Case 149: Xray for abdo pain
This man presents with a 4 hour history of severe upper abdominal pain. He was quite well previously apart from a shoulder problem for which he has been taking analgesics recently. This man is unwell, shocked with generalised peritonitis.
1. What is the likely diagnosis?
Perforated peptic ulcer2. What may have been a precipitating factor from the history?
The analgesics may have been NSAID's.3. Are any further imaging studies required before operating?
No, this man is shocked with generalised peritonitis. The indication to operate is clear. The soiling of this gentleman's peritoneal cavity must be severe and this needs to be addressed. Occasionally when operating a perforated sigmoid diverticulitis is encountered necessitating a Hartmann's resection and stoma formation., This should be explained to the patient and relatives preoperatively.There is a case for conservative treatment of a perforated peptic ulcer. These patients must be haemodynamically stable, preferably with localised peritonitis and usually a relative contraindication to operative intervention eg significant cardiac failure. A water soluble contrast study showing no further leaking from the ulcer is good evidence to pursue a conservative approach.
PubMed - Conservative treatment of 155 cases of perforated peptic ulcer.