A Daily Beer Drinker With Agonizing Gas and Back Pain

Erik D. Schraga, MD

Disclosures

February 09, 2021

As demonstrated in this case, the absence of free air within the abdominal cavity on a plain, upright abdominal or chest radiograph is not always noted. In fact, evidence of free air with a perforated viscus is seen in only approximately 30% of cases.[1]CT has a much higher sensitivity for visualizing free air and may show evidence suggesting the location of the perforation.

Endoscopy must be avoided if a perforation is suspected because air insufflation in the stomach may open a perforation that has sealed, resulting in increased leakage of gastric juice into the peritoneum. As an alternative to endoscopy, an upper gastrointestinal series using a water-soluble contrast agent may be performed.

A perforated ulcer should initially be treated with adequate resuscitation, which may include airway management (if indicated), the administration of adequate fluids (especially if signs of hypovolemia or a systemic inflammatory response, such as hypotension or tachycardia, are present), and pain control. Broad-spectrum antibiotics should be administered early and, ultimately, urgent surgery is required to close the peritoneum and irrigate the peritoneal cavity.[6,7]

The patient in this case became hypotensive and developed tachycardia in the ED after the completion of abdominal and pelvic CT scanning, despite aggressive fluid resuscitation. He developed a fever, and despite the administration of further rounds of parenteral pain medications, his pain worsened. No specific etiology for the perforation could be identified on CT.

The consultant surgeon brought the patient to the operating room; a large amount of bilious material was found within the abdomen during exploration, in addition to an ulcer on the anterior surface of the antrum of the stomach, near the pylorus. The perforation was closed with sutures, and the omentum was brought up and tacked over the perforation. The abdomen was irrigated copiously, and the skin was then closed.

The patient had an uncomplicated postoperative course on IV antibiotics, and he was discharged home after an adequate recovery.

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