A 48-year-old woman from Mumbai with a 6-month history of recurrent epigastric pain and dyspepsia presents with acute severe pain, vomiting, and abdominal rigidity. On examination, her temperature is 38.2°C, heart rate 110/min, blood pressure 100/62 mmHg. Abdominal examination reveals generalized rigidity and rebound tenderness. Upright chest X-ray shows free air under the diaphragm. She reports no recent NSAID use but admits to chronic stress. H. pylori serology is positive. What is the most likely diagnosis and the immediate management?

Explanation

## Acute Presentation: Perforated Peptic Ulcer This patient has **acute perforation of a peptic ulcer** — a surgical emergency. The clinical triad is: 1. **Acute severe epigastric pain** (sudden onset) 2. **Peritonitis signs** (rigidity, rebound, fever) 3. **Free air on imaging** (pneumoperitoneum on upright CXR) ## Distinguishing Duodenal vs. Gastric Perforation | Feature | Duodenal Ulcer | Gastric Ulcer | | --- | --- | --- | | **Frequency of perforation** | 70–80% of perforations | 20–30% of perforations | | **H. pylori association** | ~90% | ~70% | | **NSAID association** | Common | More common (60–70%) | | **Location** | Anterior wall (erodes into pancreas) | Greater curvature (erodes into spleen/colon) | | **Surgical approach** | Omental patch (Graham) + PPI | Antrectomy ± gastrectomy | | **Prognosis** | Better with patch + PPI | Worse; requires resection | **Key Point:** This patient has **H. pylori-positive duodenal ulcer perforation** (no NSAID use, positive serology, 6-month dyspepsia history). Duodenal perforations are anterior-wall lesions and are managed by **simple closure with omental patch**, NOT resection. ## Surgical Management Algorithm ```mermaid flowchart TD A[Perforated peptic ulcer]:::outcome --> B{Hemodynamically stable?}:::decision B -->|No| C[Resuscitate, ICU]:::action B -->|Yes| D{Ulcer location?}:::decision D -->|Duodenal| E[Omental patch + PPI]:::action D -->|Gastric| F{H. pylori positive?}:::decision F -->|Yes| G[Antrectomy + PPI]:::action F -->|No| H[Gastrectomy + D2 dissection]:::action E --> I[Postop: High-dose IV PPI]:::action G --> I H --> I I --> J[H. pylori eradication]:::action ``` ## Why Graham Patch (Omental Patch)? **High-Yield:** The **Graham patch** (omentum sutured over the perforation) is the gold standard for duodenal ulcer perforation because: - Simple, quick closure (15–20 min) - Low morbidity and mortality (~1–2%) - Preserves normal anatomy - Combined with **high-dose IV PPI**, rebleeding/reperforation is <5% - Vagotomy is NO LONGER done (PPI is superior) **Clinical Pearl:** The anterior duodenal wall ulcer erodes into the **pancreatic head**, causing severe epigastric pain radiating to the back. Free air enters the peritoneal cavity, causing acute peritonitis. This is a **surgical emergency** — mortality rises 5–10% for every 6 hours of delay. ## Postoperative PPI Therapy **Mnemonic — "PPI-PATCH":** - **P**roton pump inhibitor (omeprazole 40 mg IV BD for 72 hours) - **P**erforation (closed with patch) - **A**ntacid (IV PPI) - **T**herapy (eradicate H. pylori) - **C**are (ICU monitoring) - **H**ealing (repeat endoscopy at 6 weeks) **Key Point:** Modern evidence shows that **PPI monotherapy** (without vagotomy) is sufficient for duodenal ulcer perforation. Vagotomy increases morbidity without improving outcomes. [cite:Harrison 21e Ch 297]