What are the key physical exam findings in patients with Peptic Ulcer Disease (PUD)?

Physical Exam Findings in Peptic Ulcer Disease

In uncomplicated PUD, physical examination is typically limited to epigastric tenderness, but the critical clinical imperative is recognizing signs of life-threatening complications—particularly peritonitis from perforation—which fundamentally changes management from medical to surgical emergency.

Uncomplicated PUD Physical Findings

Epigastric tenderness is the primary physical exam finding in uncomplicated peptic ulcer disease, though the majority of patients (nearly two-thirds) remain completely asymptomatic 1. When present, examination reveals:

• Epigastric tenderness on palpation - localized to the upper abdomen, particularly the epigastric and right hypochondrial regions 2
• No signs of peritoneal irritation in uncomplicated cases - absence of rigidity, guarding, or rebound tenderness 2
• Vital signs typically remain stable in uncomplicated disease 2

Critical Complication Warning Signs

Physical examination findings become dramatically more significant when complications develop, and recognizing these signs is essential to prevent mortality:

Perforation (Most Critical)

Localized or generalized peritonitis is the hallmark of perforated peptic ulcer, though it may be present in only two-thirds of patients 3. Key findings include:

• Sudden onset severe epigastric pain with abdominal rigidity - suggests perforation and carries 30% mortality if treatment is delayed 1
• Signs of peritonitis: guarding, rebound tenderness, board-like rigidity 3
• Physical examination findings may be equivocal - peritonitis may be minimal or absent, particularly in patients with contained or sealed perforations 3
• Fever and tachycardia indicate complications requiring immediate investigation 1

Bleeding Complications

• Occult blood in stool or hematemesis indicates upper GI bleeding 1
• Signs of hemodynamic instability: tachycardia, hypotension, pallor 4
• Vomiting may accompany bleeding or obstruction 1, 2

Gastric Outlet Obstruction

• Succussion splash on abdominal examination 4
• Visible gastric peristalsis in thin patients 4
• Abdominal distension 4

Critical Clinical Pitfalls

Never dismiss cardiac causes in patients presenting with epigastric pain - myocardial infarction can present with epigastric pain as the primary manifestation, and ECG with troponins must be obtained 1. This is a life-threatening diagnostic error to avoid.

Physical examination alone cannot rule out perforation - up to one-third of patients with perforated peptic ulcer may have minimal or absent peritoneal signs, particularly with contained leaks 3. When clinical suspicion exists despite equivocal physical findings, imaging is mandatory.

The absence of physical findings does not exclude significant disease - nearly two-thirds of peptic ulcer cases are asymptomatic, and complications can be the first presentation 1.

Algorithmic Approach to Physical Examination

1. Assess vital signs first - hemodynamic instability or fever indicates complications 1, 2

2. Examine for peritoneal signs:

   • If rigid abdomen with rebound/guarding present → suspect perforation, obtain immediate imaging (CT preferred) 3
   • If equivocal or minimal peritoneal signs → perforation still possible in one-third of cases, proceed with imaging if clinical suspicion exists 3

3. Check for bleeding indicators:

   • Perform rectal examination for occult blood 1
   • Assess for hemodynamic compromise 4

4. Evaluate for obstruction:

   • Assess for succussion splash and visible peristalsis 4
   • Check for abdominal distension 4

When clear signs of peritonitis are present on physical examination, this is sufficient to justify surgical exploration even without imaging in resource-limited settings 3. However, CT scan is strongly recommended when promptly available for better characterization of perforation site and size 3.