What is the most appropriate next step in management for a patient with suspected abdominal perforation, severe abdominal pain, nausea, vomiting, and free air under the diaphragm on chest x-ray, with laboratory results indicating leukocytosis, impaired renal function, and who is already receiving antibiotics and fluids?

Management of Perforated Peptic Ulcer

Immediate laparotomy (option E) is the most appropriate next step in management for this patient with a perforated peptic ulcer presenting with signs of peritonitis and free air under the diaphragm on chest X-ray. 1

Clinical Assessment and Diagnosis

This 37-year-old man presents with classic signs of perforated peptic ulcer:

• Sudden onset of severe, constant abdominal pain that woke him from sleep
• Rigid abdomen with absent bowel sounds
• Signs of systemic inflammatory response (tachycardia, tachypnea, mild fever)
• Leukocytosis (18,200/mm³)
• Free air under the diaphragm on chest X-ray

The presence of free air on imaging combined with clinical peritonitis is diagnostic of hollow viscus perforation, most commonly from a perforated peptic ulcer given the clinical scenario.

Management Algorithm

1. Initial Resuscitation (already initiated)

   • IV fluid resuscitation
   • Broad-spectrum antibiotics

2. Definitive Management

   • Surgical intervention via laparotomy is indicated due to:
     • Presence of peritonitis
     • Free air on imaging
     • Hemodynamic changes (tachycardia)
     • Elevated inflammatory markers

3. Surgical Approach

   • Primary repair with omental patch is the standard procedure for most perforated peptic ulcers 2
   • For larger perforations (≥2 cm), more extensive procedures may be required 1

Why Other Options Are Not Appropriate

• Barium swallow (A): Contraindicated in suspected perforation as barium can spill into the peritoneal cavity and worsen peritonitis 1

• CT scan of abdomen (B): While CT is recommended for suspected perforations, this patient already has definitive evidence of perforation (free air on X-ray) and clinical peritonitis requiring immediate surgical intervention. Delaying surgery for additional imaging would increase morbidity and mortality 1

• H2-receptor blocking agent (C): While acid suppression is part of management, it is adjunctive therapy and not the primary intervention for a confirmed perforation 1

• Upper endoscopy (D): Contraindicated in acute perforation as insufflation can worsen peritoneal contamination 1

Important Considerations

• Mortality increases fourfold when surgical delay exceeds 24 hours after bowel perforation 1
• In patients with perforated peptic ulcer, the presence of peritonitis and free air on imaging are clear indications for immediate surgical intervention 1
• Intraoperative biopsy should be performed to rule out malignancy, as up to 8.8% of perforated gastric ulcers may harbor malignancy 2
• Damage control surgery may be considered if the patient develops hemodynamic instability during the procedure 1

Postoperative Management

• Continue antibiotics postoperatively (typically for 3-5 days)
• Acid suppression therapy
• Helicobacter pylori testing and eradication if positive
• Follow-up endoscopy to ensure healing and rule out malignancy

This patient's presentation with acute peritonitis, free air on imaging, and systemic inflammatory response requires immediate surgical intervention without delay for additional diagnostic studies.