Respiratory distress and chest pain: a perforated peptic ulcer with an unusual presentation

Abstract

BackgroundDyspnea and chest pain are common presenting complaints to the ED, and coupled together can present a challenging diagnostic dilemma in patients in extremis. A thoughtful evaluation is required, giving due diligence to the immediate life threats as well as multiple etiologies which can cause serious morbidity. A perforated peptic ulcer is one such possibility and requires rapid diagnosis and prompt intervention to avoid the associated high risk of morbidity and mortality.MethodWe present a case report of a 54 year old man with respiratory distress and chest pain as the initial Emergency Department presentation of a perforated duodenal ulcer.ResultsWe discuss an unusual presentation of a perforated duodenal ulcer that was recognized in the emergency department and treated promptly. The patient was surgically treated immediately, had a prolonged and complicated post-operative course, but is ultimately doing well. We also provide a brief literature review of the risk factors, imaging choices, and management decision required to treat a perforated ulcer.ConclusionsPerforated ulcers can have highly varied presentations and are occasionally difficult to diagnose in a complicated patient. Knowledge of the risk factors and a thorough history and physical can point to the diagnosis, but timely and appropriate imaging is often required because delays in diagnosis and treatment lead to poor outcomes. Early administration of antibiotics and immediate surgical repair are necessary to limit morbidity and mortality.

Chronic subclinical perforation of a duodenal ulcer presenting with an abdominal abscess in a patient with seronegative rheumatoid arthritis

“…Patients usually present with severe abdominal pain, though they may have atypical6 symptoms and/or they may be overlooked due to comorbidities7 or concurrent therapies 8. Our patient presented with primarily worsening severe joint pains and a history of black stools.…”

Duodenal perforation: role of multi detector computed tomography (MDCT)

“…7 In that case, plain abdominal X-ray films to document the associated pneumo-peritoneum is sufficient. 8 Clinical onset of a perforated gastric or duodenal ulcer may be atypical 9 or subtle some times because of comorbidities 10 and concurrent therapies. 11 In this situation, the contribution of imaging like MDCT is more valuable.…”

Perforated duodenal ulcer presenting with a subphrenic abscess revealed by plain abdominal X-ray films and confirmed by multi-detector computed tomography: a case report

“…When a perforated peptic ulcer is clinically suspected it represents an emergent condition prompting immediate surgery [ 13 ]. However, the clinical onset of a perforated gastric or duodenal ulcer may be atypical [ 4 ] or the perforation may be clinically overlooked in the presence of comorbidities [ 5 ] or it can be masqueraded by concurrent therapies [ 6 ]. In our patient’s case, it can be argued that an anti-inflammatory effect was somehow induced by the multi-kinase inhibitor drug imatinib, which our patient had been taking daily for seven years.…”

“…Less commonly, clinical onset of a perforated gastric or duodenal ulcer may be atypical [ 4 ] or subtle because of comorbidities [ 5 ] and/or concurrent therapies [ 6 ]. In such cases, the contribution of imaging may be substantial [ 7 - 12 ].…”