General Surgery · Year 3 · from General Surgery
Case 1: Perforated Peptic Ulcer Disease
Patient Demographics
- Age: 45 years
- Sex: Male
- Occupation: Restaurant manager
Chief Complaint
"I have sudden severe pain in my stomach that started 3 hours ago."
History of Present Illness
The patient presents to the emergency department with acute onset of severe epigastric pain that began suddenly while at work. He describes the pain as "the worst pain of my life," sharp, and radiating to his back. He has been unable to find a comfortable position. He had one episode of non-bloody emesis. He reports a history of epigastric burning for several months, worse with stress and coffee, which he has been self-treating with antacids. He admits to taking ibuprofen frequently for chronic knee pain.
Past Medical History
- Chronic knee pain (old sports injury)
- No prior surgeries
- No known H. pylori infection
Medications
- Ibuprofen 600 mg 2-3 times daily
- Occasional over-the-counter antacids
Social History
- Smokes 1 pack per day for 20 years
- Heavy coffee consumption (5-6 cups daily)
- Social alcohol (3-4 drinks on weekends)
- High-stress job
Physical Examination
- Vitals: BP 102/68 mmHg, HR 112 bpm, RR 22/min, Temp 37.6°C, SpO2 97%
- General: Middle-aged male in severe distress, lying motionless, knees drawn up
- Abdomen:
- Inspection: Not moving with respiration, flat
- Palpation: Board-like rigidity, diffuse tenderness
- Percussion: Absent liver dullness (Chilaiditi sign variant - suggests free air)
- Bowel sounds: Absent
Laboratory Results
- WBC: 15,800/μL
- Hemoglobin: 14.2 g/dL
- Creatinine: 1.4 mg/dL
- Lactate: 3.2 mmol/L
- Amylase/Lipase: Normal
Imaging
Upright Chest X-ray:
- Free air under the diaphragm bilaterally
CT Abdomen/Pelvis (limited due to clinical urgency):
- Large pneumoperitoneum
- Free fluid in the abdomen
- Perforation site appears to be anterior duodenum/prepyloric region
Diagnosis
Perforated peptic ulcer with peritonitis
Resuscitation
- Large-bore IV access x 2
- Aggressive fluid resuscitation
- Nasogastric tube decompression
- Foley catheter
- IV antibiotics (piperacillin-tazobactam)
- IV PPI (pantoprazole bolus + infusion)
Operative Management
Emergent exploratory laparotomy:
- Findings: 8 mm perforation of anterior duodenum with surrounding inflammation
- Procedure: Graham patch repair using omental patch
- Thorough peritoneal lavage
- No evidence of malignancy
Postoperative Management
- ICU admission for 24 hours
- NPO, NGT to suction
- IV PPI continued
- Antibiotics continued for 5 days
- H. pylori testing: Positive (stool antigen)
- Triple therapy for H. pylori initiated when able to take PO
Postoperative Course
- NGT removed POD 3
- Diet advanced slowly
- Discharged POD 5 on PPI and H. pylori eradication therapy
- Strict NSAID avoidance counseled
- Smoking cessation strongly recommended
Follow-up
- H. pylori eradication confirmed at 6 weeks
- EGD at 8 weeks: Healed ulcer bed, no residual ulcer
- Continue PPI for 8 weeks total
- Transitioned to H2 blocker for maintenance
Teaching Points
- NSAIDs and H. pylori are the two major causes of peptic ulcer disease
- Free air on imaging indicates perforated hollow viscus
- Perforated PUD is a surgical emergency
- Graham patch is the standard repair for perforated duodenal ulcer
- H. pylori testing and treatment essential after repair
- NSAID cessation critical to prevent recurrence
Clinical Image
Image Description: Upright chest X-ray demonstrating free air under the diaphragm (pneumoperitoneum), a classic finding in perforated peptic ulcer. The crescentic lucency between the liver and right hemidiaphragm indicates intraperitoneal free air.
Attribution: Image from Wikimedia Commons, Category:Pneumoperitoneum. Source: https://commons.wikimedia.org/wiki/Category:Peptic_ulcers