H. pylori infection, smoking and high intake of dietary salt   are reported to be some of the etiological factors leading to PPU. Advancing age, serious medical comorbidities, hypotension , diagnosis and treatment delays for more than one day  are indicators of poor prognosis.
PPU presents typically with sudden onset of severe epigastric pain which soon progresses to generalized abdominal pain. The patient may like to lie still as the movement may aggravate pain. The subsequent clinical symptoms depend upon whether the omentum is able to seal off the perforation and heal it. 'Board-like abdominal rigidity' can develop in patients and localized or generalized peritonitis progresses. . At this time, the patient may present with hypotension, high-grade fever , altered sensorium and sepsis . Typical clinical manifestations can be absent in older patients or those who are immunocompromised. This can delay the diagnosis and result in high rates of mortality.
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There were also four significantly different variables between them: fever, hemoglobin value, site of perforation and operative method. Total postoperative complication rate was 41.3% and 39 patients (16.6%) died. [ncbi.nlm.nih.gov]
At this time, the patient may present with hypotension, high-grade fever, altered sensorium and sepsis. Typical clinical manifestations can be absent in older patients or those who are immunocompromised. [symptoma.com]
This causes severe pain due to peritonitis. The pain is so intense that patient is often able to recollect the exact time and place it started. Pain is constant and spreads to the entire abdomen. [tandurust.com]
The first symptom of a perforated peptic ulcer is usually intense and severe pain. [yourfibrosupport.com]
Symptoms Sudden, sharp and severe pain in upper abdomen Spreading of pain to rest of abdomen Pain gets worse after oral ingestion or movements Feeling of giddiness and fainting Fever Weakness Signs Tachycardia Fever Pallor Reduced abdominal wall movements [speciality.medicaldialogues.in]
Severe pain, systemic inflammatory response from chemical peritonitis and fluid deficit either due to poor intake or vomiting or pyrexia leads to compensatory tachycardia. [wjgnet.com]
This usually causes severe pain and is a medical emergency. What are the treatments for a duodenal ulcer? General advice Lifestyle measures can improve symptoms, such as: Lose weight if you are overweight. [patient.info]
The study showed pneumoperitoneum, contrast stasis in heart with decreased caliber of vessels below the abdominal aortic level, and diffuse lymphedema at the abdominal walls. Emergent laparotomy was performed. [ncbi.nlm.nih.gov]
Sealed perforated ulcer with pseudotumor formation is very rarely encountered. Here we present a case of gastric pseudotumor induced by perforation of a peptic ulcer. [ncbi.nlm.nih.gov]
Hypotension is a late finding as is high fever. Obliteration or complete absence of liver dullness was only noted in 37%, so as a diagnostic tool, this has its limitations [ 7 ]. In blood analysis a moderate leukocytosis will be found. [karger.com]
CONCLUSIONS: PPU should be suspected in adolescents who manifest acute abdominal pain and have peritoneal signs. Children with PPU have a more favorable outcome than adults. [ncbi.nlm.nih.gov]
Dark, tarry bowel movements or vomiting material that resembles coffee grounds may signal bleeding from a peptic ulcer. Seek medical evaluation as soon as possible if you experience symptoms that might indicate a peptic ulcer. [livestrong.com]
He denies any nausea or vomiting. His abdomen is rigid with generalized rebound tenderness. Bowel sounds are absent. What's the situation? Mrs. [journals.lww.com]
In some cases there is coffee ground vomiting. What Causes Perforated Peptic Ulcer? Today perforated peptic ulcer has become relatively rare; however, it is still considered a life threatening condition. [tandurust.com]
Weakness, dizziness, sweating, nausea, vomiting, and palpitations occur soon after eating, especially hyperosmolar foods. [merckmanuals.com]
CONCLUSION: Perforated peptic ulcer disease is emerging as a frequent cause of acute abdomen in our centre and affects the youth commonly. [ncbi.nlm.nih.gov]
Perforation of peptic ulcer is one of the causes of acute abdomen in which early diagnosis and treatment dramatically decrease morbidity and mortality [ 1 ]. [gynecolsurg.springeropen.com]
Although sonography is useful as a first-line diagnostic tool for acute abdomen in the emergency department, it is less helpful in the diagnosis of peptic ulcer perforation. [qjmed.oxfordjournals.org]
The patient may provide a history of partially treated peptic ulcer disease, recurrent epigastric pain, chronic intake of anti-ulcer medications, NSAIDS and/or steroids. [symptoma.com]
The majority of patients give a history of indigestion or epigastric pain typical of a duodenal or gastric ulcer. [gpnotebook.co.uk]
ABC Look for S/S of hypovolemia Start on O2 What might epigastric pain mimic? Maybe rigid, surgical abdomen Exquisite epigastric pain Pale, diaphoretic from shocky T/F: Like diarrhea, PUD can be clinically diagnosed. [quizlet.com]
Snapshot A 65-year-old male presents with complaints of epigastric pain and belching which improves when he eats food but gets worse a few hours after his meal. He said he has noticed a change in the color of his stool. [step2.medbullets.com]
Presentation [ 7 ] Symptoms Symptoms of peptic ulcer disease are sometimes very nonspecific and a diagnosis is unreliable on history alone: Epigastric pain, usually 1 to 3 hours postprandial - it may sometimes wake the patient in the night, and be relieved [patient.info]
This leads to not only pain but abdominal tenderness, meaning touching or pressing on the abdomen provokes increased pain. [livestrong.com]
Improvement is indicated by decrease in the pulse rate, temperature, and abdominal tenderness and by an improvement in the general well being of the patient. [ots1.narod.ru]
If the abdominal tenderness increases, the patient becomes hemodynamically unstable, or the contrast medium flows freely into the abdomen, then an operation is indicated. Operation in conservatively treated patients proceeds in 10% [ 6 ]. [gynecolsurg.springeropen.com]
Abdominal tenderness and classical signs of peritonitis could be elicited in 88.1% and 66.7% of the patients with PPU in this study. Other symptoms also included nausea (35.7%), severe dyspepsia (33.3%), constipation (29.8%) and fever (21.4%)[ 50 ]. [wjgnet.com]
Postoperative respiratory and renal failure were associated with intraoperative hypotension (systolic pressure less than 90 mm Hg). Mortality was associated with age greater than 55 and intraoperative hypotension. [ncbi.nlm.nih.gov]
In advanced cases with sepsis, there may be tachycardia, hypotension and altered consciousness. [symptoma.com]
In cases in which the patient presents more than 24 h after the onset of symptoms or shows the clinical signs of acute abdomen, hypotension, or sepsis, surgery should be done immediately [ 4, 6 ]. [gynecolsurg.springeropen.com]
Poor outcomes have been associated with increasing age, major medical illness, peri-operative hypotension [ 25 ], and delay in diagnosis and management (greater than 24 hours) [ 26 ]. [wjes.biomedcentral.com]
In advanced cases with sepsis, there may be tachycardia, hypotension and altered consciousness. [symptoma.com]
Tachycardia Anxious _ uncomfortable in pain. Finding: Palpation : Tenderness (Severe). Rebound tenderness Rigidity: Often described as board like rigidity. (Rather classic). [medindia.net]
Pain was the consistent symptom while tachycardia, tenderness, and guarding were the signs present in all 70 (40%) patients. Gas under diaphragm (pneumoperitoneum) was found in 67 (95.71%). [scopemed.org]
The chemical peritonitis due to efflux of gastroduodenal contents and severe pain lead to tachycardia. The classic triad of sudden onset of abdominal pain, tachycardia and abdominal rigidity is the hallmark of PPU. [wjgnet.com]
A high index of clinical suspicion, a detailed history, and a thorough physical examination are vital for the early diagnosis of PPU. The patient may provide a history of partially treated peptic ulcer disease, recurrent epigastric pain, chronic intake of anti-ulcer medications, NSAIDS and/or steroids. Signs of peritonitis may be absent on physical examination, especially if the perforation gets sealed . In advanced cases with sepsis, there may be tachycardia, hypotension and altered consciousness.
Laboratory tests are usually nonspecific with leukocytosis, elevated inflammatory markers, metabolic acidosis, and elevated levels of serum amylase suggestive of PPU . Antibiotics should be started early in PPU but it is important to perform blood cultures prior to starting antibiotics  especially if bacterial peritonitis is suspected.
Plain X-ray chest or abdomen obtained in the upright position may show air under the diaphragm which is indicative of perforation of an abdominal organ. In the absence of pneumoperitoneum on plain X-ray, computed tomography (CT) scan with oral contrast is performed. It has a sensitivity of 98% and can also help to exclude other causes of the acute condition like pancreatitis   . PPU should be suspected if CT reveals pneumoperitoneum, thickening of the bowel wall, intraperitoneal fluid, fat streaking and/or hematoma in the mesentery and leak of contrast into the peritoneal cavity .
The differential diagnosis of pneumoperitoneum in children is discussed, as are childhood perforated peptic ulcer in general, and the unique clinical features present in this case in particular. [ncbi.nlm.nih.gov]
PPU should be suspected if CT reveals pneumoperitoneum, thickening of the bowel wall, intraperitoneal fluid, fat streaking and/or hematoma in the mesentery and leak of contrast into the peritoneal cavity. [symptoma.com]
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