Surgery was urgently consulted and the patient consented and taken to the OR where she was found to have a single punctate perforation located at the gastric antrum just proximal to pylorus. An EGD was then performed which revealed a full-thickness gastric perforation with fluid and air escaping from the stomach into the abdomen. The perforation was closed by primary repair followed by abdominal washout and the patient did well post-operatively.
Perforated Viscus
Epidemiology
- Incidence increases with age
- A history of peptic ulcer disease or diverticular disease is common
Etiology
- More often a duodenal ulcer that erodes through the serosa
- Colonic diverticula, large bowel, and gallbladder perforations are rare
- Spillage of bowel contents causes peritonitis
Presentation
- Acute onset of epigastric pain
- Vomiting in 50%
- Fever may later develop
- Pain may localize with omental walling off of peritonitis
- Shock may be present with bleeding or sepsis
Physical Exam
- Fever, usually low grade
- Tachycardia
- Decreased bowel sounds
- Overall condition worsens over time
- Abdominal examination reveals diffuse guarding and rebound
- "Washboard" abdomen in later stages
Useful Tools
- WBC usually elevated owing to peritonitis
- Amylase may be elevated
- LFT results are variable
- Upright radiographic view reveals free air in 70-80% of cases
Management
- IVF resuscitation
- NPO, consider NG-tube
- Broad-spectrum antibiotics with intestinal flora coverage (gram negative, anaerobic)
TAKE AWAY:
- Pain is sudden and followed quickly by signs of peritonitis and shock
- Diagnose by plain radiograph or CT scan
- Surgical repair is necessary in conjunction with IVF resuscitation and antibiotics
References:
Rosen's Emergency Medicine Concepts and Clinic Practice, 8th Ed, 2014, Chapter 27: Abdominal Pain by Gavin R. Budhram and Rimon N. Bengiamen
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