Perforated Peptic Ulcer The term 'perforated peptic ulcer' refers to the perforation of either gastric or duodenal ulcers. It is more common in males aged 35-45 years, with anterior duodenal ulcers perforating more commonly than posterior ones. Perforation can occur in acute or pre-existing ulcers and is precipitated by steroids, alcohol, and anti-malarials.
Stages of Perforation There are three major stages: chemical peritonitis causing severe pain and vomiting; reaction/illusion stage leading to decreased pain for six hours; diffuse bacterial peritonitis caused by migration of bacteria from GI tract into the peritoneum.
Clinical Features Patients present with persistent severe epigastric pain that later becomes generalized. Other features include Blumberg sign (rebound tenderness), fever, vomiting, dehydration, oliguria due to bile leakage into the peritoneum. Toxicity symptoms such as tachycardia and hypotension also occur.
Investigations & Treatment 'Plain x-ray abdomen' shows gas under diaphragm in 70% cases but may not show it if gas leak is less than 1 million liters or there are adhesions between liver and diaphragm.'Ultrasound abdomen' reveals free fluid/gas.'Treatment involves admission for IV fluids/antibiotics followed by emergency laparotomy where infected fluid is removed before suturing the site of perforation.
Gastric Ulcer & Dry Perforation 'Perforated gastric ulcer occurs most commonly near lesser curvature/antrum area which requires biopsy during treatment.Primary closure/distal gastrectomy are performed based on patient's condition.Dry perforation refers to sealed duodenal ulcer treated conservatively with IV fluids/Ryles tube aspiration/laparoscopy when necessary.