36. Perforated peptic ulcer disease.

Question 1

Perforated peptic ulcer disease - Epidemiology

Answer 1

• occurs in males more than females at a ratio of 12:1-20:1

Question 2

Perforated peptic ulcer disease - Etiology

Answer 2

• NSAIDs – responsible for most perforations
• Most perforations occur b/w meals on empty stomach
• Free perforation: when duodenal gastric contents spill freely into ab cavity diffuse peritonitis
  o 90% of perforated DU occur in ant. duodenal bulb (ant wall is thin + free)
  o 60% in lesser curvature
  o 40% throughout

Question 3

Perforated peptic ulcer disease - Pathology:

Answer 3

• Perforation occurs when an anteriorly/laterally placed ulcer erodes through the full thickness of the wall of duodenum into peritoneal cavity spilling acid peptic juice, bile + pancreatic juice
• Ulcer at lesser curvature – perforates into greater sac
• Ulcer at post wall – perforates into lesser sac

Question 4

Perforated peptic ulcer disease - Pathology Types

Answer 4

o Acute perforation
 Stage 1: PU perforates, acid peptic juice, bile, pancreatic juice come into general pancreatic cavity. This stage is called “stage of peritoneum” – pt in severe pain – Hippocratic face
 Stage 2: peritoneum reacts to it by secreting peritoneal fluid copiously – this gives for short time. Stage of reaction = 3-6hrs
 Stage 3: this stage then is diffuse bact-peritonitis “stage of peritonitis” – 12hrs after perforation

o Subacute perforation
 “leaking peptic ulcer” – circumscribed area of peritoneal cavity becomes contaminated by leakage

o Chronic perforation
 Ulcer perforates but area is walled off by adhesion or by viscera such as liver, colon

Question 5

Perforated peptic ulcer disease - Clinical Presentation

Answer 5

Pain = duodenal ulcer = ½ after eating

• Epigastric ulcer = pain is continuous + increasing
• Hippocratic face = peritonitis pain
• Bloomberg sign
• Silent abdomen with no bowel sounds

Question 6

Perforated peptic ulcer disease - Diagnostic Investigations

Answer 6

• Increased WBC, increased serum amylase. Dx on physical examination
• Aspiration of peritoneal cavity= bile stained fluid
• Gastroscopy = contraindicated – causes shock from intestine pain
• Gastrogratin – soluble contrast. Do not use barium
• CXR = free gas under right cupula of diaphragm
• CT imaging more accurate

Question 7

Perforated peptic ulcer disease - Treatment

Answer 7

• Surgery = suture of perforation – laporoscopic

- Abx – pre + post op