Although peptic ulcer disease most frequently presents as gastrointestinal bleeding, perforation is an important cause of abdominal pain in the older patient (see
Chap 73). The expected description of a sudden, acute onset of epigastric pain is reported in only one-half of patients over age 70 with a perforated ulcer. 6 The pain has usually been present only for a matter of hours and is generally severe, constant, and present to some degree in the epigastrium. Free intraperitoneal perforation can cause generalized pain or lower-quadrant symptoms.8 Vomiting is infrequent. The physical examination is expected to reveal epigastric tenderness, although muscular guarding is variable. In one study, only 21 percent of the elderly with a perforated ulcer had epigastric rigidity. 6 Fever is generally not present early on.
The key diagnostic mistake is excluding this diagnosis because of a lack of "free air" on plain radiographs. Roughly 40 percent of patients with perforated ulcers will not have this finding on their initial radiographs. The left lateral decubitus view or the lateral view of the upright chest radiograph may help to detect the presence of free air. Repeat radiographs after installation of 500 mL of air by a nasogastric tube increases the diagnostic yield of plain radiographs. Computed tomography is capable of detecting small amounts of air in the peritoneal cavity. In one series, missed perforated ulcer was the leading cause of death in elderly patients with abdominal pain, and in each case the plain radiographs did not reveal free air. 7
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