The EM Educator Series: Abdominal Pain that won’t go away… Gastric/Bowel Perforation

Author: Alex Koyfman, MD (@EMHighAK) // Reviewed by: Brit Long, MD (@long_brit) and Manpreet Singh, MD (@MprizzleER)

Welcome back to the EM Educator Series. These posts provide brief mini-cases followed by key questions to consider while working. The featured questions provide important learning points for those working with you, as well as vital items to consider in the evaluation and management of the specific condition discussed.

This week has another downloadable PDF document with questions, links and answers you can share with learners as educators in #MedEd. Please message us over Twitter and let us know if you have any feedback on ways to improve this for you. Enjoy!

Case 1:

A 35-year-old male with no past medical history presents with mid epigastric pain for 2 weeks. He has no relief after three rounds of opioid medication, with significant tenderness to palpation. Upright chest x-ray reveals free air in the abdomen.

Case 2:

A 44-year-old female with no past medical history presents with severe abdominal pain and involuntary guarding on exam.



  • What’s your approach to abdominal pain, and what is your differential?
  • Who is at risk for gastric or bowel perforation, and how can it present?
  • Do analgesics mask exam findings?
  • What is the utility, and limitations of, obtaining an upright chest x-ray or acute abdominal series?
  • What antibiotics should you consider in the patient with perforation?
  • If imaging is delayed or not obtainable, when should you call the surgeon?  If perforation is suspected, should you wait for imaging to discuss the case with the surgeon?


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