Perforated viscus is a potentially fatal complication of obstruction, ischemia, trauma, surgery and medications. It is recognized by clinical suspicion based on history and symptoms of severe abdominal pain and rebound tenderness, as well as imaging showing free air in the abdomen. We hereby present a case of a patient who came with atypical symptoms that eventually diagnosed as perforated viscus.
A 52 year old male with known case of scoliosis post corrective surgery on 2016 presented to emergency department complaining of unable to pass out any urine since morning associated with suprapubic pain. Otherwise, he did not experience any dysuria or fever. Bladder catheterization was done promptly resulting with nil urine output. He was then uptriaged to red zone as he was breathlessness. His blood pressure was stable with heart rate 154bpm, respiratory rate of 40bpm, temperature 38.7 and oxygen saturation 95% under room air. Lung auscultation noted crackles at right lower zone with reduce air entry. Per abdomen was soft, distended, tender on deep palpation over suprapubic, bladder not palpable with sluggish bowel sound. Bedside ultrasound bladder not visible with no free fluid. Eventually his CXR revealed right subdiaphragmatic free air. He was then intubated and underwent emergency laparotomy which was noted to have perforated prepyloric ulcer with 2L gross contamination of turbid fluid. Unfortunately patient succumbed due to septic shock 22hours post surgery.
Discussion & conclusion
Although perforated viscus patient typically came with severe abdominal pain, it still should be included in differential diagnosis in unstable patient who came with vague symptom as they can present in unusual presentation. Thorough history and examination will help us to identify these group of patients.
perforated viscus, atypical symptom