What does the KUB show? It shows a double-wall sign, which should raise a very high suspicion for a perforated viscus. Normally, you can only see the inside of the bowel wall. If you see both sides, suspect free air. In this case it was a perforated peptic ulcer.

What should be your next step? Give antibiotics and call a surgeon.


Gastritis and peptic ulcer disease (PUD) typically present with epigastric pain, which is often more severe when the stomach is empty. Nausea may occur, but fever, vomiting, and diarrhea are typically absent. Risk factors include NSAID use, as well as tobacco, alcohol, and stimulants. Helicobacter pylori is a sole or contributing cause in many cases.

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The main complication of peptic ulcer disease is bleeding, which is more likely to occur when PUD is painless and thus progresses insidiously to a more advanced state. A more rare but more serious complication is perforation, which typically presents as sudden abdominal pain, which is often, but not always, severe. Perforation is diagnosed by radiographic imaging. See the table below for sensitivities of plain films and CT.

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A majority of cases of peptic ulcer disease are fortunately uncomplicated and are therefore treated initially with antacids. H2 blockers are often a better initial choice than proton pump inhibitors, as they work faster and have fewer side effects. For immediate pain relief, magnesium or calcium-containing hydroxides are best. It is important to understand that though they work rapidly they have a short duration of action. Endoscopy is typically resolved for refractory or complicated cases (see indications below). Treatment of perforation is surgical.

Gastritis & Peptic Ulcer Disease from the Emergency Medicine 1-Minute Consult

Symptoms Epigastric and/or left upper quadrant gnawing, often 1-3 hours after a meal and/or at night.

Alcohol, tobacco, NSAIDs, steroids, cocaine, H pylori

  • Usually clinical. Careful: 30% of MIs have only GI symptoms
  • Scope indications: Bleed, anemia, age >55, mass, weight loss, refractory
H pylori In 90% of duodenal ulcers patients, 75% of gastric ulcer patients, and 20% ulcerless patients.


Urea breath test: 99%/99%

  • H2 blocker: good start as cheaper, faster onset, and fewer risks
  • Proton pump inhibitor: stronger, but more risk of side effects
Perforation Sudden pain (may be mild): ~50%, rigidity: ~20%.


Plain films: ~60% sensitive. CT: >90% sensitive
Disposition Most home, but admit for bleed, perforation, need for urgent scope or concern for ACS 

Brady Pregerson, MD, is an emergency physician at Cedars-Sinai Medical Center in Los Angeles and at Tri-City Medical Center in Oceanside, California.


Pregerson B. Emergency Medicine1-Minute Consult Pocketbook. 5th ed.; 2017.