A perforated gastro-duodenal ulcer is a surgical emergency requiring urgent assessment and intervention. The incidence of this condition has decreased markedly since the introduction of proton pump inhibitors and Helicobacter pyloritriple therapy for peptic ulcer disease.

Aetiology/predisposing factors

1. ▪ Chronic benign duodenal ulcer: Helicobacter pylori infection is an important predisposing factor (80% of perforated ulcers).

2. ▪ Acute ulceration secondary to drugs: steroids, NSAIDs.

3. ▪ Excessive alcohol consumption.

4. ▪ Acute ulceration secondary to physiological stressors: burns, trauma, sepsis, chemotherapy and radiotherapy.

5. ▪ Perforation of a malignant gastric ulcer.

Pathogenesis

Ulcer is usually located anteriorly, resulting in the release of gastric contents and air into the peritoneal cavity. Posterior ulcers erode into the gastro-duodenal artery and result in haemorrhage. Anterior perforation may be duodenal, pyloric or gastric and may be sealed naturally by omental folds or open to the general peritoneum. Release of gastroduodenal contents induces chemical peritonitis which if untreated results in bacterial peritonitis.

Symptoms

History of peptic ulcer disease. Sudden excruciating epigastric pain, haematemesis or melaena. Shoulder pain due to diaphragmatic irritation. Significant vomiting is usually late and due to peritonitis and ileus. Peritoneal soiling may trickle along the right paracolic gutter and localize in the right iliac fossa to mimic appendicitis. Patient may have beenon NSAIDs, steroids, heavy drinker, or have other predisposing factors mentioned above.

Signs

Severity depends on degree of peritoneal soiling. Upper abdominal tenderness, rebound tenderness and board-like rigidity. Later when ileus ensues abdominal distension, silent abdomen and signs of shock and sepsis.

Differential diagnosis

Acute pancreatitis, acute cholecystitis, acute appendicitis, intestinal infarction.