Perforated Peptic Ulcer: A Case Report of a Dreaded Complication of an Insidious Disease

Abstract

Perforated peptic ulcers, though relatively rare, represent critical surgical emergencies with potentially life-threatening consequences. Their significance lies not only in their acute presentation but also in the diagnostic challenges they pose, particularly in patients with complex medical histories. Here we present a case of a 71-year-old female with a complex medical history, including insulin-dependent type 2 diabetes mellitus, hypertension, hyperlipidemia, hypothyroidism, dementia, diverticulitis, and chronic back pain, who initially were unresponsive and cyanotic. Despite challenges in diagnosis due to her medical complexity and opioid use, she was ultimately diagnosed with a perforated duodenal ulcer. Tragically, despite immediate surgical intervention, she succumbed to her illness, highlighting the complexities involved in managing perforated peptic ulcers, especially in patients with multiple chronic medical conditions. Peptic ulcer disease (PUD) can often remain asymptomatic, leading to delayed diagnosis and potentially life-threatening complications like perforation. Mortality rates associated with perforated peptic ulcers vary widely, ranging from 1.3% to 20%, with risk factors including nonsteroidal anti-inflammatory drug (NSAID) use, Helicobacter pylori infection, smoking, and corticosteroid use. Diagnosis necessitates a high index of suspicion, thorough clinical examination, and imaging modalities such as computed tomography (CT) scans with oral contrast. Treatment strategies range from nonoperative management with intravenous (IV) histamine H2-receptor blockers or proton pump inhibitors (PPIs) to surgical intervention, depending on the patient's hemodynamic stability. However, the case presented underscores the challenges in timely diagnosis and intervention, particularly in patients with complex medical histories, where symptoms may be masked or attributed to other comorbidities. Recent studies indicate a demographic shift toward older age and a higher prevalence among females, emphasizing the importance of increased awareness and vigilance among healthcare providers. Early recognition of symptoms, prompt investigation, and interdisciplinary collaboration are crucial in optimizing outcomes for patients presenting with perforated peptic ulcers, especially in the context of their underlying medical conditions.

Keywords: altered mental status; diabetes mellitus; hemodynamic instability; high mortality; hyperlipidemia; hypertension; nsaid; peptic ulcer disease; perforated peptic ulcer; surgical emergency.

Figure 1. CT of the abdomen and pelvis without IV contrast: axial (A) and coronal (B) images in soft tissue windows.

CT of the abdomen and pelvis without IV contrast. Axial (A) and coronal (B) images in soft tissue windows demonstrate a collection of gas adjacent to the duodenal bulb concerning perforated duodenal ulcer (white arrow). There is also free fluid (black arrowheads) and free air (white arrowheads) concerning frank uncontained perforation. CT, computed tomography; IV, intravenous

Figure 2. CT chest without IV contrast: axial images in soft tissue window (A) and lung window (B).

CT chest without IV contrast. Axial images in soft tissue window (A) and lung window (B). Images demonstrate a small reactive right pleural effusion (white arrow) due to the inflammation from the perihepatic free fluid (white arrowhead). Images also redemonstrate the free intraperitoneal air (black arrowhead). CT, computed tomography; IV, intravenous