Perforated peptic ulcer

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1 Perforated peptic ulcer - Despite the widespread use of gastric anti-secretory agents and eradication therapy, the incidence of perforated peptic ulcer has changed little, age limits increase NSAIDs elderly Anterior d.u& incisura g.u most common perforate Clinical features History of peptic ulceration sudden-onset, severe generalized abdominal pain as a result of the irritant effect of gastric acid on the peritoneum bacterial peritonitis supervenes over a few hours patient may be shocked with a tachycardia abdomen exhibits a board-like rigidity The abdomen does not move with respiration Very frequently, the elderly patient who is taking NSAIDs will have a less dramatic presentation, board-like rigidity not observed Difficult diagnosis: potent analgesic effect of NSAID Small perforation Posterior g,u perforation to lesser sac Sealed perforation Diabetic patient(silent) Investigations An erect plain chest radiograph will reveal free gas under the diaphragm in more than 50% of cases CT scan imaging is more accurate S.amylase to distinguish from pancreatitis Treatment resuscitation and analgesia Laparotomy P a g e 1

2 thorough peritoneal toilet to remove all of the fluid and food debris Duodenal perf. it can usually be closed by several well-placed sutures, closing the ulcer in a transverse direction omental patch =leak sealing Massive duodenal or gastric perforation=billroth II gastrectomy Gastric ulcers should, if possible, be excised and closed, so that malignancy can be excluded definitive procedures TV+PP or HSV: in well-selected patients and in expert hands this is a very safe strategy Minimally invasive techniques if the expertise is available Anti h. pylori + ppi post op. Conservative management of perforated ulcer - Patients with a delayed presentation (i.e. greater than 24 hours) and extensive co-morbid factors. - In patients who are hemodynamically stable with minimal abdominal symptoms Causes of upper gastrointestinal bleeding Condition Incidence (%) Ulcers 60 - Esophageal 6 - Gastric 21 - Duodenal 33 Erosions 26 - Esophageal 13 - Gastric 9 - Duodenal 4 Mallory Weiss tear 4 Esophageal varices 4 Tumor 0.5 Vascular lesions, e.g. Dieulafoy s disease 0.5 Others 5 P a g e 2

3 Bleeding peptic ulcers - In recent years, the population affected has become much older and the bleeding is commonly associated with the ingestion of NSAIDs - The three cardinal principles in the management are: 1- Vigorous resuscitation of the initial bleed to restore hemodynamic stability, followed by monitoring for re-bleeding and appropriate resuscitation if this should occur. 2- Prompt investigation to establish the cause. 3- Institution of appropriate measures to arrest bleeding and prevent further hemorrhage. - Upper gastrointestinal endoscopy should be carried out by an experienced operator - In patients in whom the bleeding is relatively mild, endoscopy may be carried out on the morning after admission. - In all cases of severe bleeding it should be carried out immediately Medical and minimally interventional treatments - proton pump antagonist - tranexamic acid, an inhibitor of fibrinolysis, reduces the re-bleeding rate - injection of the bleeding ulcer with adrenaline or sclerosant, - laser photocoagulation - coagulation with bipolar diathermy Surgical treatment - if bleeding persists, or recurs despite endoscopic intervention surgery, should attempted - factors which should encourage surgical intervention A large vessel, visible in the ulcer base a major initial bleed, a re-bleed in hospital advanced age Patient who has required more than 6 units - The aim of the operation is to stop the bleeding - The most common site of bleeding from a peptic ulcer is the duodenum P a g e 3

4 - the duodenum, and usually the pylorus, are opened longitudinally - bleeding controlled by using well-placed sutures that under-run the vessel - Pyloroplasty is then closed with interrupted sutures in a transverse direction - Bleeding G.U same line +biopsy or excision - Definitive acid lowering surgery is not now required - very large ulcer eroding into a major branch of the left gastric artery may necessitate a subtotal gastrectomy incorporating the ulcer GASTRIC OUTLET OBSTRUCTION - gastric outlet obstruction should be considered malignant until proven otherwise - Clinical features In benign gastric outlet obstruction there is usually a long history of peptic ulcer disease pain may become unremitting and in other cases it may largely disappear vomitus is characteristically unpleasant in nature and is totally lacking in bile, recognize foodstuff taken several days previously Examination wt loss, unwell look, dehydrated Succession splash +ve - Metabolic effects - Acid loss - hypochloraemic alkalosis - initially, sodium and potassium levels may be relatively normal - Initially, the urine has a low chloride and high bicarbonate content - Progressive hyponatremia - Dehydration - Na retention - Potassium and hydrogen are excreted - Urine becoming paradoxically acidic - hypokalemia P a g e 4

5 Management - aim correcting the metabolic abnormality dealing with the mechanical problem intravenous isotonic saline with potassium Supplementation stomach should be emptied using a wide-bore gastric tube.+ lavage the stomach - Investigation FBC,s. electrolyte, Endoscopy biopsy to exclude malignancy. Contrast radiology - Treatment an anti-secretory agent, initially given intravenously severe cases are treated surgically, usually with a gastroenterostomy rather than a pyloroplasty Endoscopic treatment with balloon dilatation has been practised and may be most useful in early case Causes of gastric outlet obstruction - Ca stomach - Peptic ulcer - Adult pyloric stenosis - Pyloric mucosal diaphragm Intractability/Non-healing - rare indication for operation nowadays Surgical treatment should be considered in patients with - non-healing or intractable peptic ulcer who have multiple recurrences, - Large ulcers (>2 cm), - complications (obstruction, perforation or hemorrhage), or - suspected gastric cancer Done by: #MOHDZ Dr.Loay Surgery P a g e 5

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