Perforated peptic ulcer (PPU) is a comparatively rare complication of peptic ulcers and is associated with a mortality rate of up to 40% [1] [2] [3] [4]. The incidence of PPU has decreased in the Western countries but it may be encountered more frequently amongst the elderly [5], and especially in females [4]. Long-standing treatment with non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, H. pylori infection, smoking and high intake of dietary salt [2] [6] are reported to be some of the etiological factors leading to PPU. Advancing age, serious medical comorbidities, hypotension [7], diagnosis and treatment delays for more than one day [8] are indicators of poor prognosis.

PPU presents typically with sudden onset of severe epigastric pain which soon progresses to generalized abdominal pain. The patient may like to lie still as the movement may aggravate pain. The subsequent clinical symptoms depend upon whether the omentum is able to seal off the perforation and heal it. 'Board-like abdominal rigidity' can develop in patients and localized or generalized peritonitis progresses. [9]. At this time, the patient may present with hypotension, high-grade fever [5], altered sensorium and sepsis [9]. Typical clinical manifestations can be absent in older patients or those who are immunocompromised. This can delay the diagnosis and result in high rates of mortality.

A high index of clinical suspicion, a detailed history, and a thorough physical examination are vital for the early diagnosis of PPU. The patient may provide a history of partially treated peptic ulcer disease, recurrent epigastric pain, chronic intake of anti-ulcer medications, NSAIDS and/or steroids. Signs of peritonitis may be absent on physical examination, especially if the perforation gets sealed [10]. In advanced cases with sepsis, there may be tachycardia, hypotension and altered consciousness.

Laboratory tests are usually nonspecific with leukocytosis, elevated inflammatory markers, metabolic acidosis, and elevated levels of serum amylase suggestive of PPU [10]. Antibiotics should be started early in PPU but it is important to perform blood cultures prior to starting antibiotics [11] especially if bacterial peritonitis is suspected.

Plain X-ray chest or abdomen obtained in the upright position may show air under the diaphragm which is indicative of perforation of an abdominal organ. In the absence of pneumoperitoneum on plain X-ray, computed tomography (CT) scan with oral contrast is performed. It has a sensitivity of 98% and can also help to exclude other causes of the acute condition like pancreatitis [4] [12] [13]. PPU should be suspected if CT reveals pneumoperitoneum, thickening of the bowel wall, intraperitoneal fluid, fat streaking and/or hematoma in the mesentery and leak of contrast into the peritoneal cavity [14].

The primary treatment for a perforated peptic ulcer is surgical repair of the perforation. This is usually done through an open surgery or laparoscopically, depending on the patient's condition and the surgeon's expertise. Before surgery, patients are typically stabilized with intravenous fluids, antibiotics to prevent infection, and medications to reduce stomach acid. In some cases, non-surgical management may be considered if the perforation is small and the patient is stable.

The prognosis for a perforated peptic ulcer depends on several factors, including the patient's overall health, the size and location of the perforation, and how quickly treatment is initiated. With prompt surgical intervention, many patients recover well. However, delays in treatment can lead to complications such as widespread infection, organ failure, and even death. Long-term outcomes also depend on addressing the underlying causes of the ulcer to prevent recurrence.

Peptic ulcers are primarily caused by an imbalance between stomach acid and the protective lining of the stomach or duodenum. The most common causes include infection with Helicobacter pylori bacteria and the use of nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen and aspirin. Other contributing factors can include smoking, excessive alcohol consumption, and stress.

Peptic ulcers are a common condition worldwide, affecting millions of people each year. The risk of developing a perforated ulcer increases with age and is more common in men than women. The prevalence of Helicobacter pylori infection and the use of NSAIDs are significant factors influencing the incidence of peptic ulcers and their complications.

The pathophysiology of a perforated peptic ulcer involves the erosion of the stomach or duodenal lining by stomach acid, leading to a full-thickness defect. This allows gastric or intestinal contents to spill into the sterile abdominal cavity, causing peritonitis. The inflammatory response can lead to sepsis, a life-threatening condition characterized by widespread inflammation and organ dysfunction.

Preventing a perforated peptic ulcer involves managing the risk factors for peptic ulcers. This includes eradicating Helicobacter pylori infection with appropriate antibiotics, using NSAIDs cautiously, and adopting lifestyle changes such as quitting smoking and reducing alcohol intake. Regular medical check-ups and early treatment of peptic ulcers can also help prevent complications.

A perforated peptic ulcer is a critical condition resulting from a hole in the stomach or duodenal lining, leading to severe abdominal infection. Prompt diagnosis and surgical treatment are essential for a favorable outcome. Understanding the causes and risk factors can aid in prevention and reduce the likelihood of recurrence.

If you suspect you have a perforated peptic ulcer, it is crucial to seek immediate medical attention. Symptoms include sudden, severe abdominal pain, nausea, vomiting, and signs of shock. Treatment typically involves surgery to repair the perforation and prevent further complications. Managing risk factors such as Helicobacter pylori infection and NSAID use can help prevent this condition.

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