Pain Characteristics in Perforated Peptic Ulcer
The hallmark pain presentation of perforated peptic ulcer is sudden onset of severe upper abdominal pain, typically accompanied by tachycardia and abdominal rigidity, though this classic triad may not always be present. 1, 2
Primary Pain Characteristics
Sudden onset of abdominal pain is the typical presenting feature of gastroduodenal perforation. 1 The pain characteristics include:
- Acute, severe upper abdominal pain that begins suddenly and is the most consistent feature 1, 2
- Epigastric and right hypochondrial tenderness are common locations for maximal pain 3
- The pain is associated with the classic triad: sudden abdominal pain onset, tachycardia, and abdominal rigidity 2
Important Clinical Caveat: Variable Presentation
Physical examination findings may be equivocal, and peritonitis may be present in only two-thirds of patients with perforated peptic ulcer. 1 This is a critical pitfall to recognize:
- Peritonitis may be minimal or absent, particularly in patients with contained or sealed perforations 1
- Localized or generalized peritonitis is typical but not universal 1, 4
- Abdominal examinations were equivocal in the majority of patients in some series, especially with posterior perforations 5
Posterior Perforation: A Distinct Presentation
Posterior perforations present differently and are easily missed:
- Insidious onset of upper abdominal pain rather than sudden onset 5
- Delayed presentation is characteristic 5
- Equivocal abdominal examination findings occur in most cases 5
- These patients may have sealed perforation with localized retroperitoneal abscess rather than free perforation 5
Associated Clinical Features
Beyond pain characteristics, look for:
- Abdominal distension, which significantly increases risk of complications 6
- Signs of shock (hypotension, tachycardia) indicating more severe perforation 5, 6
- History of NSAID use or known peptic ulcer disease 3, 7
Diagnostic Approach When Pain is Present
When a patient presents with suspected perforated peptic ulcer based on pain characteristics:
- CT scan is the strongly recommended first-line imaging (Strong recommendation, 1C) 1, 4
- Chest/abdominal X-ray should be performed initially only when CT is not promptly available (Strong recommendation, 1C) 1, 4
- Routine laboratory studies and arterial blood gas analysis are strongly recommended, though findings are non-specific 1, 4
- Leukocytosis, metabolic acidosis, and elevated serum amylase are commonly associated but non-specific findings 1, 8