These findings may signify the presence of a bleeding ulcer, a perforated ulcer with peritonitis, or an obstructing ulcer with protracted vomiting and volume depletion. Fever and tachypnea suggest the presence of ulcer perforation with peritonitis. Special attention should be given to the patient's mental status, skin and mucous membranes, heart and lungs, and, of course, the abdomen and rectum, which should be examined with great care. Involuntary guarding, rigidity, rebound tenderness, and a paucity or absence of bowel sounds suggest ulcer perforation with peritonitis. These findings may be less prominent or even absent in the very young, the elderly, and patients on corticosteroids or opiate analgesics.
Abdominal distention suggests gastric outlet obstruction or ileus.
A succussion splash in the stomach suggests gastric outlet obstruction or delayed gastric emptying caused by ileus, especially if the patient has not eaten within six hours. Hematochezia or maroon-colored stool may be present if bleeding is voluminous and intestinal transit is rapid. Detection of melena, hematochezia, or maroon-colored stool should prompt placement of a nasogastric tube to obtain an aspirate of gastric contents. If this aspirate is grossly bloody, the diagnosis of upper GI bleeding is confirmed and the likelihood of a bleeding ulcer is increased. MEN I with Zollinger-Ellison syndrome, but the pretest probability of this condition is too low in patients presenting with ulcerlike symptoms to recommend routine measurement of serum calcium.