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GI Perforation on Steroids — SCE Rheumatology MCQ

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HardRheumatology EmergenciesGI Perforation on SteroidsSCE Rheumatology

A 50-year-old woman with systemic lupus erythematosus has taken prednisolone 30 mg daily for 6 weeks. After 48 hours of initially vague epigastric discomfort, she becomes tachycardic and hypotensive, but has only mild abdominal tenderness without rigidity. She has not undergone recent surgery or endoscopy. CT demonstrates a focal defect in the anterior wall of the duodenal bulb, adjacent extraluminal gas and free intraperitoneal gas. There is no diffuse bowel-wall oedema, target sign, comb sign or ascites. Which diagnosis best accounts for the clinical and radiological findings?

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Correct answer: C — Perforated peptic ulcer with glucocorticoid-attenuated peritonism

The focal duodenal wall defect, adjacent extraluminal gas and pneumoperitoneum establish a perforated peptic ulcer. Prednisolone can suppress the inflammatory response, so severe intra-abdominal disease may produce disproportionately mild tenderness or absent rigidity. Its UK SmPC also lists peptic ulceration with perforation as an adverse effect. This requires immediate surgical assessment despite the attenuated examination. Lupus enteritis or mesenteric vasculitis usually produces bowel-wall oedema, target and comb signs, mesenteric inflammation and ascites rather than an isolated duodenal defect. Serositis may cause pain and ascites but not extraluminal gas. Benign postoperative pneumoperitoneum is excluded by the absence of a recent intervention. Pancreatitis does not explain a focal bowel-wall defect or free intraperitoneal gas.

Reference: Electronic Medicines Compendium. Prednisolone 5 mg soluble tablets, Summary of Product Characteristics, sections 4.4 and 4.8. Revised 1 June 2026. https://www.medicines.org.uk/emc/product/102342/smpc