This Article is About
primary health care
upper abdominal pain
peptic ulcers
abdominal cavity
health care provider
direct correlation
internal organs
Perforated Duodenal Ulcer
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An ulcer is a deep defect in the skin or epithelial mucosa (that is the inner lining) of internal organs. Peptic ulcer diseases in this given article refer to the defect or ulcer formed in the stomach and duodenum. The duodenum is that section of the small intestine which joins the stomach.

Perforation is a fairly common complication of duodenal ulcers. The incidence of duodenal ulcers in the United States is an estimated 10 percent of the population and accounts for nearly two thirds of all peptic ulcers.

The incidence of perforation of duodenal ulcers varies significantly from one country to the next and has a direct correlation to the incidence of peptic ulcer diseases in the general population, general access to health care and management and the compliance of the affected individuals.

Perforation of a duodenal ulcer is a surgical emergency. It is one of the more frequent complications of duodenal ulcers. There is no age limit. This complication can occur at any age in the presence of a duodenal ulcer.

Perforation causes the contents of the duodenum to be released through the site of perforation into the peritoneal or abdominal cavity. This results in inflammation of the lining of the abdominal walls and is called viscus peritonitis.

The classical or typical presentation is a patient who presents to the emergency room of the hospital or to the primary health care provider complaining of sudden onset of severe upper abdominal pain, oftentimes desribed as a stabbing pain. The pain is constant in nature and often accompanied by repeated episodes of vomiting.

The recurrent episodes of vomiting lead to loss of body fluids and dehydration. The dehydration causes weakness and electrolyte imbalance. In severe cases this can lead to confusion, coma and even death.

There is often a preexisting diagnosis of duodenal ulcer. Of note many persons do not present with the typical history and symptoms.

In some cases the symptoms may be one of a vague pain, which is made worse by the ingestion of even fluids and increasing in intensity over a few days before presentation. Loss of appetite is present but vomiting which is common is not present in some cases.

The patient on presentation is generally ill looking, dehydrated and in painful distress and sometimes even restless and confused. There is usully reduction in blood pressure and marked tenderness on palpation of the upper abdomen (epigastrium).

Emergency measures are aimed at resuscitation by fluid replacement and to restore electrolyte imbalance. The condition is usually quite painful and the patient is often times restless. The appropriate pain relief medications and sedation are administered by injections. Antibiotics are given to minimize the spread of infection. It must be noted that non-steroidal anti-inflammatory drugs are totally contraindicated as these are oftentimes the causative factors for peptic ulcer diseases.

Diagnosis of a perforated duodenal ulcer is confirmed by plain abdominal radiographs (x-rays). The presence of air under the diaphragm is confirmation of the perforation or rupture of a hollow viscus (internal organ).

Endoscopy is also a most useful tool for confirming the diagnosis of perforation of a duodenal ulcer. Endoscopy, which uses the technology of fibre optics, allows for the direct visualization and location of the ulcer and perforation. It also enables a biopsy to be performed to exclude the possibility of malignancy.

While the patient is being stabilized and the diagnosis is confirmed, preparation is made for surgery. This is the optimum treatment of choice. Surgery is aimed at repair of the site of perforation. Surgical resection and repair are also aimed at reducing the excess production of acid to prevent and minimize the recurrence of peptic ulcer disease in the affected individual.

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