Perforated PU

Question 1

A 50-year-old- male, smoker with a long history of NSAIDs use for osteoarthritis, presented at A&E with acute onset abdominal pain in the epigastrium. On examination there was abdominal tenderness, rigidity and infrequent bowel sounds.

Q1: What’s the most probable diagnosis?

Answer 1

Based on Hx of using NSAIDS + finding of examination – > perforatee GASTRIC/DUODENAL UCLER
X-ray was done.

Question 2

Q2: Can you please comment on it

Answer 2

Radiographic of chest and upper GI
I’ll look for the name, age of pt and date of it
Pathology is air under diaphragm in the rt side.

Question 3

Q3: What’re the risk factors for perforation of a peptic ulcer?

Answer 3

using NSAIDS, previous PU, using of steroids, heavy smoking and malignancy

Question 4

Q4: How can the use of NSAIDs promotes ulcer perforation?

Answer 4

Inhibition of PG. Synthesis which inhibit cox-1
Topical irritation of epithelium
Impraiment of the barriers of mucosa
Reduction of blood flow to mucosa
Interference with repaiof superficial mucosal injuries

Question 5

Q5: How would you manage this patient intially? What would be your definitive treatment?

Answer 5

According to CCRISP protocol
NPO / PPI / IV FLUIDS / ANALGESIC
Invx; CT with contrast
Management; I will take patient to theatre for exploration either open or lap
In surgery will do omental patch repair, good peritoneal toilet and take sample for biopsy
..

Question 6

Q6: Do you know the meaning of NCEPOD? How would you classify this operation according to it?
National confidential query of pt outcome and death.
Urgent classification
Others
- immediate mins (life thereat like Rapture AAA)
- urgent 6 hours (perforated PU)
- Expedited during days like tendon or nerve injury
- elective (planned like cholecystectomy)

Answer 6

National confidential query of pt outcome and death.
Urgent classification
Others
- immediate mins (life thereat like Rapture AAA)
- urgent 6 hours (perforated PU)
- Expedited during days like tendon or nerve injury
- elective (planned like cholecystectomy)

Question 7

Q7: What medication would you give this patient postoperatively?

Answer 7

Long term PPI and eradication therapy for H.pylori

Question 8

Q8: How does PPIs work?

Answer 8

Binding irreversible to H-Ka ATPase pump on preital cells prevent gastric acid secretion

Question 9

Q9: What are the physiological actions of gastric HCL?

Answer 9

Work as antimicrobial
Conversion of pipsenogen to pepsen
Stimulate small intestine to secreat sercretin
Promote absorption of iron, Ca.

Question 10

Q10: Can you explain the physiological process by which gastric HCL is released?

Answer 10

3 phases of gastric secretion
CHEPALIC Phase
Vegal stimulation to release HCL and gastrin
GASTRIC PHASE
Stomach destined and low hydrogen will Cause gastrin release responsible for 60% of gastric acid release
Intestinal phase