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

AlonzoAmaroAmolenda

AnactaAndal

Beginning Data

Male 45 year old Chief Complain Severe Abdominal Pain

History of Present Illness

3 years PTA

bull Crampy epigastric painbull Relieved by food intake or antacidsbull Melenabull UGI endoscopy Erosive Gastritisbull Unrecalled medications

1 year PTA

bull Epigastric pain bull Melena bull Self‐medicated Omeprazole

A few hours PTA

bull Severe epigastric pain

ADMISSION

History of Present Illness

Past Medical History

(-) HPN

(-) DM

Family History

(-) Cancer

Personal History

bull 10 pack‐years smoking bull Drinks alcoholic beverage for 8 years

Physical Examination Conscious coherent in distress BP= 14090 PR= 105min RR=26min T=

378 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 1057303

guarding and tenderness on all quadrants DRE brown stool on tactating finger

Salient FeaturesPertinent Subjective

Male 45 yo 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

bull PR= 105min RR=26min

bull Abdomen flat hypoactive bowel sounds (+) guarding and tenderness on all quadrants

bull DRE brown stool on tactating finger

Clinical Impression

Peptic Perforation

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

Surgical Therapy

Surgery is recommended in patients who present with the followingHemodynamic instabilitySigns of peritonitisFree extravasation of contrast on upper GI

contrast studies

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

Intraoperative Details

Exploratory Laparotomy life-threatening comorbid conditions amp

severe intraabdominal contamination Graham patch using omentumSeveral full-thickness simple sutures are

placed across the perforation A segment of omentum is placed over the

perforation amp silk sutures are secured

OMENTAL PATCH

Intraoperative details

Minimal contamination stable patienthighly selective vagotomytruncal vagotomy and pyloroplastyvagotomy 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 infectionantibiotic 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 gt70 y) Diarrhea (30 after vagotomy) Dumping syndromes (10 after vagotomy

and drainage procedures) Gastric outlet obstruction Recurrent peptic ulcer

Andal Charlotte

RISKS Elderly chronically ill and are taking one

or more ulcerogenic drugsMean age is gt60 yo

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 both

History of smoking alcohol abuse and postoperative stress

COMPLICATIONS Gastric and duodenal contents may leak

into the peritoneumGastric and duodenal secretions bile ingested

food and swallowed bacteria

PeritonitisIncreased risk of infection and abscess

formation Third-spacing of fluid in the peritoneal

cavityInadequate circulatory volume hypotension and

decreased urine output

COMPLICATIONS

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