Clinical manifestations

Clinically the perforations are divided into three stages: of shock, illusionand peritonitis (Mondor, 1939).

Stage of shock (lasts for about 6 hours)

• Intensive upper abdominal pain at the time of perforation (Delafua compares it with “pain due to stabbing with a dagger”).

• Elicer’s sign – irradiation of pain to the right shoulder or scapula.

• Tenderness of abdominal wall. In elderly patients tension of muscles of abdominal wall is absent or insignificant through old-age relaxation of muscles.

• Percussion of liver will reveal attenuated dullness due to free gas.

• Auscultation will reveal a silent abdomen.

• Blumberg’s sign.

• Temperature is normal.

• Blood pressure may be lost.

• Pulse is rapid.

Stage of illusion (lasts for about 6–12 hours)

• As more exudate accumulates, chemical irritation of peritoneum becomes less, the patient feels better with less pain.

• The same signs may be found by rigidity becomes less.

• Abdominal distention will start.

• Temperature becomes elevated.

Stage of peritonitis

• The patient is extremely toxic with tachycardia and high temperature.

• The abdomen is rigid, distended and silent.

• Blumberg’s sign.

• Blood pressure is often lost.

Covered perforation (A. M. Shnicler, 1912). In this pathology the perforation is closed by fibrin, by omentum or sometimes ^_ by food particle. After that some amount of stomach content and air left into the abdominal cavity. This protective mechanism leads to relief from stomachache, but moderate tenderness of abdominal wall in right epigastria region persists (Ratner’s sign). On percussion hepatic dullness is doubtful. During X-ray examination it is not always possible to mark gas in right hypochondrium

Consequences of the covered perforation are: repeated perforation with development of classic clinical signs; subdiaphragmatic or subhepatic abscess; complete closing of defect by surrounding tissue with gradual convalescence of patient.

The atypical perforation is the perforation, at which gastric or intes­tinal content does not enter the abdominal cavity, but enters the retro­peritoneal space (ulcers of posterior wall of duodenum), large or small omentum (ulcers of lesser curvature of stomach), hepatoduodenal liga­ment.

In such patients during the perforation pain is not acutely expressed. During palpation insignificant rigidity of muscles of anterior abdominal wall is observed. On occasion, especially in the late stages of disease, can be hypodermic emphysema and crepitation.

The differential diagnosis includes acute cholecystitis, acute pancreatitis, strangulating intestinal obstruction, acute appendicitis, perforation of some other portion of the intestinal tract, and mesenteric thrombosis. A past history of ulcer disease is predictive, but in 30% of patients perforation is the first manifestation of peptic ulcer disease.