Perforation is heralded by the abrupt onset of severe epigastric pain as gastric or duodural contents spill into the peritoneal cavity, followed by the development of chemical and then bacterial peritonitis. Patients may not have a prior history of peptic ulcer disease and may in fact have no antecedent history of ulcer-like symptoms. Elderly patients may not have dramatic pain or impressive peritoneal findings.

When the diagnosis is suspected, appropriate laboratory tests, including a complete blood count, type and crossmatch, and a lipase level determination, should be performed; two large-bore intravenous lines started; oxygen and a monitor placed; a nasogastric tube inserted and placed on suction; and an acute abdominal series obtained. Free air is not always present. Some authorities suggest instillation of air into the stomach through the nasogastric tube in order to detect perforation. This procedure may open a sealed perforation, causing more spillage, and if free air is still not visualized, it does not rule out a perforation; thus, it is not recommended. Broad-spectrum antibiotics should be given and a surgical consult promptly obtained. In some cases, nonsurgical therapy has been successful, but operative intervention is the standard in the United States.

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