[12] Perforated Peptic Ulcer Flashcards
What kind of PU most commonly perforates?
DU
Why are DUs the most common PU to perforate?
Because the first part of the duodenum has the highest acid concentration
What might an anterior perforation of a DU lead to?
Air under the diaphragm
What might a posterior perforation of a DU lead to?
Can erode into gastroduodenal artery, leading to bleed
What proportion of the duodenum is retroperitoneal?
3/4
Is there air under the diaphragm if a DU perforates in a retroperitoneal part of the duodenum?
No
How do perforated peptic ulcers present?
Sudden onset severe pain, beginning in epigastrum then becoming generalised
Vomiting
Peritonitis
What are the differential diagnoses for perforated peptic ulcers?
Pancreatitis
Acute cholecystitis
AAA
MI
How are perforated peptic ulcers investigated?
Bloods
Urine dipstick
Imaging
What bloods are done in perforated peptic ulcer?
FBC U&E CRP G&S Clotting
When is an ABG required in perforated peptic ulcers?
If there is ?mesenteric ischaemia
What imaging is done in perforated peptic ulcers?
Erect CXR
AXR
How long must a patient be standing before taking an erect CXR?
15 mins
What % of patients with perforated peptic ulcers will have air under the diaphragm on erect CXR?
70%
What might give a false positive on erect CXR?
Chailadti’s sign
What might be seen on AXR in perforated peptic ulcers?
Rigler’s sign
What is Rigler’s sign?
Air on both sides of bowel wall
What are the options in management of perforated peptic ulcers?
Conservative
Surgical
What is involved in resuscitation in perforated peptic ulcers?
NBM Aggressive fluid resuscitation Analgesia Abx NGT
What analgesia is given in perforated peptic ulcers?
Morphine 5-10mg/2hour max, with or without cyclizine
How is fluid balance monitored in perforated peptic ulcers?
Urinary catheter, maybe a CVP line
What Abx may be given in perforated peptic ulcers?
Cef and met
When might conservative management of perforated peptic ulcers be considered?
If the patient isn’t peritonitic
What is involved in the conservative management of perforated peptic ulcers?
Careful monitoring
Fluids
Antibiotics
What makes conservative management for perforated peptic ulcers possible?
The omentum may seal the perforation spontaneously, preventing operation
What technique is used in the surgical management of perforated peptic ulcers?
Laparotomy
How is a perforated DU managed surgically?
Abdominal washout and omental patch repair
How is a perforated GU surgically repaired?
Excise ulcer and repair defect
What surgical option may rarely be required in perforated PU?
Partial or complete gastrectomy
What should be done if a gastrectomy is performed for perforated PU?
Send specimen for histology to exclude cancer
What % of perforated PUs are associated with H. Pylori infection?
90%
