A retrospective survey of elderly patients admitted with perforation of a duodenal ulcer showed that some presented with typical symptoms and signs of a perforation, while others presented as a gastro-intestinal bleed or with confusion or malaise. Diagnosis tended to be delayed in the latter group and mortality was higher. Earlier diagnosis may be helped by taking a chest radiograph or lateral decubitus films of the abdomen with a repeat film in a few hours if the diagnosis is still being considered.