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Background
In a recent multicentre European study, the prevalence of peptic ulceration was 8.1% in children presenting with abdominal pain, the majority of patients being males in the second decade of life. 1 Helicobacter pylori infection and non-steroidal anti-inflammatory drug ingestion are the main aetiological risk factors in the paediatric age. 2 The classic presentation of patients with peptic ulcers is one of epigastric pain, often associated with vomiting.
Perforated peptic ulcer disease in children is rare, seen in only 5% of cases, and is usually associated with a preceding history of typical pain, and presentation with generalised peritonitis. In the largest study in the literature, 52 cases of perforated duodenal ulcer disease were reported over a 20-year period. 3 All patients in this series reported a history of abdominal pain and 94.2% had signs of peritonitis at presentation.
As with all acute abdominal emergencies, rapid diagnosis and prompt treatment are the keys to a successful outcome, this being of particular importance in cases of visceral perforation. Faced with radiological evidence of perforation but an uncertain origin, options include cross-sectional imaging or immediate surgery. Diagnostic laparoscopy, as selected, excludes the radiation exposure of abdominal CT as well as its associated time delay. It also allows direct visualisation of the whole peritoneal cavity, thorough evacuation of food material and gastric secretions as well as providing direct visualisation of the perforation and facilitating repair.
Case presentation
A 12-year-old boy presented to the emergency surgical intake via the out of hours general practitioner service with very severe lower abdominal pain that woke him from sleep. The pain was constant in nature, scoring 10 out of 10 in severity, but did not radiate and no exacerbating factors were reported. The pain was associated with vomiting but no alteration in bowel habit. There was no medical or family history of note. He had no urinary or respiratory symptoms, took no medications and lived with four siblings who were all well.
On examination, he appeared flushed, with tenderness in the lower abdomen and peritonism that was markedly worse over the left iliac fossa. He was tachycardic with a heart rate of 140 bpm, blood pressure of 110/89 mm Hg, a temperature of 36.6°C and a respiratory rate of 20 bpm. Peripheral...