What are the symptoms of a perforated ulcer?

Symptoms of a Perforated Ulcer

A perforated peptic ulcer typically presents with sudden onset of severe abdominal pain, though localized or generalized peritonitis is present in only two-thirds of patients, making the diagnosis challenging when physical examination findings are equivocal or minimal. 1

Cardinal Clinical Presentation

Abdominal Pain:

• Sudden onset of severe abdominal pain is the hallmark symptom 1
• Pain may be localized initially but often progresses to generalized peritonitis 1
• Upper abdominal tenderness, particularly in the epigastric and right hypochondrial regions 2

Critical Caveat: Peritonitis may be minimal or completely absent, particularly in patients with contained or sealed perforations, making clinical diagnosis unreliable in up to one-third of cases 1. This is a common pitfall that can lead to delayed diagnosis and increased mortality.

Signs of Peritonitis and Sepsis

Physical Examination Findings:

• Localized or generalized peritonitis (present in approximately 67% of patients) 1
• Abdominal rigidity and guarding 1
• Reduced or absent bowel sounds 1

Systemic Signs of Sepsis/Septic Shock:

• Altered mental state 1
• Dyspnea and respiratory distress 1, 3
• Tachycardia (heart rate > 94 bpm is associated with non-operative management failure) 1
• Tachypnea 1
• Reduced pulse pressure 1
• Decreased urine output 1

Important Note: Respiratory distress and chest pain can be the initial presenting symptoms, creating a diagnostic challenge that mimics cardiac or primary pulmonary pathology 3. This unusual presentation requires high clinical suspicion.

Laboratory Abnormalities

Non-Specific Laboratory Findings:

• Leukocytosis (elevated white blood cell count, potentially as high as 24,000×10³/μL) 1, 2
• Metabolic acidosis 1
• Elevated serum amylase 1
• Hyperlactatemia 1
• Arterial hypoxemia 1
• Increased creatinine 1
• Coagulation abnormalities 1
• Elevated C-reactive protein 2

Critical Point: These laboratory findings are non-specific and must be interpreted in the clinical context, as they may be modified by preexisting disease or medications 1.

Severity Assessment Parameters

Hemodynamic Instability Indicators:

• Shock at admission (significant risk factor for mortality) 4
• Mean arterial pressure < 65 mmHg 1
• Urine output < 0.5 ml/kg/h 1
• Persistent lactate elevation 1

Timing Factors:

• Perforation present > 24 hours before admission is a significant risk factor for complications and mortality 4
• Abdominal meteorism (distended bowel loops) predicts non-operative management failure 1

Radiological Signs

Plain Radiography:

• Free intraperitoneal air (pneumoperitoneum) visible on upright chest X-ray or left lateral decubitus films 1
• Present in only 30-85% of perforations, with high variability 1
• Classic "gas under the diaphragm" sign 2

CT Scan Findings (More Sensitive):

• Extraluminal gas (97% of cases) 5
• Fluid or fat stranding along the gastroduodenal region (89%) 5
• Ascites (89%) 5
• Focal wall defect and/or ulcer (84%) 5
• Wall thickening (72%) 5
• Unexplained intraperitoneal fluid 1
• Pneumoperitoneum 1
• Bowel wall thickening 1
• Mesenteric fat streaking 1

Important Limitation: Up to 12% of patients with perforations may have a normal CT scan 1. When clinical suspicion is high despite negative imaging, water-soluble contrast administration via nasogastric tube with repeat imaging improves diagnostic sensitivity 1.

Associated Comorbidities and Risk Factors

Patient Factors Affecting Presentation:

• Elderly patients (> 70 years) may have atypical presentations and are less likely to respond to conservative treatment 1
• Significant associated illnesses increase risk of complications and mortality 4
• History of NSAID use is common 2
• Preexisting medications may mask typical signs 1

Clinical Decision-Making Algorithm

When to Suspect Perforated Ulcer:

1. Sudden severe abdominal pain + any signs of peritonitis = immediate imaging 1
2. Clear peritonitis on examination + free air on X-ray = sufficient for surgical exploration in peripheral hospitals without CT access 1
3. Equivocal examination + negative X-ray = proceed to CT scan 1
4. Respiratory distress + chest pain + abdominal tenderness = consider perforated ulcer in differential 3

Mortality Risk: Perforated peptic ulcer carries a 30-day mortality of 23.5% and causes approximately 40% of all ulcer-related deaths, making it a true surgical emergency requiring prompt recognition 1, 5, 6. Every hour of delay from admission to surgery is associated with a 2.4% decreased probability of survival 1.