Clinical and roentgen observations of a newly perforated peptic ulcer.

Abstract

In the last seven and a half years, 699 I patients have been discharged from the Pennsylvania Hospital with a diagnosis of peptic ulcer. Eighty-five, or 12.7 per cent of this number, showed clinical evidence of perforation. This percentage, it must be remembered, is based upon a specific group admitted to a hospital and does not represent the incidence of perforation in all cases. While it is thus apparent that perforation is not an uncommon complica tion of ulcer, its demonstration during the course of a barium study has only rarely been reported. In the following case perforation oc curred following fluoroscopy, while the pa tient was awaiting further examination, and unusually early roentgenograms were thus obtainable. Case Report A 59-year-old man, seen in November 1950, gave a history of symptoms beginning the preceding June, with a gradual increase in “nervous tension.” He had lost 10 pounds in weight in the past three months, apparently related to a decrease in appetite. His past medical history was non-contributory, and in a systemic review the only positive finding was the occurrence of occasional attacks of indigestion. He was considered a psychiatric problem because of his emotional background in relation to several weighty personal problems and had been treated for “nervous spasms” by his local physician. It was accepted that he had functional disease, and a routine upper gastro-intestinal examination was ordered to rule out an organic lesion. Fluoroscopically, the stomach was negative; the duodenal cap was large and irregular, with a niche on the lesser curvature side. It showed irritability and was tender to normal palpation. After completion of the initial part of the examination, the patient, in an apparently normal state and while awaiting further filming for motility studies, suddenly experienced acute pain in the right upper quadrant of the abdomen, approximately one-half hour after the ingestion of the barium meal, associated with rigidity of a moderate degree. While being examined, he voluntarily complained of right shoulder pain. A clinical diagnosis of perforated peptic ulcer was made. Two films were taken in the ensuing thirty minutes, before the patient was admitted to the hospital. Fifteen minutes after the onset of the sharp pain , an upright film of the chest was obtained to demonstrate air under the diaphragm. No evidence of free air in the peritoneal cavity was found (Fig. 1). Thirty minutes after the onset of symptoms, a scout film of the abdomen showed a very thin streak of barium outside the intestinal tract (Fig. 2), proving the clinical diagnosis. In approximately one and one-half hours, all the classical signs of perforation had developed, including loss of liver dullness and abdominal rigidity. Less than three hours after the original symptoms, films were made in the erect and horizontal positions before the patient was sent to the operating room.