A 75 yo, previously completely healthy patient came to my ER and complained about upper GI pain for 3 days, no other complains. The exam showed a very painful and tense abdominal wall upon pressure. Labs got some elevated WBC (11.2 Bil/l) without elevated CRP or any other parameter. The abdominal plain is shown on the right (click the thumbnail for a larger view).
After the clinical examination I could bet that he had a perforated ulcer (or whichever perforation) and was roughly “dissapointed” seeing the x-ray picture. I discussed the case with collegues and we decided to perform a gastroscopy to exclude an ulcer and eventually even provoke the free abdominal air in the case of a covered perforation. The gastroscopy showed a hardly to find postpyloric ulcer, showed on the left (click the thumbnail for a larger view).
Two hours after later another abdominal plain x-ray was performed – shown on the right (click the thumbnail for a larger view).
We did a laparotomy with excision of the ulcer. The patient recovered quite quckly as no preoperative health problems could interfere.
Conclusion: A doubtful clinical situation suggesting a perforation could be better evaluated with an endoscopy to provoke the clear findings of a perforation.
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