Abrupt onset of abdominal pain
What was causing this patient’s epigastric abdominal pain, which began several days after he’d been hospitalized for acute pericarditis?
Diagnosis: Duodenal perforation caused by indomethacin
The CT scans revealed inflammation (arrows, FIGURE 1A) and thickening of the second and third portion of the duodenum and the pres- ence of extraluminal air at the site of the perforation (arrows, FIGURE 1B). There was also free fluid along the right paracolic gutter and into the pelvis. We diagnosed a small intestinal perforation in this patient, which was likely caused by a nonsteroidal anti-inflammatory drug (NSAID)-induced ulcer.
How NSAIDs affect the GI tract
NSAIDs inhibit cyclooxygenase (COX), the enzyme responsible for prostaglandin production. Specifically, the COX-1 enzyme is responsible for the production of prostaglandins in the gastrointestinal (GI) tract. Prostaglandins play an important role in protecting the GI mucosa. By inhibiting the synthesis of prostaglandins, the permeability of the GI tract is increased and the natural protective barrier of the mucosa is destroyed.1
Gastroduodenal damage is a well-known adverse effect of NSAIDs. Ulcers have been noted on upper endoscopy in regular NSAID users, and the risk of developing a symptomatic ulcer and complications increases with every year of regular NSAID use.2 Ulcers in the GI tract can be complicated by perforation.1
Patients will complain of sudden onset abdominal pain
Important clues in the patient history for a perforated GI tract include sudden onset of severe abdominal pain that may present initially as epigastric pain and progress to generalized abdominal pain that may radiate to one or both shoulders.3 Physical exam findings for a perforated GI tract may include abdominal tenderness and rigid abdomen; fever and tachycardia may also be present.3 Concern for possible abdominal perforation should be evaluated with a complete blood count, basic metabolic panel, and radiographic studies.3
