Perforated Duodenal Ulcer

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Peptic ulcer disease is generally a medical condition where advances in diagnosis and treatment have made surgical intervention only reserved for its complications. Perforated duodenal ulcers remain a relatively common complication.

While a reasonable number of patients who present with acute perforated duodenal ulcer have had a diagnosis of peptic ulcers before, the majority have no prior diagnosis or investigations done. Presentation is usually of sudden severe epigastric pain which rapidly spreads to the whole abdomen associated with fear of movement.

Examination findings are typically those of generalized tenderness with board-like rigidity of the abdomen and rebound tenderness. The erect chest X-ray shows free air under the diaphragm in 75% of cases.

This is surgical emergency but resuscitation with Normal Saline, NGT insertion, analgesia and urinary catheterization should be done. FBC and U+Es are done in preparation for surgery. The prognosis is poor if surgery is delayed. The adage of "the sun should not rise and set' before surgery is done is appropriate for this condition. IV antibiotics should be given as soon as signs of peritonitis are picked.

First Line                                       

	Medicine	Dose	Frequency	Duration
	benzyl penicillin iv	2.5MU	4 times a day
and	gentamicin iv	120mg	once a day
and	metronidazole iv	500mg	3 times a day

NB. Gentamicin should not be used if renal assessment is not satisfactory.

Second Line

	Medicine	Dose	Frequency	Duration
	ceftriaxone iv	1g	2 times a day
and	metronidazole iv	500mg	3 times a day