From emergency room to morgue: deaths due to undiagnosed perforated peptic ulcers. Report of four cases with review of the literature.
Peptic ulcer perforation is well recognized as a cause of peritonitis and can result in death. Although amenable to surgery, delay in making the correct diagnosis results in increased mortality. Accurate diagnosis has been hindered by demographic changes in the affected population. In recent years, the population at risk has increased. Specifically, a rising incidence has been observed in women, in the elderly, and in patients with previously undiagnosed peptic ulcer disease. Described are four patients with perforated peptic ulcers, three of which were not detected prior to autopsy. In three of the four instances the patient had been observed in and discharged from a hospital emergency room during the 30 h prior to death. In the fourth case, the decedent had been seen in and discharged from the emergency room four times during the month prior to death. In all patients, the presenting historical, physical, and/or radiographic findings were indicative of perforation. The death of a patient within days of a visit to an emergency room should prompt a forensic autopsy. The role of medical examiners in providing quality assurance feedback to emergency rooms located within their jurisdiction is emphasized.