Peptic Ulcer, Perforated

Insidious

Step 1: View clinicals

A 67 year old lady presents with severe, dull epigastric pain for 6 hours, which was almost instantaneous in onset. The pain is exacerbated by movement, does not radiate and is associated with mild nausea. No other symptoms are present. Her medical history is only significant for well controlled hypertension for 10 years. She does not drink or smoke.


Step 2: Order all relevant investigations

Full Blood Count

WBC/DC: 3,400/mm3 N: 52%, L: 39% Hb: 12.3 g/dl PCV (Hct): 39% Platelets: 185,000/mm3

ECG

Serial ECGs are obtained; all appear normal.

Contrast CT Abdomen

Free gas in the peritoneum and a small right subphrenic collection are seen. Addition of oral contrast shows a large ulcer in the gastric antrum, with no contrast leakage into the peritoneal cavity. The gallbladder, pancreas, abdominal aorta & mesenteric vein appear normal.

Urgent Barium Meal

The Barium Meal will be arranged tomorrow.


Step 3: Select appropriate management

Endoscopic therapy stat
NG Tube stat
IV Antibiotics stat
IV Pantoprazole stat


Score: ★★☆