A 48-year-old woman from Delhi presents with acute-onset severe epigastric pain radiating to the back, associated with vomiting. She has a 10-year history of peptic ulcer disease treated intermittently with antacids. On examination, she is in distress, blood pressure 100/65 mmHg, heart rate 110/min. Abdomen is rigid with rebound tenderness. Erect chest X-ray shows free air under the diaphragm. What is the most likely diagnosis and the immediate management?

Explanation

## Perforated Peptic Ulcer: Diagnosis and Emergency Management ### Clinical Presentation **Key Point:** This patient presents with the classic triad of perforated peptic ulcer: 1. **Acute, severe epigastric pain** (often described as "worst pain of life") 2. **Rigid, board-like abdomen** with rebound tenderness (peritonitis) 3. **Free air under the diaphragm** on erect chest X-ray (pathognomonic) ### Diagnostic Confirmation **High-Yield:** Free air on chest or abdominal imaging (pneumoperitoneum) is diagnostic of perforation. This is a **surgical emergency** requiring immediate intervention. | Finding | Significance | |---------|-------------| | Erect CXR with free air | Diagnostic of perforation | | Rigid abdomen + rebound | Peritonitis (surgical emergency) | | Hemodynamic instability | Septic shock from peritonitis | | History of PUD | Risk factor; NSAID/stress ulcer likely | ### Immediate Management Algorithm ```mermaid flowchart TD A[Perforated peptic ulcer]:::outcome --> B[Resuscitation]:::action B --> C[IV fluids, blood products]:::action B --> D[Broad-spectrum antibiotics]:::action B --> E[NG tube, NPO]:::action A --> F[Surgical consultation]:::action F --> G{Hemodynamically stable?}:::decision G -->|Yes| H[Proceed to OR]:::action G -->|No| I[ICU stabilization first]:::action I --> H H --> J[Exploratory laparotomy]:::action J --> K[Ulcer repair/closure]:::action K --> L[Peritoneal lavage]:::action L --> M[Drain placement]:::action ``` **Clinical Pearl:** The only definitive treatment for perforated peptic ulcer is **surgical repair**. Medical management alone (PPI, antibiotics) will result in peritonitis, sepsis, and death. ### Pre-operative Resuscitation ("Damage Control") 1. **IV access:** Two large-bore cannulae 2. **Fluids:** Aggressive crystalloid resuscitation (target MAP >65 mmHg) 3. **Antibiotics:** Broad-spectrum (e.g., ceftriaxone + metronidazole) within 1 hour 4. **NG tube:** Decompress stomach, reduce aspiration risk 5. **NPO status:** Prepare for surgery 6. **Analgesia:** Opioids are safe; pain relief improves hemodynamics ### Surgical Options **High-Yield:** Choice depends on ulcer location and surgeon expertise: - **Duodenal ulcer:** Primary closure with omental patch (Graham patch) ± vagotomy (rarely done now) - **Gastric ulcer:** Biopsy + closure (rule out malignancy) - **Large/multiple ulcers:** Consider partial gastrectomy **Mnemonic:** **SNAP** = Surgical, No delay, Antibiotics, Peritoneal lavage ### Mortality & Outcomes - **Mortality:** 5–30% depending on age, comorbidities, and time to surgery - **Risk factors for poor outcome:** Age >70, shock at presentation, delayed surgery (>24 hrs) - **Prevention:** H. pylori eradication + PPI therapy reduces recurrence to <1%