Perforated Ulcer Flashcards
X-ray to order if suspected perforated ulcer
Erect chest X-ray
Surgical name for air under the diaphragm
Pneumoperitoneum
Explain to examiner what u see on a erect chest X-ray showing air under diaphragm
This is an erect chest X-ray showing a pneumoperitoneum
You can see free intra abdominal air under the hemidiaphragm
This may be caused my a perforated viscus (E.g. peptic ulcer)
Treatment is an omental patch
Causes of pneumoperitoneum
Perforated duodenal ulcer - due to prolonged NSAIDs
Perforated gastric ulcer - due to prolonged NSAIDS and marijuana use
Ruptured diverticulum- risk with increased age and history of smoking
Ruptured lower end of esophagus- due to prior history of GERD, excessive vomiting and drinking (alcoholism)
Ruptured appendix- presents with abdominal pain
The area of the duodenum that perforates is the _______ aspect or surface of the ________ of the duodenum
First
Anterior wall
Why does it perforates on the anterior wall
Has the highest acid concentration
Presented of patient with a perforated ulcer
Sudden onset, severe abdominal pain
Pain may refer to shoulder tip (kehr’s sign)
Vomiting leading to dehydration
Patient will be in shock ( tachycardic, tachypneic, hypotensive)
Guarding and rebound tenderness-board like rigidity elicited on examination
% of perforated duodenal ulcers have air under the diaphragm
70-90%
Clinically how can you tell it is a perforated ulcer
Air injected into stomach through NG tube to demonstrate pneumoperitonuem
Loss of liver dullness to percussion
Upper GI endoscopy
Gastrografin In X-ray
Blood Investigations for a perforated ulcer
CBC RFT ABG AMYLASE GROUP AND CROSS
Imagining investigations for perforated ulcer
- Erect chest X-ray
- Upper GI series with water soluble contrast (gastrograffin)
Bloods and imagining done, Any other investigations?
Nasogastric air insufflation if no pneumoperitoneum but perforation suspected.
13C breath test for H pylori
Prep patient with perforated ulcer for surgery as the his intern.
- IV access with 2 large bore peripheral IVs : fluid resuscitate to restore intravascular vol ( ringers lactate 3L/24hrs ) and electrolyte repletion
- Monitor vitals q4hrly: RR, pulse, BP, PO2
- NGT- to decompress the stomach
- Urinary Catheter: to monitor input/output
- Adequate analgesics: morphine 0.1mg/kg (for pain relief)
- Antibiotics therapy: IV cefitaxone 1g bd and IV metronidazole 500mg tds- to decrease risk of infection
- Administer proton pump inhibitors: Esomeprazole (protects the stomach mucosa from acids )
- consent the patient for surgery
Which operation you propose your senior resident will be doing ?
Omental patch
3 lines explain what would be happening in the theater room ( operation of a perforated ulcer)
- inspect stomach, identify duodenal perforation and an adequate size tension free patch of omental is used to cover the perforation
- omental patch is secured using 3 sutures through healthy duodenum on either side of the perforation.
- Leak test done and peritoneal cavity irrigated with saline solution to prevent contamination.
Post op what antibiotics would you send home patient with
Metronidazole, amoxicillin and clarithromycin
Operation for recurrent perforated ulcer despite taking meds
Selective vagotomy + partial gastrectomy + drainage procedure (gastroduodenostomy)
Additional procedures:
- Truncal vagotomy + pyloroplasty
- Highly selective vagotomy
Ulcer erodes posterior lay what happens to the patient
Massive upper and lower GI bleed
Name of two ulcers presenting at the same time
Kissing ulcer
Causes that can lead to peptic ulcer disease which can then lead to getting a perforated ulcer
- prolonged used of NSAIDS
- prolonged used of steroids
- Marijuana and cocaine use
- H.pylori infection
- Zollinger-Ellison syndrome
Chronic scarring of the pyloric region due to PUD lead to long term and what other pathology might cause the same effect
Gastric outlet obstruction
Gastric cancer
What other two lesions can H pylori cause other than PUD
MALT lymphoma
Gastric adenocarcinoma
Loop of bowel under the diaphragm is called what sign
What are the causes ?
Is it presents with abdominal pain then what is it called ?
Chilaiditi sign
Chronic disease - such as in lung and liver
Chilaiditi s syndrome
Perforation clinical signs
Kehr’s sign - shoulder tip pain Hypovolemia Severe pain Tachycardic Tachypnea Guarding and rebound tenderness- board like rigidity
