Perforated PUD

Question 1

Perforated PUD

Answer 1

peptic ulcer erodes wall of stomach or duodenum at a point where it covered only by visceral peritoneum — acid gastric juice enter peritoneal cavity — chemical peritonitis

Question 2

symptoms of perforated PUD

Answer 2

• sudden severe and constant pain (begin in epigastrium and gradually extend to involve for the whole abdomen)
• all movement including respiration make the pain worse causing patient lie immobile

Question 3

PE of perforated PUD

Answer 3

• look ill and obviously in pain, lying completely still
• tachycardia
• respiration is shallow
• temperature is usually normal

Question 4

Abdominal examination of perforated PUD

Answer 4

Inspection

• abdomen is flat and does not rise and fall with respiration
• abdominal muscles can be seen tightly contracted

Palpation

• tenderness and guarding confined to epigastrium and right side but eventually the entire peritoneal cavity is contaminated
• board-like rigidity
• no intraabdominal viscus or masses

Percussion

• painful
• liver dullness may be diminished or completely absent
• free fluid

Auscultation
- bowel sound disappear once generalized peritonitis

Rectal examination
- pelvic tenderness

Question 5

Investigation of perforated PUD

Answer 5

• FBC
• coagulation profile: baseline investigation
• serum amylase and urinalysis: TRO pancreatitis (serum amylase is reliable only within 14 hours onset of pain)
• RFT
• LFT: to differentiate between variceal and non-variceal bleeding (variceal bleeding: derangement due to chronic liver insufficiency)

Question 6

Imaging of perforated PUD

Answer 6

• CXR: to look for air under diaphragm

* if no air under diaphragm–> CT scan (detection of free intraperitoneal gas)

Question 7

Management of perforated PUD

Answer 7

• stabilise
• NBM
• NG tube: decompress stomach and prevent vomiting
• IV drip
• painkiller
• pantoprazole
• GXM
• laparotomy and repair (suturing omental plug to seal perforation together with lavage of peritoneal cavity)