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Case 63: Sudden abdominal pain

A 52 year old man presents with sudden onset severe upper abdominal pain. He is tachycardic and has a rigid abdomen. You discover that he has recently been taking indomethacin for a sparined ankle.

1. What does the xray show?

Free gas under the right hemidiaphragm outlining the liver.

2. What findings on examination would suggest the diagnosis before xray

The presence of a perforated viscus and peritonitis is suggested by the rigid abdomen. Free gas may be detected by percussion over the right upper quadrant finding a loss of the area of normal liver dullness.

3. How would you manage this man?

Fluid resuscitation, intravenous antibiotics and intravenous proton pump inhibitors should be administered. Operative management is then the standard of care. Traditionally this involves an upper midline laparotomy with identification of the site of perforation (most commonly the anterior wall of the first part of the duodenum). The perforation is then patched with a pedicle of omentum surtured over the defect. No attepmt is made to directly close the defect. The abdomen is then thoroughly lavaged with sevela litres of warm saline. Increasing experience is being gained with laparoscopic management of perforated duodenal ulcers. The principles are the same as with open surgery.

A select group of patients may be suitable for non-operative management. This is because the perforation often seals spontaneously with omentum becoming adherent to the duodenum. The patient must be stable with no peritonitis and no significant comorbidities. A contrast swallow should be performed to confirm no ongoing leak. A nasogastric tube should be inserted and the patient kept fasted. Intravenous antibiotics and PPI should be continued. The patient requires frequent re-evaluation to allow early detection of any deterioration.