2Beginning DataMale, 45 year oldChief Complain: Severe Abdominal Pain
3History of Present Illness Crampy, epigastric painRelieved by food intake or antacidsMelenaUGI endoscopy: Erosive GastritisUnrecalled medications3 years PTAEpigastric painMelenaSelf‐medicated: Omeprazole1 year PTA
4History of Present Illness A few hoursPTASevere epigastric painADMISSION
5Past Medical History(-) HPN (-) DMFamily History(-) Cancer
6Personal History 10 pack‐years smoking Drinks alcoholic beverage for 8 years
7Physical Examination Conscious, coherent, in distress BP= 140/90, PR= 105/min, RR=26/min ,T= 37.8 CWarm moist skin, no active dermatosesPink palpebral conjunctivae, anicteric scleraeHeart and Lungs: regular rate and rhythm, clear breath soundsAbdomen : flat, hypoactive bowel sounds, guarding and tenderness on all quadrantsDRE: brown stool on tactating finger
9Salient Features Pertinent Objective PR= 105/min, RR=26/min Abdomen : flat, hypoactive bowel sounds, (+) guarding and tenderness on all quadrantsDRE: brown stool on tactating fingerPertinent SubjectiveMale, 45 y/oCrampy, epigastric painRelieved by food intake or antacidsMelenaUGI endoscopy: Erosive Gastritis10 pack‐years smokingDrinks alcoholic beverage for 8 years
12Initial Diagnostic Measures for Perforated PUD Upright CXR or lateral abdominal decubitus radiography.Upper GI contrast study with water soluble contrast.
13Initial 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.
15Surgical TherapySurgery is recommended in patients who present with the following:Hemodynamic instabilitySigns of peritonitisFree extravasation of contrast on upper GI contrast studies
16Preoperative Management Fluid resuscitationNGT insertionInsertion of Foley catheterBroad-spectrum antibiotics
17Intraoperative Details Exploratory Laparotomylife-threatening, comorbid conditions & severe intraabdominal contamination Graham patch using omentumSeveral full-thickness simple sutures are placed across the perforationA segment of omentum is placed over the perforation & silk sutures are secured.
19Intraoperative details Minimal contamination, stable patienthighly selective vagotomytruncal vagotomy and pyloroplastyvagotomy and antrectomy.
20Postoperative 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 infectionantibiotic regimenFollow-up with an upper endoscopy to evaluate the area of ulcer and healing of the perforation site 4-6 weeks after surgery.
21Possible 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 obstructionRecurrent peptic ulcer
22Laparoscopic Surgery in Peptic Perforation Closure Comparative Study Of Laparoscopic Versus Open Peptic Perforation ClosureJanuary 2008M.M. Porecha M.S., et. al.M.P. Shah Medical College and G.G. Hospital, Jamnagar India
23Laparoscopic 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
24Laparoscopic Surgery in Peptic Perforation Closure Study:non – randomized and prospectivecomparative study50 patients with peptic perforated ulcer25 – 43 years old25 patients – open repair25 patients - laparoscopic
26Conclusionlaparoscopic suture with omental patch repair is an attractive and superior alternative to conventional surgery with extraordinary benefits of minimal invasive surgery such asShorter 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.
28RISKSElderly, chronically ill, and are taking one or more ulcerogenic drugsMean age is >60 y.o.History of ulcer disease or symptoms of an ulcer is importantone-third of patients had a history of PUD32% of patients who presented with perforation were taking H2 blockers, antacids, or bothHistory of smoking, alcohol abuse, and postoperative stress
29COMPLICATIONSGastric and duodenal contents may leak into the peritoneumGastric and duodenal secretions, bile, ingested food, and swallowed bacteriaPeritonitisIncreased risk of infection and abscess formationThird-spacing of fluid in the peritoneal cavityInadequate circulatory volume, hypotension, and decreased urine output
30COMPLICATIONS More severe cases shock Abdominal distension as a result of peritonitis and subsequent ileusMay interfere with diaphragmatic movement, impairing expansion of the lung bases Atelectasis