Perforation of a peptic ulcer can cause acute abdominal pain both with and without a prior history of peptic ulcer. It is an acute surgical emergency requiring immediate diagnosis. Consider a history of drugs, especially NSAIDs and H2 antagonists. Perforated ulcers may follow a heavy meal. There is usually no back pain.
The maximal incidence is 45-55 years, most common in males, and a perforated duodenal ulcer is more common than a gastric ulcer. Consider the clinical syndrome in 3 stages:
2. reaction (after 2-6 hours)—symptoms improve
3. peritonitis (after 6-12 hours)
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