Pneumoperitoneum in a perforated gastric ulcer.

To cite: Lobão B. BMJ Case Reports Published online: [please include Day Month Year] doi:10.1136/bcr-2012007915 DESCRIPTION A 78-year-old woman with a history of peptic ulcer and recent use of non-steroidal anti-inflammatory medication presented to the emergency department with a 3-day history of progressively worsening abdominal distention and pain. She had been seen at the same emergency department on the day before, and was treated symptomatically with intravenous fluids and promethazine and discharged with a presumptive diagnosis of gastroenteritis. The patient was haemodynamically unstable and improved after resuscitation in the emergency department. Abdominal examination revealed notable distention, tympany and voluntary guarding with signs of peritonitis. Plain-film radiographs of the chest, as well as an abdominal x-ray obtained with the patient in a supine position (figures 1 and 2), revealed evidence of a pneumoperitoneum with gas under the infradiaphragmatic region. The findings were highly suggestive of gastric perforation. The patient was handed over to the surgical team who gave prophylactic antibiotics. Owing to the patient’s instability, an emergency laparotomy was performed and the defect repaired. A biopsy of the ulcer revealed it to be a case of peptic ulcer disease. However, the patient developed severe nosocomial infection with septic shock and died shortly after the surgery. Peptic ulcer perforation in the older patients can present with atypical symptoms and be associated to increased mortality in this patient population. 2 Death rate after surgery for perforation of peptic ulcer is 3–5 times higher in the elderly (up to 50%). This can be explained not only by the occurrence of concomitant medical diseases but also by difficulties in making the right diagnoses, resulting in a delay >24 h. A high level of vigilance and early attention to an ‘acute abdomen’ in the elderly is therefore advocated. Learning points