SEMESTER 4
INDIVIDUAL ASSIGNMENT
SUBJECT CODE:
ID: SD01-201704-002565
DEFINITION
Perforated ulcer disease is defined as an ulcer occuring in a region that touches gastric
acid and pepsin and usually refers to gastric ulcer or duodenal ulcer.Ulcers average between
one-quarter and one-half inch indiameter. They develop when digestive juices produced inthe
stomach, intestines, and digestive glands damage thelining of the stomach or duodenum. Gastric and
duodenal ulcers are two kinds of peptic ulcers. A peptic ulcer is a sore that’s on the inside of
the stomach lining (gastric) or the upper part of the small intestine (duodenal).A person can
have one or both ulcers at the same time. Having both types is known as gastroduodenal.
PATHOPHYSIOLOGY
DIAGNOSTIC
Blood test: The presence of certain infection-fighting cells could mean you have an
H. pylori infection.
Stool culture: A stool sample is sent for lab testing. H. pylori bacteria will grow over
the course of a few days, if present.
Urea breath test: A urea breath test involves swallowing a pill that contains carbon
and breathing into a bag that’s sent to a lab. High levels of carbon dioxide can
indicate presence of H. Pylori.
An esophagogastroduodenoscopy (EGD): a form of endoscopy, also known as
a gastroscopy, is carried out on people in whom a peptic ulcer is suspected
TREATMENT
1.Younger people with ulcer-like symptoms are often treated with antacids or H2
antagonists before endoscopy is undertaken.
2.People who are taking nonsteroidal anti-inflammatories (NSAIDs) may also be prescribed
a prostaglandin analogue (misoprostol) in order to help prevent peptic ulcers.
3.Acid reducing medication:H2 antagonists or proton-pump inhibitors decrease the amount of acid in
the stomach, helping with healing
PROTON PUMP INHIBITORS DRUG :Drug that block acid production and promote healing of ulcer
Acid reducers, also called H2 blockers, reduce acid production and relieve ulcer pain.
Cimetidine (Tagamet)
Ranitidine (Zantac)
Famotidine (Pepcid)
Nizatidine (Axid)
4.Antibiotic
When H. pylori infection is present, the most effective treatments are combinations of 2
antibiotics (e.g. clarithromycin, amoxicillin, tetracycline, metronidazole) and a proton-pump
inhibitor (PPI), sometimes together with a bismuth compound. In complicated, treatment-
resistant cases, 3 antibiotics (e.g. amoxicillin + clarithromycin + metronidazole) may be used
together with a PPI and sometimes with bismuth compound. An effective first-line therapy for
uncomplicated cases would be amoxicillin + metronidazole + pantoprazole .
5.Surgery
Perforated peptic ulcer is a surgical emergency and requires surgical repair of the perforation.
Most bleeding ulcers require endoscopy urgently to stop bleeding with cautery, injection,
or clipping.
Laparoscopy
Laparoscopy allows the surgeon to explore and wash out the entire peritoneal cavity. The
benefits of less postoperative pain, shorter length of hospital stay and earlier return to
work after laparoscopic surgery for perforated peptic ulcer may offset the costs needed
for performing laparoscopic repair.Laparoscopic repair also offers the advantage of better
cosmesis.Laparoscopic approach to hemodynamically stable patients with free air at X-
ray and/or CT for diagnostic purposes.t laparoscopic repair of PPU in stable patients with
PPU <5mm in size and in presence of appropriate laparoscopic skills
Open surgery
Open surgery in presence of septic shock or in patients with absolute contraindications
for pneumoperitoneum.We suggest open surgery in presence of perforated and bleeding
peptic ulcers, unless in stable patients with minor bleeding and in presence of advanced
laparoscpic suturing skills
COMPLICATION
Pneumonia (30%)
Wound infection
HEALTH EDUCATION
PATIENTS PARTICULARS:
1. MEDICAL RECORD:
2. NAME:MRS.CHAN SEW YING
3. GENDER:FEMALE
4. AGE:56 YEARS OLD
5. ETHNIC:CHINESE
6. OCCUPATION:FACTORY WORKER
7.
Chief complaint:
Mrs.Chan Sew Ying is 56 years old,female who presents to HTAR with abdominal pain
x2/7 since 9/9/2017@6pm and vomiting x1/7,2 episode.She describes pain at Right Illiac
Forsa radiate to lower part at abdomen.
Otherwise:BO normal
:No fever
:PU normally
:No URTI/UTI
:No LOA/LOW
:No altered bowel habit
:No sob,chest pain,palpitation
:No diarhea
O/E:Alert,tachypniec
BP:107/60
PR:90
RR:19
T:37 c
PHYSICAL EXAMINATION
Neck:
No swelling
No lump
Chest region:
Heart:
Normal heart sound (lub dub sound)
Regular rhythm and good good volume
No palpation
Lungs:
Breathing normally
Clear lung
Chest symmentry during respiration not asymmetrical
No crepitation
No chest deformities
Abdomen:
Guarded,not distended,generalized tenderness
Previous Scar,well healed,no hernia
Soft
No mass
Rebound negative
Bowel sound present,not hyperactive
Nervous system:
Sensation normal
Patient was alert and concious
Upper&lower limbs:
No upper limb swelling
Patient can walk
Genital&rectum:
Normal bowel habit(x1 day)
PR:brownish stool,no impacted stool
Investigation
BLOOD INVESTIGATION:
fbc:HB 12,WBC 12.16,PLT 294,HCT 40
Rp:NA 139,K 3.7,UREA 4.4,CREAT 43
Lft:TP 76,A/B 45,ALT 39,ALP 75,TW 10.1
vbg:PH 7.35,PLO 43.4,HW 22.61
Lact:3.3
UFEME:Negative
AXR:fecal loaded,no dilated bowel
CXR AP sitting::no air under diaphragm
PR:Brownish stool,no impacted stool
CT abdomen:Perforated@pylorus
Scan finding:no mass,no free fluid
MANAGEMENT PLAN
10/9/2017
IV cefobid 2g stat & 1g BD
IV Flagyl 500mg stat & TDS
KNBM 4 pints:2 pints normal saline
:2 pints Destrose
IV pantoprazole 40mg OD
IV tramadol 50mg OD
CT abdomen
Chest Xray
For ecg
To post case for repair PGU KIV bowel resection
To insert RTFF and aspirate 4 hourly
Continue antibiotic
Admit 3A
Start IV pantoprazole stat 40mg & ON
KNBM with IV drip 4 pints normal saline
10/9/2017@6pm
For 6xm 4 pints-2 pints to OT
-2 pints reserve
Repeat VBG
Call OT once 2 pints pc is ready
For PGU repair today
11/9/2017
Patient post laparotomy with perforated gastric ulcer repair under GA
Patient intubated ETT 7.0mm
Onservation taken and recorded:
BP:99/66mmhg
PR:102
SPO2:100%
IVD 1 pint havt
IV ivoadrenaline
Tripple lumen at right subclavian(inserted in OT)
2 silicone drain size 8
CBD inserted
Ryles tube free flow
Specimens:Peritoneal fluid for c&s
:Ulcer edge for HRL
Send patient to icu
12/9/2017
Wound inspection
Cont ABX
Reeducate PT
Chest physio and incentive spirometry
Neb saline 4 hourly
Keep all drain
Drain charting per shift
TED stocking
Management/progress in ICU
Post op:Laparotomy and PGU repair
Saturating well under NPO2
DXT stable
Tolerating clear fluid 50cc/3h on fentanol
HEALTH EDUCATION
Take NSAIDs with meals or medications that protect your stomach lining, if you
need NSAIDs.
Avoid or limit caffeinated drinks and alcohol. They may worsen your symptoms.
Refrain from smoking, as it can slow healing.
Take all of your antibiotics, if prescribed, for H. pylori infections. Not taking the
entire amount can bring the infection back.
Take steps to reduce the stress in your life. , reducing stress can keep gastric and
duodenal ulcer symptoms from getting worse.