History
A careful medical history often suggests the source of the problem, which is subsequently confirmed by clinical examination and radiologic study findings. Possible etiologies include the following:
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Penetrating injury or blunt trauma to the lower chest or abdomen
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Aspirin, nonsteroidal anti-inflammatory drug (NSAID), or steroid intake, particularly in elderly patients
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Treatment for peptic ulcer disease or ulcerative colitis; perforation due to acute ulcerative colitis (usually identified by the history of the primary disease and the results of past investigations)
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Abdominal pain
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Vomiting - This occurs, albeit uncommonly, in patients with a perforated ulcer; vomiting is, however, frequently noted in patients with acute cholecystitis; in patients with appendicitis, pain almost always precedes vomiting by 3-4 hours, whereas the converse is true in gastroenteritis
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Hiccup - This is a common late symptom in patients with a perforated peptic ulcer
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History of travel to or of residing in tropical areas, with symptoms suggestive of typhoid fever (eg, fever, abdominal pain, abdominal distention, constipation, bilious vomiting)
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History of chronic disease, such as ulcerative colitis
With regard to abdominal pain, it is important to ask patients about the time of onset of pain, the duration and location of pain, the characteristics of pain, relieving and aggravating factors, and other symptoms associated with abdominal pain. A history of similar attacks may also suggest the etiology.
Sharp, severe, sudden-onset epigastric pain that awakens the patient from sleep often suggests perforated peptic ulcer. Differentiate this from conditions such as cholecystitis and pancreatitis. Painless perforation of a peptic ulcer can occur with steroid use. The presence of shoulder pain suggests involvement of the parietal peritoneum of the diaphragm.
In elderly patients, consider the possibility of perforated diverticulitis or ruptured acute appendicitis if the pain is located in the lower abdomen. Approximately 30-40% of elderly patients with acute appendicitis present more than 48 hours after the onset of abdominal pain. (Delayed presentation is usually associated with increased risk of perforation.) Elderly patients may have minimal pain.
In young adults with pain in the lower abdominal quadrant, consider perforated appendicitis as a possible diagnosis. Acute appendicitis with sudden perforation is usually associated with illness of several hours. The pain is typically localized in the right lower quadrant of the abdomen, unless the disease process has progressed to generalized peritonitis. In young women, also consider ruptured ovarian cyst and ruptured tubo-ovarian abscess in the differential diagnosis.
Physical Examination
Assess the patient's general appearance, take vital signs, and assess for any hemodynamic changes. (Take pulse and blood pressure measurements with the patient lying in bed and sitting, and note any postural changes.)
Examine the abdomen for any external signs of injury, abrasion, and/or ecchymosis. Observe patients' breathing patterns and abdominal movements with breathing, and note any abdominal distention or discoloration. (In perforated peptic ulcer disease, patients lie immobile, occasionally with knees flexed, and the abdomen is described as boardlike.)
Carefully palpate the entire abdomen, noting any masses or tenderness. Tachycardia, fever, and generalized abdominal tenderness may suggest peritonitis. Abdominal fullness and doughy consistency may indicate intra-abdominal hemorrhage. Tenderness on percussion may suggest peritoneal inflammation. Bowel sounds are usually absent in generalized peritonitis.
Rectal and bimanual vaginal and pelvic examinations may help in assessing conditions such as acute appendicitis, ruptured tubo-ovarian abscess, and perforated acute diverticulitis.
