General Surgery · Year 3 · from General Surgery
Case 2: Perforated Peptic Ulcer
Patient Demographics
- Age: 52 years
- Sex: Male
- Occupation: Construction foreman
Chief Complaint
"I have sudden, severe pain in my upper abdomen that started 4 hours ago."
History of Present Illness
The patient presents to the ED with acute onset of severe epigastric pain that began suddenly while at work 4 hours ago. He describes the pain as "like a knife stabbing me" with radiation to both shoulders. He has been unable to move without severe pain and has not had any bowel movements or passed gas since symptom onset. He reports a history of epigastric burning and discomfort over the past several months, which he self-treated with over-the-counter antacids. He admits to taking ibuprofen daily for chronic back pain for the past 3 years.
Past Medical History
- Chronic low back pain
- Hypertension
- No prior surgeries
Medications
- Ibuprofen 800 mg three times daily
- Lisinopril 10 mg daily
Social History
- Smokes 1 pack per day for 30 years
- Drinks 4-5 beers daily
- Divorced, lives alone
Physical Examination
- Vitals: BP 98/62 mmHg, HR 118 bpm, RR 24/min, Temp 37.2°C, SpO2 96% on room air
- General: Middle-aged male in severe distress, lying motionless, appears diaphoretic
- Cardiovascular: Tachycardic, regular rhythm
- Abdomen:
- Inspection: Scaphoid, not moving with respiration
- Auscultation: Absent bowel sounds
- Palpation: Board-like rigidity, diffuse tenderness, severe guarding
- Percussion: Loss of liver dullness (suggests free air)
- Extremities: Cool, mottled
Laboratory Results
- WBC: 14,200/μL
- Hemoglobin: 15.8 g/dL (hemoconcentrated)
- Platelets: 198,000/μL
- Creatinine: 1.6 mg/dL
- BUN: 32 mg/dL
- Lactate: 3.8 mmol/L
- Lipase: 45 U/L (normal)
- pH: 7.32, pCO2: 32, HCO3: 18 (metabolic acidosis)
Imaging
Upright Chest X-ray: Free air under both hemidiaphragms (pneumoperitoneum)
CT Abdomen/Pelvis (performed rapidly):
- Large pneumoperitoneum
- Free fluid in the peritoneal cavity
- Anterior perforation of the prepyloric antrum
- No evidence of malignancy
Diagnosis
Perforated peptic ulcer with generalized peritonitis
Resuscitation
- Two large-bore IV access
- Aggressive crystalloid resuscitation (2L bolus)
- Nasogastric tube placement
- Foley catheter
- Broad-spectrum antibiotics (piperacillin-tazobactam)
- IV PPI (pantoprazole 80 mg bolus then infusion)
- Blood type and crossmatch
Management Decision
Given hemodynamic instability, diffuse peritonitis, and large pneumoperitoneum, emergent surgical exploration is indicated. The patient is taken to the OR within 90 minutes of presentation.
Operative Findings and Procedure
- Exploratory laparotomy via upper midline incision
- 1.5 cm perforation in the anterior prepyloric region
- 2 liters of purulent, bilious peritoneal contamination
- Graham patch repair with omental plug
- Thorough peritoneal lavage (10L warm saline)
- Placement of 2 abdominal drains
Postoperative Course
- ICU admission for hemodynamic monitoring
- Mechanical ventilation for 24 hours
- Vasopressor requirement resolved by POD 1
- NGT removed POD 3
- Diet advanced slowly
- Triple therapy for H. pylori initiated
- Discharged POD 8
Teaching Points
- Sudden onset severe abdominal pain with rigidity = surgical emergency
- NSAID use is a major risk factor for peptic ulcer disease
- Free air on imaging indicates hollow viscus perforation
- Resuscitation should not delay definitive surgical management in unstable patients
- H. pylori testing and treatment essential post-repair
Clinical Image
Image Description: Upright chest X-ray demonstrating free air under the right hemidiaphragm (pneumoperitoneum), a classic finding in hollow viscus perforation. The crescent of air between the liver and diaphragm is clearly visible.
Attribution: Image from Wikimedia Commons, public domain. Source: https://commons.wikimedia.org/wiki/Category:Pneumoperitoneum