EM SAQs · Perforated viscus
Perforated viscus — peptic ulcer with free gas
ACEM-style SAQ on perforated peptic ulcer — concurrent resuscitation, antibiotics, imaging limits and site-specific surgery.
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Prompt
A 64-year-old man on long-term NSAIDs develops sudden severe epigastric pain. He lies still with a board-like abdomen and absent bowel sounds. HR 120, BP 95/60. Outline your ED management. What is the sensitivity of an erect CXR for free gas, and how does site of perforation change the operation? (10 marks)
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Reveal model answerShowHide
Working diagnosis. Perforated peptic ulcer (NSAID + sudden timed pain + board-like rigidity) until proven otherwise.[1]
Concurrent ED management (not sequential).
- ABCDE; two large-bore IV; oxygen; NBM; NG tube.
- Crystalloid resuscitation titrated to MAP/UO/lactate; catheter; bloods including lipase, lactate, G&S, cultures if septic; ECG to exclude inferior MI.
- Immediate antibiotics: piperacillin-tazobactam 4.5 g IV OR ceftriaxone 2 g IV + metronidazole 500 mg IV.
- Analgesia morphine 5 mg IV titrated.
- Urgent surgical referral for source control in parallel with imaging.
Imaging. Erect CXR free subdiaphragmatic gas supports diagnosis but sensitivity is about 85% on the erect film (lower supine) — a normal CXR does not exclude perforation; CT if clinical suspicion remains or site/planning needed.[4]
Site-specific operations.
- Peptic ulcer: Graham (omental) patch (± H. pylori therapy later).
- Appendix: appendicectomy.
- Diverticulum Hinchey III–IV: typically Hartmann procedure.
- Colon (cancer/ischaemia/colitis): resection (Hartmann/subtotal colectomy).
References3ShowHide
- [1]Tarasconi A, Coccolini F, Biffl WL, et al. Perforated and bleeding peptic ulcer: WSES guidelines. World Journal of Emergency Surgery, 2020.PMID 31921329
- [4]Chiu YH, Chen JD, Tiu CM, et al. Reappraisal of radiographic signs of pneumoperitoneum at emergency department. American Journal of Emergency Medicine, 2009.PMID 19328377
- [2]Sermonesi G, Tian BWCA, Vallicelli C, et al. Cesena guidelines: WSES consensus statement on laparoscopic-first approach to general surgery emergencies and abdominal trauma. World Journal of Emergency Surgery, 2023.PMID 38066631