A 52-year-old man from Delhi presents to the emergency department with sudden onset severe epigastric pain and vomiting for 2 hours. He has a 10-year history of dyspepsia managed with occasional antacids and denies NSAID use. On examination, he is pale, diaphoretic, with a rigid abdomen and rebound tenderness. Blood pressure is 100/65 mmHg, heart rate 110/min. Abdominal X-ray shows free air under the diaphragm. What is the most appropriate immediate management?

Explanation

## Clinical Diagnosis: Perforated Peptic Ulcer **Key Point:** Free air under the diaphragm on plain X-ray in a patient with acute severe epigastric pain and peritoneal signs is pathognomonic for peptic ulcer perforation — a surgical emergency. **High-Yield:** Perforation occurs in 5–10% of peptic ulcer disease cases and is the most common complication requiring surgery. Classic presentation: sudden onset severe pain, rigid abdomen with rebound/guarding, and pneumoperitoneum on imaging. ## Immediate Management Algorithm ```mermaid flowchart TD A[Perforated PU diagnosed]:::outcome --> B[Resuscitation]:::action B --> C[IV access, fluids, electrolytes]:::action B --> D[Nasogastric tube decompression]:::action C --> E[Broad-spectrum antibiotics]:::action D --> E E --> F[Emergency surgical consultation]:::action F --> G[Operative repair within 6 hours]:::action G --> H[Graham patch or primary closure]:::outcome ``` **Clinical Pearl:** The "golden period" for surgical intervention is within 6 hours of perforation. Delay increases mortality from 5% to >30% due to peritonitis and sepsis. **Mnemonic: PERFORATED PU Management — FAST** - **F**luids and resuscitation (IV access, blood products if needed) - **A**ntibiotics (broad-spectrum: ceftriaxone + metronidazole) - **S**urgical consultation (immediate) - **T**ube decompression (nasogastric) ## Why This Answer Is Correct The patient has hemodynamic instability (BP 100/65, HR 110), peritoneal signs, and confirmed pneumoperitoneum. Surgical exploration is the definitive treatment. Preoperative stabilization (NG tube, fluids, antibiotics) must occur in parallel but does not delay surgery. ## Why Other Options Are Wrong 1. **High-dose PPI therapy alone:** Perforation is a surgical emergency; medical management alone will lead to sepsis and death. PPIs are adjunctive only. 2. **Endoscopy with hemoclip:** Endoscopy is contraindicated in perforation (risk of further peritoneal contamination and worsening sepsis). Hemoclip is for bleeding, not perforation. 3. **CT with contrast and antibiotics:** While CT may be used in stable patients with suspected perforation, this patient has clear pneumoperitoneum on plain film and hemodynamic instability — CT delays definitive surgical care.