Learning points:
The case of Mr CC provided a number of interesting learning points.
This is a rare presentation for junior surgical trainees, but well known to senior surgeons.
As in most surgical diagnoses, history, examination and simple blood tests revealed the diagnosis.
Recent dyspepsia symptoms and increased alcoholic intake on holiday provided clues to the diagnosis
The lack of air under the diaphragm on the chest radiograph is unusual, occurring in only 10% of cases.
Optimal management would have included a CT scan on admission as well as earlier surgical intervention. However, whilst this would have prevented an uncomfortable night on the ward for the patient, delayed laparotomy is not felt to increase mortality.
The chest infection could be attributed to a splinting of the diaphragm secondary to peritonitis.
Adequate resuscitation and early diagnosis enable a positive outcome in this patient.

Further Reading:

Surgical management of perforated duodenal ulcer: the changing scene.
The West Indian medical journal, Dec 2004, vol. 53, no. 6, p. 378-81.
Plummer-J-M, McFarlane-M-E-C, Newnham.

Laparoscopic and endoscopic management of perforated duodenal ulcers.
Journal of the American College of Surgeons, Mar 2004, vol. 198, no. 3, p. 352-5.
Malkov-Igor-S, Zaynutdinov-A-M, Veliyev-N-A, Tagirov-Marat-R, Merrell-Ronald-C.

Changing trend in emergency surgery for perforated duodenal ulcer.
Journal of the College of Physicians and Surgeons--Pakistan, Dec 2003, vol. 13, no. 12, p. 708-10, Gürleyik-Emin.

Current practice of emergency vagotomy and Helicobacter pylori eradication for complicated peptic ulcer in the United Kingdom.
The British journal of surgery, Jan 2003, vol. 90, no. 1, p. 88-90,
Gilliam-A-D, Speake-W-J, Lobo-D-N, Beckingham-I-J.

Epidemiology of duodenal ulcer perforation: a study on hospital admissions in Norfolk, United Kingdom.
Digestive and liver disease, May 2002, vol. 34, no. 5, p. 322-7,Canoy-D-S, Hart-A-R, Todd-C-J.

Effect of Helicobacter pylori eradication on the ulcer recurrence rate after simple closure of perforated duodenal ulcer: retrospective and prospective randomized controlled studies.
The British journal of surgery, Aug 2001, vol. 88, no. 8, p. 1054-8,
Kate-V, Ananthakrishnan-N, Badrinath-S.
Simple closure or vagotomy and pyloroplasty for the treatment of a perforated duodenal ulcer: comparison of results.
Digestive surgery, 2000, vol. 17, no. 3, p. 225-8.
Gutiérrez-de-la-Peña-C, Márquez-R, Fakih-F, Domínguez-Adame-E, Medina-J.