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Silent free perforation of duodenal ulcer in an elderly patient presenting with melena: management directed by upper endoscopy and percussion of the liver.

A 70-year-old man was admitted to hospital having had one tarry stool 6 hours beforehand. There was no history of abdominal pain, vomiting, or use of nonsteroidal anti-inflammatory drugs (NSAIDs). His blood pressure was normal and abdominal wall tenderness was absent. Laboratory tests showed mild anemia (hemoglobin 102 g/l). An upper endoscopy revealed deep ulceration on the anterior bulbar wall with visible liver in the depth of the picture (Figure 1). Because of absence of overt symptoms and signs of acute abdomen confined perforation was suspected. During and after the examination the patient had no pain. Percussion of the liver, which was not done previously, showed absence of liver dullness and suggested free perforation. Radiographic examination showed pneumoperitoneum. Surgery, performed 24 hours after the patient s admission to the hospital, confirmed the perforation of duodenal ulcer. The patient was discharged on the 11th postoperative day.