Assessment Tools for Perforated Gastric Ulcers
For patients with suspected perforated gastric ulcer, obtain CT scan imaging as the primary diagnostic tool, combined with routine laboratory studies including arterial blood gas analysis, and use the Boey, PULP, or ASA scoring systems for risk stratification and outcome prediction. 1
Diagnostic Assessment Tools
Imaging Studies
CT scan is the gold standard imaging modality for suspected perforated gastric ulcer due to superior sensitivity in detecting free air and ability to characterize perforation site and size 1. The World Journal of Emergency Surgery provides a strong recommendation (1C) for CT imaging in acute abdomen from suspected perforation 1.
Key CT findings include:
- Free intraperitoneal air (pneumoperitoneum) 1
- Unexplained intraperitoneal fluid 1
- Bowel wall thickening 1
- Mesenteric fat streaking 1
- Extraluminal water-soluble contrast (when administered) 1
Important caveat: Up to 12% of patients with perforations may have a normal CT scan 1. When free air is not seen on imaging but clinical suspicion remains high, perform imaging with addition of water-soluble contrast either oral or via nasogastric tube (weak recommendation, 2D) 1.
Plain radiography (chest/abdominal X-ray) should only be used as initial diagnostic assessment when CT is not promptly available (strong recommendation, 1C) 1. Erect and left lateral decubitus X-rays have similar diagnostic accuracy, with the latter better tolerated by patients with peritonitis 1. However, free air is detected in only 30-85% of perforations on plain films, making this highly variable and unreliable 1, 2.
Laboratory Assessment Tools
Routine laboratory studies and arterial blood gas analysis are strongly recommended (strong recommendation, 1D) 1, 3.
Key laboratory findings (though non-specific):
- Leukocytosis 1, 3, 2
- Metabolic acidosis 1, 3, 2
- Elevated serum amylase 1, 3, 2
- Hyperlactatemia 2
- Arterial hypoxemia 2
- Increased creatinine 2
- Coagulation abnormalities 2
Critical point: These laboratory tests are non-specific and cannot diagnose gastric ulcer alone—they only detect complications or associated findings 3.
Risk Stratification Scoring Systems
The World Journal of Emergency Surgery suggests adopting scoring systems including the Boey, PULP, and ASA scores for risk-stratification and outcome prediction (weak recommendation, 2C) 1.
Comparative Performance of Scoring Systems
- Boey score: Most commonly used but shows elevated variability in accuracy across different studies 1
- PULP score: Predicted mortality equally well as ASA score and better than Boey score, but is difficult to apply and has not been validated outside the initial center 1
- ASA score: Predicted mortality equally well as PULP score and better than Boey score 1
- Hypoalbuminemia: Remains the strongest single predictor of mortality regardless of scoring system used 1
Severity Assessment Tools
For evaluating disease severity and sepsis, use SOFA (Sequential Organ Failure Assessment) or qSOFA (quick SOFA) scoring systems (weak recommendation, 2C) 1.
Clinical Parameters to Assess at ED Referral
Symptoms requiring evaluation:
Physical signs requiring evaluation:
- Tachycardia (heart rate >94 bpm associated with non-operative management failure) 1, 2
- Tachypnea 1, 2
- Reduced pulse pressure 1, 2
- Decreased urine output 1, 2
Important caveat: These findings may be modified by preexisting disease or medications, requiring careful clinical history collection 1.
Hemodynamic Assessment Tools
For unstable patients, utilize hemodynamic monitoring (invasive or non-invasive) to optimize fluid/vasopressor therapy (strong recommendation, 1C) 1.
Target resuscitation parameters:
- Mean arterial pressure (MAP) ≥ 65 mmHg 1, 2
- Urine output ≥ 0.5 ml/kg/h 1, 2
- Lactate normalization 1, 2
Clinical Presentation Assessment
Physical examination findings are unreliable: Peritonitis may be present in only two-thirds of patients, and may be minimal or absent particularly in contained/sealed perforations 1, 4, 2. This makes clinical diagnosis challenging in up to one-third of cases 2.
Typical presentation includes:
- Sudden onset of severe abdominal pain 1, 4, 2
- Localized or generalized peritonitis (when present) 1, 4, 2
- Abdominal rigidity and guarding 4, 2
Common Pitfalls to Avoid
Do not rely on plain X-ray alone when CT is available—the 30-85% detection rate for free air means you will miss 15-70% of perforations 1, 2.
Do not assume normal CT excludes perforation—up to 12% may have normal CT, requiring water-soluble contrast study if clinical suspicion remains high 1.
Do not dismiss the diagnosis based on absence of peritonitis—one-third of patients may have minimal or absent peritoneal signs, particularly with sealed perforations 1, 4, 2.
Do not delay imaging for laboratory results—perforated peptic ulcer carries 30-day mortality of 23.5%, and every hour of delay from admission to surgery decreases survival probability by 2.4% 2.