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Multiple air fluid levels
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Dilated loops of bowel
Pneumoperitoneum
Ureteral obstruction
Dilation of the aorta
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The patient's history of heavy over-the-counter pain relievers (likely non-steroidal anti-inflammatory drugs) and peritoneal signs on physical exam are consistent with a perforated peptic ulcer. This results in pneumoperitoneum, often seen on abdominal or chest x-ray. Perforated peptic ulcer is the most common cause of bowel perforation. If there is high clinical suspicion, an abdominal or chest radiograph should be ordered to look for pneumoperitoneum, which is free air in the abdomen. If present, diagnosis is confirmed and the patient should be taken to the operating room emergently. Emergent exploratory laparotomy with surgical repair is indicated for all patients with bowel perforation. Note that the patient's fever, tachycardia, and guarding are all signs of peritonitis secondary to the perforation. Ramakrishnan et al. review peptic ulcer disease (PUD). They note that bleeding is the most common indication for surgery in PUD, although proton pump inhibitors (PPIs) and endoscopic therapy can control most bleeds. Perforation and gastric outlet obstruction are two rare but serious complications. Hernández-Díaz et al. found that PPIs reduce the incidence of upper gastrointestinal (GI) bleeds and perforation in PUD. They found that PPI prescriptions during the month after PUD diagnosis were associated with a relative risk of upper GI complications of 0.56. Therefore, PPIs reduce the risk of upper GI complications by almost 50%. Illustration A shows pneumoperitoneum on abdominal radiograph. Note the presence of air (black) under the diaphragm. Incorrect Answers: Answers 1 and 2: Dilated loops of bowel with multiple air fluid levels are consistent with bowel obstruction. This patient's presentation is more consistent with peritonitis in the setting of perforated PUD. Answer 4: Ureteral obstruction due to nephrolithiasis results in colicky abdominal pain. The patient often moves around in discomfort, in contrast to peritonitis where patients tend to lie still. Answer 5: Dilation of the aorta occurs in abdominal aortic aneurysm, which sometimes presents with a pulsatile mass on abdominal exam.
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