Diagnosis
• The most characteristic symptom is the suddenness of the onset of epigastric pain.
• The pain rapidly becomes generalised although occasionally it moves to the RLQ.
• The patient stays still.
• There may be a history of previous dyspepsia, previous or current treatment for a DU, or ingestion of NSADs.
• On examination the patient is in obvious pain.
• Hypotension is a late finding as is a high fever.
• The abdominal findings are characteristically described as of board-like rigidity.
• With time the patient may improve with dilution of the duodenal contents by exudate from the peritoneum but this is later replaced by the signs and symptoms of bacterial peritonitis.
• Once an ulcer perforates, the subsequent clinical picture is influenced by whether or not the ulcer self seals.
• In approximately 40–50% of cases the ulcer self-seals with omentum or by fusion of the duodenum to the underside of the liver between the gallbladder and the falciform ligament.
• This is important when one considers whether or not laparotomy is indicated to deal with the perforation itself as will be seen below.
• On an erect Chest X Ray free air can be seen in about 80% of cases.
• In doubtful cases a water-soluble gastroduodenogram will show the leak from the duodenum or its sealing.
• This can be a useful test when one is considering non-operative treatment or in the situation where the diagnosis is in doubt.