Signs and Symptoms of Gastric Ulcer Perforation
Gastric ulcer perforation classically presents with sudden-onset severe epigastric pain accompanied by abdominal rigidity, tachycardia, and signs of peritonitis, though up to one-third of patients may have equivocal or minimal peritoneal findings. 1, 2
Cardinal Clinical Features
Pain Characteristics
- Sudden, severe epigastric pain that typically becomes generalized across the abdomen 1, 2
- Pain onset is abrupt and represents the hallmark presenting feature 2
- Pain may initially be localized to the upper abdomen before spreading 1
Physical Examination Findings
- Abdominal rigidity (board-like abdomen) 1, 2
- Abdominal tenderness with guarding and rebound tenderness 1
- Abdominal distension 1
- Masked liver dullness on percussion (loss of hepatic dullness due to free air) 1
- Absent bowel sounds 1
- Diffuse peritonitis in most cases, though may be localized 1, 2
Systemic Signs
- Fever 1
- Tachycardia 1, 2
- Tachypnea 1
- Confusion or altered mental status (in severe cases with septic shock) 1
Critical Clinical Caveat
Peritonitis may be present in only two-thirds of patients with perforated peptic ulcer, and physical examination findings can be equivocal or minimal, particularly in patients with contained or sealed perforations. 2 This represents a significant diagnostic pitfall—the absence of classic peritoneal signs does not exclude perforation. 2
Laboratory Findings (Non-Specific)
- Leukocytosis with neutrophilia 1, 2
- Elevated C-reactive protein (CRP) 1
- Lactic acidosis (suggests perforation or necrosis) 1
- Elevated serum amylase levels 1, 2
- Metabolic alkalosis (from vomiting and dehydration) 1
Timing of Symptom Development
- Symptoms typically develop within the first 48 hours following perforation 1
- Toxic symptoms of peritonitis are usually delayed but represent an ominous sign when present 1
Diagnostic Approach When Perforation is Suspected
Imaging Recommendations
CT scan with IV contrast is the first-line diagnostic test (Recommendation Grade 1C) 1, 3, 2
Plain chest/abdominal radiographs should only be used when CT is not immediately available 3, 2
- Less sensitive than CT for detecting free air 1
Ultrasound has limited utility (sensitivity 88%, specificity 76%) but may be considered in pregnant women or children to limit radiation exposure 3
High-Risk Patient Populations
Patients with gastric ulcer perforation (as opposed to duodenal) tend to be: 4
- Significantly older
- More likely to have concomitant medical problems
- More likely to be on steroids
- More likely to be hospitalized at time of perforation
- Have higher perioperative mortality rates