Review Question - QID 203307

This patient most likely presents with a perforated peptic ulcer as demonstrated by his chest radiograph demonstrating free intraperitoneal air under the diaphragm. Treatment is emergent surgical intervention.

A peptic ulcer is an erosion of the mucosal lining of the stomach causing abdominal pain and discomfort. Peptic ulcer disease (PUD) is very common, with a lifetime risk of 10% in the population. Complications of PUD include rupture of an ulcer which results in severe abdominal pain and peritoneal signs on physical exam. Patients with peptic ulcer rupture will typically have normal EKGs, cardiac enzymes, and amylase/lipase. On chest radiograph, free air under the diaphragm indicates a viscous rupture - most commonly from a perforated ulcer in a patient with severe abdominal pain and a history of PUD. A ruptured peptic ulcer is a true surgical emergency and warrants emergent surgical intervention and repair.

Ramakrishnan and Salinas review the diagnosis and management of peptic ulcer disease. They state symptoms of peptic ulcer disease include epigastric discomfort (specifically, pain relieved by food intake or antacids and pain that causes awakening at night or that occurs between meals), loss of appetite, and weight loss. Surgery is indicated if complications develop or if the ulcer is unresponsive to medications. Perforation and gastric outlet obstruction are rare but serious complications requiring surgical intervention.

Cartwright and Knudson review the evaluation of acute abdominal pain in adults. They state acute abdominal pain can represent a spectrum of conditions from benign and self-limited disease to surgical emergencies. Evaluating abdominal pain requires an approach that relies on the likelihood of disease, patient history, physical examination, laboratory tests, and imaging studies. The location of pain is a useful starting point and will guide further evaluation. For example, right lower quadrant pain strongly suggests appendicitis.

Figure A is an EKG demonstrating normal sinus rhythm. Figure B is a chest radiograph demonstrating free air under the diaphragm indicative of viscous rupture. Illustration A is an endoscopic image of a perforated gastric ulcer. Illustration B is a graphic representation of a perforated gastric ulcer.

Incorrect Answers:
Answer 1: This patient has a normal EKG and a chest radiograph with free air indicating a perforated viscus making MI very unlikely. Thus, activation of catheterization lab should not occur.
Answer 3: While an abdominal CT scan may be obtained in non-emergent cases of abdominal pain, patients with free air under the diaphragm have a perforated viscus until proven otherwise and require emergent operative repair.
Answer 4: Abdominal ultrasound is not indicated in this patient due to the presence of a chest radiograph with free air indicating a perforated viscus.
Answer 5: While endoscopy would demonstrate a perforated peptic ulcer, the diagnosis is already demonstrated with the chest radiograph. Thus, the patient should proceed immediately to the OR without further study.