Peptic Ulcer Disease

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Case Study: The Midnight Wake-up Call

Part 1: Initial Presentation

Patient: Mr. Arjun, a 34-year-old software engineer.Chief Complaint: Recurring “gnawing” epigastric pain for the last 3 weeks.

History of Present Illness:

• Timing: The pain is worst at night (waking him up at 2:00 AM) and when he is hungry.
• Relieving Factors: He notes that drinking a glass of milk or eating a cracker makes the pain vanish almost immediately.
• Social History: High-stress job, drinks 5–6 cups of coffee daily, and is a social smoker.
• Medications: Occasionally takes Ibuprofen for tension headaches.

Physical Exam (Initial):

• Vitals: Stable (BP: 120/80 mmHg, HR: 72 bpm).
• Abdomen: Soft, mild tenderness in the epigastric region. No guarding or rebound tenderness.

Discussion Question 1: Based on the timing of the pain and the relieving factors, is this more likely a Gastric or Duodenal ulcer?

• Answer: Duodenal Ulcer. (Pain relieved by food and nocturnal pain are classic “hunger pain” signs of DU).

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Part 2: The Acute Deterioration

Six hours after his initial clinic visit, Mr. Arjun arrives at the Emergency Department via ambulance.

Updated Status:

• He experienced sudden, “thunderclap” abdominal pain that started 1 hour ago.
• He is lying perfectly still on the stretcher, afraid to move.
• Physical Exam (ER):
  • Vitals: HR: 115 bpm: (Tachycardia), BP: 100/60 mmHg, Temp: 38.2 C.
  • Abdomen: “Board-like” rigidity. Bowel sounds are absent. He has extreme rebound tenderness.

Discussion Question 2: What complication has occurred, and what is the first radiological investigation you would order?

• Answer: Perforation. The first test is an Erect Chest X-ray to look for free air under the diaphragm (pneumoperitoneum).

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Part 3: Definitive Management

The X-ray confirms free air under the right hemidiaphragm.

Management Steps for the Student:

1. Resuscitation: IV fluids (crystalloids), NPO (Nothing by mouth), and Nasogastric (NG) tube suction to decompress the stomach.
2. Pharmacology: IV Proton Pump Inhibitors (PPIs) and broad-spectrum antibiotics (to cover for chemical/bacterial peritonitis).
3. Surgery: The patient is taken for an emergency laparotomy.

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Summary Table for Students: “The Red Flags”

Alarm Symptoms that should have prompted an urgent endoscopy earlier: