Case Scenario

• A 35years old man came to emergency department

with severe abdominal pain, constant in nature. The
pain was associated with vomiting.
• On examination patient appeared flushed, with
tenderness in the lower abdomen and that was
markedly worse over the left iliac fossa.
• The patient was having tachycardic with a heart rate
of 140 bpm, blood pressure of 110/89 mm Hg, a
temperature of 36.6°C and a respiratory rate of
20 bpm. So identify the diseases condition.
ULCER PERFOTATION

Presented By : Manisha
 Ulcer Perforation.
• A perforated ulcer, is a condition in which
untreated ulcer can burn through the wall of
the stomach (or other areas of
the gastrointestinal tract), allowing digestive
juices and food to leak into the abdominal cavity.
 Etiology of Ulcer Perforation.
• Infection of the stomach by bacteria called
Helicobacter pylori (H pylori).
• Chronic history of peptic and duodenal ulcer.
 Sign and Symptoms of Ulcer
Perforation.
(1) Sudden, Severe abdominal Pain :
The first symptom of a perforated peptic ulcer is usually
sudden, severe, sharp pain in the abdomen.
• The experience is typically so intense
• The pain is typically at its maximum immediately and
persists.
• It is characteristically made worse by any movement, and
greatly intensifies with coughing or sneezing.
• The pain is often generalized throughout the abdomen, but
is sometimes focused in the upper abdomen.
• It may radiate to the shoulders or, less commonly, the hips.
 continuee…….
(2) Abdominal tenderness, distention and rigidity .
• Spillage of digestive contents into the abdominal
cavity due to a perforated ulcer provokes intense
inflammation of the area.
• This leads to not only pain but abdominal
tenderness.
 Continue…….
• This is evident on physical examination, as people
with abdominal cavity as inflammation reflexively
stiffen the abdominal muscles. This reflex is
known as abdominal guarding.
• Fluid accumulation in the abdominal cavity due
to inflammation of the area is another
contributor to abdominal distention.
 Others sign and symptom
• Hypotension
• Decreased urine output.
• Tachycardia
• Skin may be pale and clammy
 Early Warning Signs and Symptoms

• Although a perforation may be the first indication of

peptic ulcer disease, most people with this condition
experience milder symptoms in the days or weeks
leading up to the perforation.
• Pain between the breastbone and the navel may
occur when the stomach is empty, and might be
relieved with antacids.
• The pain may come and go, and is often worse at
night.
• Dark, tarry bowel movements or vomiting material
that resembles coffee grounds may signal bleeding
from a peptic ulcer.
 Diagnosis of Ulcer Perforation.
• Rapid diagnosis is essential, since the prognosis is
excellent within the first six hours, but
deteriorates with more than a 12-hour delay.
• Perforation is largely a clinical diagnosis with the
history and physical examination providing
essential clues.
 Diagnosis of Ulcer Perforation
• X-RAY:
(a) Plain x-rays are typically obtained first.
(b) Careful interpretation of upright chest and
abdominal films can detect diagnostic free air in
many cases of perforated gastric and duodenal
ulcers.
(c) The presence of free air on abdominal imaging
is highly indicative of a perforated viscous
although about 10 to 20 percent of patients
with a perforated duodenal ulcer will not have
free air.
• chest x-ray show free air under dome of both
diaphragm due to air leak from gastric ulcer or
duodenal ulcer perforated
 Diagnosis of Ulcer Perforation
• Computed tomography or ultrasound
(a) It can be useful to detect small amounts of free air or fluid.
In a small proportion of cases, free fluid will be the only
clue indicating perforation on imaging studies and a few
percent of cases will have neither free air nor fluid .
(b) (b) Spiral and multi detector-row CTs especially 64 slice
scanners, allow the entire abdomen to be examined on a
single breath-hold and improve detection of small amounts
of air and indirect findings (eg, fluid, phlegmon, abscess,
wall pathology and adjacent inflammation) and can provide
very useful indirect clues to pathology. Spiral CTs are
undoubtedly much more sensitive than ultrasound for
detecting fluid, air, or other clues to perforation.
 Diagnosis of Ulcer Perforation
(c) Spiral CT with oral contrast sensitively
detects persisting leaks across perforated
ulcers.
 Management:
• Medical Management:
Initial management includes insertion of a
nasogastric tube, intravenous volume
replacement, treatment with an intravenous
proton pump inhibitor (PPI), and broad spectrum
antibiotics.
 Medical Management
• Intravenous PPI — Although high-dose
intravenous PPIs given at presentation promote
the cessation of bleeding and healing of ulcers,
the impact of such early treatment on
perforated ulcers has not yet been reported.
• PPI as early as possible, with an 80 mg loading
dose and 8 mg per hour of the PPI; however,
lower doses and twice daily bolus dosing may be
equally effective, as noted above.
 Medical Management
• Antibiotics : The antibiotic regimen for a patient
with a perforated ulcer should cover enteric gram
negative rods, anaerobes, and mouth flora.
• Initial empiric antibiotic therapy in the setting of
perforated ulcer include a combination
beta lactam/beta lactamase inhibitor (such
as ampicillin-sulbactam, ticarcillin-clavulanic acid,
or piperacillin-tazobactam),
• Combination of a third-generation cephalosporin
and metronidazole.
 Medical Management
• In areas where the local prevalence of extended
spectrum beta-lactamase (ESBL) producing
organisms and pathogenic E. coli is common,
empiric monotherapy with a carbapenem such
as ertapenem, imipenem, or meropenem is
appropriate.
 Surgical Management
• Perforated duodenal ulcers can generally be
treated by closure with a piece of omentum
(Graham patch) or, for perforated ulcers close to
the pylorus, by truncal vagotomy with
pyloroplasty (incorporating the perforation).
 Surgical Management
• Simple patch closure of the perforation
should be considered in the setting of ongoing
shock, delayed presentation, significant
medical comorbidities, or significant
peritoneal contamination.
 Surgical Management
• Patch closure may also be appropriate for
patients who have never been treated for
peptic ulcer disease and who are candidates
for proton pump inhibitors and antibiotic
therapy for H. pylori.
 Surgical Management
• Non - steroidal anti-inflammatory drug
(NSAID)-related perforation can generally be
treated with simple closure, as the drug can
almost always be discontinued.
• Large or complex perforated duodenal ulcers
may require specialized technique to close.
 Surgical Management
• Bancroft's technique :
• It is best suited for cases in which scarring prevents
adequate dissection of the pylorus.
• It uses a distal muscular cuff of the antrum to close
the duodenal stump, which requires complete
removal of the antral mucosa to avoid the
complications of a retained antrum.
 Surgical Management
• Nissen's technique is particularly useful when
a posterior duodenal ulcer has penetrated into
the pancreas and is not amenable to
resection. It requires the duodenum to be
dissected from the proximal portion of the
ulcer bed, leaving the ulcer intact with a small
rim of tissue for closure.
 Surgical Management
• When the risk of significant duodenal leak is
perceived to be high, it is still possible to perform
a primary ulcer repair, rather than gastrectomy,
by adding a pyloric exclusion to divert the gastric
stream away from the duodenum.
 Surgical Management
• Pyloric exclusion involves closing the pylorus with
creating a gastrojejunal anastomosis for gastric
drainage. It can be performed in several different
ways:
(a) One common method is to create a gastrotomy
along the greater curvature through which the
pylorus can be grasped and sutured closed with
nonabsorbable suture. The gastrotomy can then
either be closed primarily or used to complete the
gastrojejunostomy.
 Surgical Management
(b) Another method fires a linear stapler across
the pylorus, although care must be taken to
avoid misfire across the proximal duodenum.
 Nursing Management:
Nursing assessment:
• Assess the vital signs of the patients.
• Monitor the patient for hypotension.
• Assess the level of pain.
• Assess the patient for symptom of shock such as
fainting, excessive sweating and confusion.
• Assess the patient for blood in vomiting.
 Nursing Management:
Nursing Diagnosis
• Fluid volume deficit related to hemorrhage.
• Acute pain related to perforation of ulcer.
• Imbalanced nutrition less than body requirement
related to pain and vomiting.
• Risk of anemia related to hemorrhage.
• Risk of infection related to hemorrhage.