Peptic ulcers are erosions of the tissues lining the upper digestive tract, particularly the stomach and first portion of the small intestine, the duodenum. They are often caused by a bacterial infection that compromises your defense against the acid produced in the stomach. Peptic ulcers sometimes penetrate completely through the stomach or intestinal wall, resulting in a hole -- or perforation -- and spillage of acid, digestive enzymes and partially digested food into the abdominal cavity. Several signs and symptoms typically result, although they can occur with conditions other than a perforated ulcer.
Sudden, Severe Abdominal Pain
The first symptom of a perforated peptic ulcer is usually sudden, severe, sharp pain in the abdomen. The experience is typically so intense that most people precisely recall the exact moment the pain began. The pain is typically at its maximum immediately and persists. It is characteristically made worse by any movement, and greatly intensifies with coughing or sneezing. The pain is often generalized throughout the abdomen, but is sometimes focused in the upper abdomen. It may radiate to the shoulders or, less commonly, the hips.
Abdominal Tenderness, Distention and Rigidity
Spillage of digestive contents into the abdominal cavity due to a perforated ulcer provokes intense inflammation of the area. This leads to not only pain but abdominal tenderness, meaning touching or pressing on the abdomen provokes increased pain. This is evident on physical examination, as people with abdominal cavity inflammation reflexively stiffen the abdominal muscles when the doctor presses on the area. This reflex is known as abdominal guarding.
A perforated ulcer frequently also causes swelling of the abdomen, known as abdominal distention. Air entering the abdomen through the perforation often contributes to distention. Fluid accumulation in the abdominal cavity due to inflammation of the area is another contributor to abdominal distention. Abdominal guarding and distention both cause the area to feel rigid on examination. Light tapping on the abdomen will often produce a hollow, drum-like sound.
Other Signs and Symptoms
Someone with a perforated ulcer typically lies quietly -- often in a fetal position -- and breathes shallowly to avoid aggravating their abdominal pain. People with a perforated ulcer appear distressed and obviously ill, and some experience shortness of breath. The skin may be pale and clammy, and the heart rate is often rapid. Fluid accumulation in the abdomen may lead to low blood pressure, with dizziness, lightheadedness or fainting. Little to no urine production occurs in people with markedly low blood pressure.
Early Warning Signs and Symptoms
Although a perforation may be the first indication of peptic ulcer disease, most people with this condition experience milder symptoms in the days or weeks leading up to the perforation. Pain between the breastbone and the navel may occur when the stomach is empty, and might be relieved with antacids. The pain may come and go, and is often worse at night. Dark, tarry bowel movements or vomiting material that resembles coffee grounds may signal bleeding from a peptic ulcer.
When To Seek Medical Care
Seek medical evaluation as soon as possible if you experience symptoms that might indicate a peptic ulcer. Early diagnosis and treatment typically prevents the development of a perforation.
Emergency medical evaluation and treatment are necessary if you experience any signs or symptoms that could signal a perforated ulcer. Although another condition might be responsible for your symptoms, emergency medical care is needed to determine the cause, and ensure immediate and appropriate treatment.
Reviewed and revised by: Tina M. St. John, M.D.
- The British Journal of Surgery: Surgical Delay Is a Critical Determinant of Survival in Perforated Peptic Ulcer
- The American Surgeon: Helicobacter Pylori Is Not the Predominant Etiology for Peptic Ulcers Requiring Operation
- Irish Journal of Medical Science: Mortality in Perforated Duodenal Ulcer Depends Upon Preoperative Risk: A Retrospective 10-Year Study
- Merck Manual Professional Version: Acute Perforation
- Merck Manual Professional Version: Acute Abdominal Pain
- Gastrointestinal Emergencies, 2nd Edition; Tony C. K. Tham, et al.
- Surgery: Basic Science and Clinical Evidence, 2nd Edition; Jeffrey A. Norton, et al.