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Alonzo.Amaro.Amolenda Anacta.Andal. Beginning Data  Male, 45 year old  Chief Complain: Severe Abdominal Pain.

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Presentation on theme: "Alonzo.Amaro.Amolenda Anacta.Andal. Beginning Data  Male, 45 year old  Chief Complain: Severe Abdominal Pain."— Presentation transcript:

1 Alonzo.Amaro.Amolenda Anacta.Andal

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

3 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

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

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

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9 Salient Features 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 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

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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.

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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

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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

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 H 2 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


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