Perforated peptic ulcer (PPU) is a comparatively rare complication of peptic ulcers and is associated with a mortality rate of up to 40% [1] [2] [3] [4]. The incidence of PPU has decreased in the Western countries but it may be encountered more frequently amongst the elderly [5], and especially in females [4]. Long-standing treatment with non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, H. pylori infection, smoking and high intake of dietary salt [2] [6] are reported to be some of the etiological factors leading to PPU. Advancing age, serious medical comorbidities, hypotension [7], diagnosis and treatment delays for more than one day [8] 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. [9]. At this time, the patient may present with hypotension, high-grade fever [5], altered sensorium and sepsis [9]. 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.

• Fever

  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]

• Severe Pain

  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]

  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]

  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]

• Cough

  It is characteristically made worse by any movement, and greatly intensifies with coughing or sneezing. Richard Pankhurst (1835–1897, aged 62) had a perforated ulcer and died on 5 July 1897. [en.wikipedia.org]

  It is characteristically made worse by any movement, and greatly intensifies with coughing or sneezing. The pain is often generalized throughout the abdomen, but is sometimes focused in the upper abdomen. [livestrong.com]

  It is characteristically made worse by any movement, and greatly intensifies with coughing or sneezing. Notable cases Edit Richard Pankhurst (1835–1897, aged 62) had a perforated ulcer and died on 5 July 1897. [en.m.wikipedia.org]

  Pain becomes worse from touch, movement, cough and sneeze. Patient breathes shallowly to avoid pain. The abdomen is markedly board like rigid. Few hours after rupture, the abdomen will be swollen and there is complete absence of bowel sound. [tandurust.com]

• Abdominal Pain

  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]

• Vomiting

  Symptoms can include: repeated episodes of vomiting, with large amounts of vomit that contain undigested food a persistent feeling of bloating or fullness feeling very full after eating less food than usual unexplained weight loss An endoscopy can be [nhs.uk]

  Weakness, dizziness, sweating, nausea, vomiting, and palpitations occur soon after eating, especially hyperosmolar foods. [merckmanuals.com]

  The signs that you are having an ulcer emergency are: Blood (black or red) in stool Blood in vomit or vomit that looks like coffee grounds Increasing pain Weakness Mental confusion Severe abdominal distension If you think you or someone you know is having [everydayhealth.com]

  […] stools Chest pain Fatigue Vomiting, possibly bloody Weight loss Ongoing heartburn To detect an ulcer, you may need a test called an upper endoscopy (EGD). [medlineplus.gov]

• Acute Abdomen

  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]

  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]

  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]

• Epigastric Pain

  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. [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]

  […] worse with meals duodenal ulcer chronic dull, burning, aching epigastric pain improves with meals worsens 1-3 hours after eating radiates to the back awaken patient at night Ulcer Perforation pain in right shoulder ( air under the diaphragm) rebound [step2.medbullets.com]

  A 55-year-old man presented after 3 weeks of sharp epigastric pain radiating to the right upper quadrant, fever, and generalized weakness. He had a history of significant heroin and cocaine abuse and was currently in a methadone maintenance program. [mdedge.com]

• Abdominal Tenderness

  Spillage of digestive contents into the abdominal cavity due to a perforated ulcer provokes intense inflammation of the area. 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]

  Typical signs such as abdominal rigidity and right lower quadrant tenderness (as a result of fluid tracking along the right paracolic gutter) may be seen. [wjgnet.com]

• Hypotension

  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]

  Upper gastrointestinal hemorrhage Acute presentation with upper gastrointestinal hemorrhage requires expedient resuscitation, especially as the affected population is often relatively frail and hypotension/shock can lead to other medical sequelae (e.g [radiopaedia.org]

  Fever, hypotension, and oliguria suggest sepsis and circulatory compromise. [aafp.org]

• Tachycardia

  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]

• Thrombosis

  A second modality should be added to induce thrombosis of the artery. [wjes.biomedcentral.com]

• Photosensitivity

  Rare but not serious problems may include taste disturbance, peripheral oedema, photosensitivity, fever, arthralgia, myalgia and sweating. [patient.info]

• Flushing

  Several authors have suggested that laparoscopic surgery is not superior to laparotomy due to a lack of direct tactile sense, longer operative times and difficulty in peritoneal cavity flushing. [nature.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 [10]. 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 [10]. Antibiotics should be started early in PPU but it is important to perform blood cultures prior to starting antibiotics [11] 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 [4] [12] [13]. 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 [14].

• Pneumoperitoneum

  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]

• Leukocytosis

  Laboratory tests are usually nonspecific with leukocytosis, elevated inflammatory markers, metabolic acidosis, and elevated levels of serum amylase suggestive of PPU. [symptoma.com]

  Blood analysis revealed normal red blood cells but leukocytosis of 15,000/μl. Transaminases as well as amylases were within normal limits. [gynecolsurg.springeropen.com]

  Serious problems include liver dysfunction, hypersensitivity reactions (including urticaria, angio-oedema, bronchospasm, anaphylaxis), depression, interstitial nephritis, blood disorders (including leukopenia, leukocytosis, pancytopenia, thrombocytopenia [patient.info]

  Leukocytosis and raised C-reactive protein may be raised as a result of inflammation or infection[ 57 ]. Elevated creatinine, urea and metabolic acidosis reflects systemic inflammatory response syndrome (SIRS) and prerenal injury[ 58 ]. [wjgnet.com]

Of these, 9 were about the history of treatment, 7 about conservative treatment, and 26 were about the surgical procedure of which 8 were addressing laparoscopic correction. Overall there is no consensus, but some advice is given. [ncbi.nlm.nih.gov]

* Tramadol may mask symptoms of peptic ulcer complications, yet tramadol's effect on peptic ulcer prognosis is unknown. [ncbi.nlm.nih.gov]

The introduction of antibiotics improved the prognosis of ulcer perforation surgery greatly. Postoperative lethality decreased until 1950 but has remained stable since then. [doi.org]

Advancing age, serious medical comorbidities, hypotension, diagnosis and treatment delays for more than one day are indicators of poor prognosis. [symptoma.com]

Links: clinical features of perforated peptic ulcer epidemiology investigations management prognosis [gpnotebook.co.uk]

This improvement in the prognosis for patients with perforated peptic ulcer is the result, in large measure, of better operative technic, better anesthesia, a clearer knowledge of fluid balance and of blood replacement and the use of the antibiotics and [nejm.org]

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. [symptoma.com]

There is no increased risk of cancer with ulcers of other etiology. [merckmanuals.com]

AIM: To investigate the epidemiological trends in incidence and mortality of perforated peptic ulcer (PPU) in a well-defined Norwegian population. [ncbi.nlm.nih.gov]

Links: clinical features of perforated peptic ulcer epidemiology investigations management prognosis [gpnotebook.co.uk]

A perforated peptic ulcer is the first differential diagnosis of pneumoperitoneum, but in the socio-epidemiological context of Togo, one should also consider typhoid. [medical-dictionary.thefreedictionary.com]

Peptic ulcer disease in low- and middle-income countries presents unique epidemiology and treatment challenges that may differ significantly from evidence-based guidelines in high-income countries.}, author = {Moses, J. [lup.lub.lu.se]

Sleisenger and Fordtran's Gastrointestinal and Liver Disease: Pathophysiology/Diagnosis/Management. 10th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 51. Updated by: Michael M. [medlineplus.gov]

In: Sleisinger MH, Fordtran JS (eds) Gastrointestinal diseases: pathophysiology, diagnosis, management, 5th edn. Saunders, Philadelphia, pp 580–679 Google Scholar Donovan AJ, Berne TV, Donovan JA (1998) Perforated duodenal ulcer. [gynecolsurg.springeropen.com]

 Antral D cells secrete somatostatin which inhibits gastrin production. 13. pathophysiology of peptic ulcer disease  Peptic ulcers occur when there is an alteration in the balance between acid production and mucosal protective mechanisms.  There [slideshare.net]

BACKGROUND: To prevent or minimize leakage after simple closure of giant perforated peptic ulcers in critically ill elderly patients, we conducted a clinical study using gastric body partition to prevent upstream gastric juice and food from passing through [ncbi.nlm.nih.gov]

[…] of Helicobacter pylori for prevention of ulcer recurrence after simple closure of perforated peptic ... [evidence.nhs.uk]

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