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.
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 .