Perforated Peptic Ulcer

PERFORATED PEPTIC ULCER

Q. 1

Treatment of perforated peptic ulcer includes –

 A

i.v. fluids

 B

Drainage of paracolic gutter

 C

Immediate surgery

 D

a and c

Q. 1

Treatment of perforated peptic ulcer includes –

 A

i.v. fluids

 B

Drainage of paracolic gutter

 C

Immediate surgery

 D

a and c

Ans. D

Explanation:

Ans ‘a’ fluids; ‘c’ immediate surgery

Management of Peptic ulcer perforation

Nasogastric tube: whenever a perforated ulcer is suspected, the first step is to pass a nasogastric tube and empty the stomach to reduce further contamination of the peritoneal cavity.

Intravenous crystalloid: The patient is resuscitated aggressively by administration of intravenous crystalloid.

– Intravenous broad-spectrum antibiotics

Surgery:

Surgery is mostly indicated, although occasionally nonsurgical treatment can be used in stable patients without peritonitis, and in whom radiologic studies document a sealed perforation.

Surgery whether laparoscopy or laparotomy involves two components:

i)Thorough peritoneal toilet

to remove all the fluid and food debris

drain is not indicated

ii)Management of perforation

For duodenal ulcer perforation

The most frequently performed operation for a perforated duodenal ulcer is simple closure with an omental onlay reinforcement or patch.

This is combined with postoperative H. pylori eradication (antibiotics + antisecretory agents)

–  Insertion of a nasoenteric or jejunal feeding tube should be considered

[Note that this current practice is in marked contrast to the prior recommendation suggesting the addition of a concomitant acid-reduction procedure to ulcer closure.]

For gastric ulcer perforation

All perforated gastric ulcers are best treated by distal gastric resection with or without a truncal vagotomy (Truncal vagotomy can be added for type II & III gastric ulcers. Type I and IV gastric ulcers do not need acid reducing procedures as they are associated with hyposecretion). Ulcer is removed along with gastric resection as it carries a risk of malignancy (cf: duodenal ulcer has no risk of cancer). If ulcer is left behind, biopsy is always done.

Other procedures used for gastric ulcers are

–   patch closure with biopsy  – wedge excision and closure


Q. 2

Percentage of patients with perforated peptic ulcer who show free gas under the diaphragm –

 A

100%

 B

75%

 C

50%

 D

90%

Q. 2

Percentage of patients with perforated peptic ulcer who show free gas under the diaphragm –

 A

100%

 B

75%

 C

50%

 D

90%

Ans. B

Explanation:

Ans. is ‘b’ i.e. 75%

Sutton writes – ”The demonstration of pneumoperitoneum on plain film following a perforated viscus is, however, not invariable, and most series show that in only 75-80% of perforations is free gas demonstrable. A number of reasons for this have been suggested, including sealing of the perforation, lack of gas at the site of perforation, or adhesions around the site of perforation. However, radiographic technique is also important : a pneumoperitoneum can be detected in 76% of cases using an erect film only, but when a left lateral decubitus projection is included, a pneumoperitoneum is demonstrated in nearly 90% of cases.”

Quiz In Between



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