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Dr Ahmad abanamy hospitalDr Nuaman danawargeneral& gastrointestinal surgeon
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Perforated peptic ulcer
• 50 years ago perforated peptic ulcer was a disease of young men
• Today it is a problem seen mainly in elderly women • Overall incidence for admission with peptic ulceration
is falling • The number of perforated ulcers remains unchanged • Sustained incidence possibly due to increased NSAID
in elderly • 80% of perforated duodenal ulcers are H. pylori
positive
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• Clinical features• Most occur in patients with pre-existing dyspepsia • 10% have no previous symptoms • Classic presentation is with:
– Sudden onset epigastric pain – Rapid generalisation of pain – Examination shows peritonitis with absent bowel sounds
• 10% have an associated episode of melaena • 10% have no demonstrable gas on an erect chest x-ray • If diagnostic doubt then water soluble contrast enema may
confirm perforation • Can be associated with elevated serum amylase but not to
same level as in pancreatitis
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Free airUnder RT hemi diaphragm
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• Management• Most patients require surgery after appropriate
resuscitation • Conservative management may be considered if
significant co-morbidity • More likely to fail if perforation is of a gastric
ulcer • Laparoscopic techniques have recently been
described
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• Preoperative preparation• Fluid resuscitation with CVP or Swan Ganz
monitoring • Analgesia • Antibiotics • Nasogastric intubation
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• Operation• Oversew of ulcer first performed by Dean in 1894 • Usually performed through an upper midline incision • Oversew perforation with omental patch • Use 2/0 synthetic absorbable. • Take 1 cm bites either side of ulcer • Picture provided by Vitoon Chinswangwatanakul, Siriraj Hospital, Bangkok,
Thailand• Thorough wash out and irrigation of peritoneal cavity with 0.9% saline • If unable to find perforation open the less sac • Remember that multiple perforations can occur • If closure secure and adequate toilet then a drain is not required • Pre-pyloric ulcer behave as duodenal ulcers • All gastric ulcers require biopsy to exclude malignancy • Definitive ulcer surgery probably not required • 50% patients develop no ulcer recurrence • Postoperatively patients should receive H. pylori eradication therapy • Surgery increasingly performed laparoscopically • Associated with no increased morbidity and reduced hospital stay
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• Outcome• Operative mortality depends on four major
risk factors – Long period from perforation to admission – Increasing age – Coexisting medical disease – Hypovolaemia on admission