Perforated gastric ulcer: Perforated gastric ulcer refers to an open sore or erosion of
the stomach lining that generally results in upper gastrointestinal bleeding or
hemorrhage.
PATHOPHYSIOLOGY
CAUSES:
• Helicobacter pylori,
• NSAID
• Tobacco smoking
• Crohn disease
DIAGNOSTIC:
– BLOOD TEST
– XRAY
– CT SCAN
– STOOL CULTURE
– UFEME
TREATMENT:
Stop smoking
Stop NSAIDs
Stop alcohol
Medications : Proton pump inhibitor,
:H2 blocker
:Antacid
:Antibiotics
Surgery:Laparoscopic
:Endoscopy
PATIENT PARTICULAR
• MEDICAL RECORD:1260726
• NAME:MRS.CHAN SEW YING
• DATE OF ADMITTED: 10/9/2017
• GENDER:FEMALE
• AGE:56 YEARS OLD
• ETHNIC:CHINESE
• OCCUPATION:FACTORY WORKER
• DIFFERENTIAL DIAGNOSIS:TRO appendicitis
• DIAGNOSIS: Perforated gastric ulcer
VITAL SIGNS:
B/P:107/60mmHg
PR:90bpm
RR:19bpm
TEMP:37C
• 56 years old female presenting with :
abdominal pain x 2/7
vomiting x 1/7 ,2 episode
Pain at RIF
Radiating to lower part of abdomen
PMHx:Hypertension,on Amlodipine ,follow up Klinik Kesihatan
Klang.
:Endomentrial CA stage 1,TAHBSO done,follow up
hospital Kelantan.
Vital sign:
BP:107/60
PR:90
RR:19
T:37 c
Abdomen:
• BLOOD TEST:
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
• IMP:PERFORATED GASTRIC ULCER
MANAGEMENT
10/9/2017 10/9/2017@6pm
IV cefobid 2g stat & 1g BD For GXM 4 pints-2 pints to OT
IV Flagyl 500mg stat & TDS -2 pints reserve
Keep NBM 4 pints:2 pints normal Repeat VBG
saline
Call OT once 2 pints packed cell
:2 pints Destrose is ready
IV pantoprazole 40mg OD
IV tramadol 50mg OD
For PGU repair today
CT abdomen
Chest Xray
ECG
To post case for repair PGU KIV bowel
resection
To insert RYLE'STube Free Flow and
aspirate 4 hourly
Continue antibiotic
Start IV pantoprazole stat 40mg & ON
Keep NBM with IV drip 4 pints normal
saline
11/9/2017
Management/progress in ICU
Patient post laparotomy with – Post op:Laparotomy and PGU repair
perforated gastric ulcer repair under – Saturating well under NPO2
GA
– DXT stable
Patient intubated ETT 7.0mm
– Tolerating clear fluid 50cc/3h on
Observation taken and recorded: fentanyl
– BP:99/66mmhg
Condition on discharge from ICU
– PR:102
– GCS:eye opening-4
– SPO2:100%
– :Verbal response-5
IVD 1 pint havt
– :Motor response-6
IV ivoadrenaline
– BP:180/70mmHg
Tripple lumen at right
subclavian(inserted in OT) – HR:87bpm
2 silicone drain size 8 – RR:14bpm
CBD inserted • SPO2:100% under NPO2
Ryle's tube free flow Post ICU discharge plan:
Specimens:Peritoneal fluid for c&s – Medication:T.Bizoprolol 1.25mg OD
:Ulcer edge for HRL – :T.Amlodiphine 10mg OD
Send patient to icu – IV vitamin K 5mg OD x3/7
– Oxygen therapy:NPO2
– IV fluids:QSDI 60cc/h
– Feeding:clear fluid 50cc/3h
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
HEALTH EDUCATION:
Stop smoking
Beware of NSAIDs
Stop drink alcohol
Eat a diet rich in fruits and vegetables
Manage stress
SUMMARY