Clinical Features

• Sudden onset of abdominal pain and abdominal distention

• Nausea, vomiting, obstipation

• Fever, tachycardia, tachypnea, hypotension

• Signs of peritonitis or shock

• Decreased or absent bowel sounds

• Loss of liver dullness on RUQ percussion

• Perforated PUD:

  • Sudden onset of intense, stabbing pain, followed by diffuse abdominal pain and distention (beginning peritonitis)

  • Referred pain to the shoulder due to irritation of the diaphragm, which is innervated by the phrenic nerve (C3-C5); the shoulder skin is innervated by supraclavicular nerves (C3-C4) (see referred pain)

  • History of recurrent epigastric pain, chronic use of NSAIDs

  • Perforation of chronic ulcers may only cause mild symptoms.

• Perforated diverticulitis: constipation, previous LLQ pain

• Perforated appendicitis: progressively worsening RLQ pain, migratory pain

• Perforated malignancy or IBD: anorexia, weight loss, melena, change in bowel habits

• Diffuse: in patients with free intraperitoneal perforation

• Localized RLQ pain: contained perforated appendicitis

• Localized LLQ pain: contained perforated diverticulitis

Bowel perforation is a surgical emergency. In some cases, clinical features alone are sufficient to warrant emergency explorative laparotomy.