1. Alonzo.Amaro.Amolenda Anacta.Andal
Acute Abdominal Pain

2. Beginning Data
Male, 45 year old
Chief Complain: Severe Abdominal Pain

3. History of Present Illness
Crampy, epigastric pain
Relieved by food intake or antacids
Melena
UGI endoscopy: Erosive Gastritis
Unrecalled medications
3 years PTA
Epigastric pain
Melena
Self‐medicated: Omeprazole
1 year PTA

4. History of Present Illness
A few hours
PTA
Severe epigastric pain
ADMISSION

5. Past Medical History
(-) HPN (-) DM
Family History
(-) Cancer

6. Personal History 10 pack‐years smoking
Drinks alcoholic beverage for 8 years

7. 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

9. Salient Features Pertinent Objective PR= 105/min, RR=26/min
Abdomen : flat, hypoactive bowel sounds, (+) guarding and tenderness on all quadrants
DRE: brown stool on tactating finger
Pertinent Subjective
Male, 45 y/o
Crampy, epigastric pain
Relieved by food intake or antacids
Melena
UGI endoscopy: Erosive Gastritis
10 pack‐years smoking
Drinks alcoholic beverage for 8 years

11. Clinical Impression
Peptic Perforation

12. Initial Diagnostic Measures for Perforated PUD
Upright CXR or lateral abdominal decubitus radiography.
Upper GI contrast study with water soluble contrast.

13. 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.

14. TREATMENT PLAN

15. Surgical Therapy
Surgery is recommended in patients who present with the following:
Hemodynamic instability
Signs of peritonitis
Free extravasation of contrast on upper GI contrast studies

16. Preoperative Management
Fluid resuscitation
NGT insertion
Insertion of Foley catheter
Broad-spectrum antibiotics

17. 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.

18. OMENTAL PATCH

19. Intraoperative details
Minimal contamination, stable patient
highly selective vagotomy
truncal vagotomy and pyloroplasty
vagotomy and antrectomy.

20. 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.

21. 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

22. Laparoscopic Surgery in Peptic Perforation Closure
Comparative Study Of Laparoscopic Versus Open Peptic Perforation Closure
January 2008
M.M. Porecha M.S., et. al.
M.P. Shah Medical College and G.G. Hospital, Jamnagar India

23. Laparoscopic Surgery in Peptic Perforation Closure
Objective:
To evaluate safety & efficacy of laparoscopoic repair for perforated peptic ulcer in routine clinical practice.
To evaluate whether it is justifiable to perform laparoscopic peptic perforation closure and to find out and evaluate whether it can stand against conventional laparotomy to treat peptic perforation.
To evaluate whether laparoscopic peptic perforation closure is better than conventional laparotomy for peptic perforation closure in terms of benefits of minimal invasive surgery

24. Laparoscopic Surgery in Peptic Perforation Closure
Study:
non – randomized and prospectivecomparative study
50 patients with peptic perforated ulcer
25 – 43 years old
25 patients – open repair
25 patients - laparoscopic

26. Conclusion
laparoscopic suture with omental patch repair is an attractive and superior alternative to conventional surgery with extraordinary benefits of minimal invasive surgery such as
Shorter operative time and reduced postoperative pain.
Lesser requirement of nasogastric aspiration and lesser wound infection.
Lesser blood loss and lesser transfusion requirement.
Shorter hospital stay and early rehabilitation.
Earlier resumption of oral feeding and lesser antibiotic requirement.
Lesser occurrence of incisional hernia and burst abdomen and lesser occurrence of pelvic abscess.
Earlier return to normal physical activity and earlier return to work.

27. Andal, Charlotte
RISKS/COMPLICATIONS

28. 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 H2 blockers, antacids, or both
History of smoking, alcohol abuse, and postoperative stress

29. 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

30. 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