Clinical features of perforated peptic ulcer

Perforated peptic ulcer is characterised by severe, constant, sudden onset epigastric pain that often requires high doses of opiate analgesia before the patient settles. There may be haematemsis.

On examination:

• patient looks ill and lies unusually still
• in pain
• tachycardia
• shallow respiration

Inspection:

• abdomen is flat - does not fall and rise with respiration

Palpation:

• very tender, intense guarding & "board-like" rigidity

Percussion:

• if air has escaped into the peritoneal cavity then the liver dullness may be absent

Auscultation:

• bowel sounds do not disappear until 6 to 12 hours after the onset of pain

Peptic ulcer perforation results in a chemical peritonitis rather than a bacterial peritonitis in the initial stages - unlike perforations of the more distal bowel. Thus, in the first 24 hours or so, the patient does not show signs of general toxicity. After this period secondary bacterial infection occurs and signs of sepsis are present.

Note that if a posterior gastric ulcer perforates then the gastric contents leak into the lesser sac. This condition presents more insidiously than other peptic ulcer perforations.