Chest X-ray of a patient with perforated DU

If a peptic ulcer perforates, air will leak from the inside of the gastrointestinal tract to the peritoneal cavity. This leads to “free gas” within the peritoneal cavity. If the patient stands erect, as when having a chest X-ray, the gas will float to a position underneath the diaphragm. Therefore, gas in the peritoneal cavity, shown on an erect chest X-ray or supine lateral abdominal X-ray, is an omen of perforated peptic ulcer disease.

Primary Survey

Past history of dyspepsia, any medication especially NSAIDs, steroids, allergy.



  • Look for:
  • Tenderness in epigastrium,
  • Rt. Hemiabdomen.
  • Board like rigidity.
  • Reduced liver dullness.



  1. Set up two I/V lines with #18G branula.
  2. Start I/V fluids, Ringer’s lactate with KCl..
  3. Analgesia, Morphine + Marzine I/V.
  4. Nasogastric suction.
  5. Urinary catheterization.
  6. Antibiotics
  • Inj. ampicillin 500 mg I/V 6 hrly.
  • Inj. gentamycin 80 mg I/V 8 hrly


Secondary Survey

Detailed History


  1. Haematological:  Low Hb%, Raised TLC.
  2. Biochemical:  S/Electrolytes, S/Amylase, Urea, creatinine.
  3. Radiological:
  • X-Ray Chest PA view (free gas under the right dome of diaphragm.).
  • X-Ray Abdomen erect and supine.

Preparation for surgery


  1. Inform senior
  2. Take consent for exploratory laparotomy.
  3. Inform anaesthetist and theater staff.


Closure of perforation with omental patch.

Peritoneal lavage.

Consider definitive surgery.


Postoperative Care

  1. Nasogastric suction for 24 hours.
  2. Antibiotics for 48 hours.
  3. H2 Blockers I/V.
  4. Proton pu


Follow up

H. Pylori Eradication Therapy

?   Cap. Omeprazole 40 mg B.D.

?   Tab. Flagyl 400 mg 1 x TDS.

?    Tab. Clarithromycin 500 mg  1 x BD

?All of the above for 4 weeks

Gastroduodenoscopy after 4 weeks.