Beginning Data Male, 45 year old Chief Complain: Severe Abdominal Pain
History of Present Illness 3 years PTA Crampy, epigastric pain Relieved by food intake or antacids Melena UGI endoscopy: Erosive Gastritis Unrecalled medications 1 year PTA Epigastric pain Melena Self ‐ medicated: Omeprazole
A few hours PTA Severe epigastric pain ADMISSION History of Present Illness
Past Medical History (-) HPN (-) DM Family History (-) Cancer
Personal History 10 pack ‐ years smoking Drinks alcoholic beverage for 8 years
Physical Examination Conscious, coherent, in distress BP= 140/90, PR= 105/min, RR=26/min,T= 37.8 C Warm moist skin, no active dermatoses Pink palpebral conjunctivae, anicteric sclerae Heart and Lungs: regular rate and rhythm, clear breath sounds Abdomen : flat, hypoactive bowel sounds, guarding and tenderness on all quadrants DRE: brown stool on tactating finger
Initial Diagnostic Measures for Perforated PUD Upright CXR or lateral abdominal decubitus radiography. Upper GI contrast study with water soluble contrast.
Initial Therapeutic Measures for Perforated PUD Fluid resuscitation with replacement of fluid and electrolytes. Nasogastric decompression. Administer broad spectrum antibiotics. Insert Foley catheter. Insert central venous line or Swan-Ganz artery catheter.
Intraoperative Details Exploratory Laparotomy life-threatening, comorbid conditions & severe intraabdominal contamination Graham patch using omentum Several full-thickness simple sutures are placed across the perforation A segment of omentum is placed over the perforation & silk sutures are secured.
Intraoperative details Minimal contamination, stable patient highly selective vagotomy truncal vagotomy and pyloroplasty vagotomy and antrectomy.
Postoperative Details NGT can be discontinued on postoperative day 2 or 3, depending on the return of GI function, and diet can be slowly advanced. H. pylori infection antibiotic regimen Follow-up with an upper endoscopy to evaluate the area of ulcer and healing of the perforation site 4-6 weeks after surgery.
Possible Complications Pneumonia (30%) Wound infection, abdominal abscess (15%) Cardiac problems (especially in those >70 y) Diarrhea (30% after vagotomy) Dumping syndromes (10% after vagotomy and drainage procedures) Gastric outlet obstruction Recurrent peptic ulcer
RISKS Elderly, chronically ill, and are taking one or more ulcerogenic drugs Mean age is >60 y.o. History of ulcer disease or symptoms of an ulcer is important one-third of patients had a history of PUD 32% of patients who presented with perforation were taking H 2 blockers, antacids, or both History of smoking, alcohol abuse, and postoperative stress
COMPLICATIONS Gastric and duodenal contents may leak into the peritoneum Gastric and duodenal secretions, bile, ingested food, and swallowed bacteria Peritonitis Increased risk of infection and abscess formation Third-spacing of fluid in the peritoneal cavity Inadequate circulatory volume, hypotension, and decreased urine output
COMPLICATIONS More severe cases shock Abdominal distension as a result of peritonitis and subsequent ileus May interfere with diaphragmatic movement, impairing expansion of the lung bases Atelectasis