A 62-year-old man comes to the emergency department with severe epigastric pain lasting an hour. He has had postprandial epigastric discomfort for the past several days, but now the pain is severe and constant. The patient also feels nauseated and has vomited once since the pain began. Medical history is significant for hypertension, type 2 diabetes mellitus, hyperlipidemia, and coronary artery disease. He underwent coronary artery stenting 5 months ago. Temperature is 37.6 C (99.7 F), blood pressure is 116/70 mm Hg, pulse is 108/min, and respirations are 24/min. ECG shows Q waves in the inferior leads. Chest x-ray is shown in the image below:
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Which of the following is the best next step in management of this patient?
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This patient's history of postprandial epigastric pain followed by acute-onset, severe pain is concerning for perforated peptic ulcer. Full-thickness erosion of a peptic ulcer through the stomach or duodenal wall quickly releases both air and caustic (ie, pH ~1-2) gastric secretions/contents into the peritoneal cavity, resulting in pain and a systemic inflammatory response (eg, tachycardia, tachypnea). Upright chest x-ray revealing intraperitoneal free air (pneumoperitoneum) confirms the diagnosis of perforation.
Immediately following diagnosis, the following should be initiated:
Patients require emergent surgical exploration (laparotomy or laparoscopy) because delay to surgery has been associated with increased mortality (up to 30%). A minority of patients (eg, minimal/localized symptoms, stable vital signs) may receive a trial of medical management with surgical backup available.
(Choice A) Acute myocardial infarction (MI) can present with epigastric pain and nausea/vomiting. However, this patient's Q waves on ECG indicate an old, rather than an ongoing, MI. In addition, MI is unlikely to cause pneumoperitoneum.
(Choice B) If plain x-rays are negative and perforation is suspected, CT scan can help detect smaller amounts of free air or fluid. However, upright chest x-ray already confirms perforation in this patient. In addition, a CT scan with oral contrast is rarely used for life-threatening conditions (eg, perforated peptic ulcer) because oral contrast use delays disposition by 45-60 minutes.
(Choice D) Cholecystitis can present with epigastric pain and nausea/vomiting. However, pain typically involves the right upper quadrant, and pneumoperitoneum is not seen, even with gallbladder perforation (ie, the gallbladder does not contain significant air).
(Choice E) Although acute mesenteric ischemia often occurs in patients with cardiovascular risk factors (eg, hyperlipidemia, coronary artery disease), pneumoperitoneum is not expected except in severe cases with bowel necrosis, in which case surgical intervention is the correct next step.
(Choice F) In this patient with a perforated peptic ulcer, nasogastric tube placement would decrease the amount of gastric contents available to leak through the perforation; however, surgical intervention is necessary because of the severe symptoms and systemic inflammatory response.
(Choice G) Upper endoscopy should be performed after the perforation has healed to evaluate for cancer and/or Helicobacter pylori infection. Endoscopy is contraindicated in the setting of acute perforation because it can worsen the injury.
Educational objective:
Peptic ulcer disease can be complicated by perforation, revealed as intraperitoneal free air. Emergent surgical exploration is indicated for patients with severe symptoms and a systemic inflammatory response.