1. Alonzo.Amaro.Amolenda Anacta.Andal

2. Beginning Data  Male, 45 year old  Chief Complain: Severe Abdominal Pain

3. History of Present Illness 3 years PTA Crampy, epigastric pain Relieved by food intake or antacids Melena UGI endoscopy: Erosive Gastritis Unrecalled medications 1 year PTA Epigastric pain Melena Self ‐ medicated: Omeprazole

4. A few hours PTA Severe epigastric pain ADMISSION History of Present Illness

5. Past Medical History (-) HPN (-) DM Family History (-) Cancer

6. Personal History 10 pack ‐ years smoking Drinks alcoholic beverage for 8 years

7. Physical Examination  Conscious, coherent, in distress  BP= 140/90, PR= 105/min, RR=26/min,T= 37.8 C  Warm moist skin, no active dermatoses  Pink palpebral conjunctivae, anicteric sclerae  Heart and Lungs: regular rate and rhythm, clear breath sounds  Abdomen : flat, hypoactive bowel sounds, guarding and tenderness on all quadrants  DRE: brown stool on tactating finger

9. Salient Features Pertinent Subjective  Male, 45 y/o  Crampy, epigastric pain  Relieved by food intake or antacids  Melena  UGI endoscopy: Erosive Gastritis  10 pack ‐ years smoking  Drinks alcoholic beverage for 8 years Pertinent Objective PR= 105/min, RR=26/min Abdomen : flat, hypoactive bowel sounds, (+) guarding and tenderness on all quadrants DRE: brown stool on tactating finger

11. Clinical Impression  Peptic Perforation

12. Initial Diagnostic Measures for Perforated PUD  Upright CXR or lateral abdominal decubitus radiography.  Upper GI contrast study with water soluble contrast.

13. Initial Therapeutic Measures for Perforated PUD  Fluid resuscitation with replacement of fluid and electrolytes.  Nasogastric decompression.  Administer broad spectrum antibiotics.  Insert Foley catheter.  Insert central venous line or Swan-Ganz artery catheter.

15. Surgical Therapy Surgery is recommended in patients who present with the following: Hemodynamic instability Signs of peritonitis Free extravasation of contrast on upper GI contrast studies

16. Preoperative Management  Fluid resuscitation  NGT insertion  Insertion of Foley catheter  Broad-spectrum antibiotics

17. Intraoperative Details  Exploratory Laparotomy  life-threatening, comorbid conditions & severe intraabdominal contamination  Graham patch using omentum Several full-thickness simple sutures are placed across the perforation A segment of omentum is placed over the perforation & silk sutures are secured.

18. OMENTAL PATCH

19. Intraoperative details  Minimal contamination, stable patient highly selective vagotomy truncal vagotomy and pyloroplasty vagotomy and antrectomy.

20. Postoperative Details  NGT can be discontinued on postoperative day 2 or 3, depending on the return of GI function, and diet can be slowly advanced.  H. pylori infection  antibiotic regimen  Follow-up with an upper endoscopy to evaluate the area of ulcer and healing of the perforation site 4-6 weeks after surgery.

21. Possible Complications  Pneumonia (30%)  Wound infection, abdominal abscess (15%)  Cardiac problems (especially in those >70 y)  Diarrhea (30% after vagotomy)  Dumping syndromes (10% after vagotomy and drainage procedures)  Gastric outlet obstruction  Recurrent peptic ulcer

22. Andal, Charlotte

23. RISKS  Elderly, chronically ill, and are taking one or more ulcerogenic drugs Mean age is >60 y.o.  History of ulcer disease or symptoms of an ulcer is important one-third of patients had a history of PUD 32% of patients who presented with perforation were taking H 2 blockers, antacids, or both  History of smoking, alcohol abuse, and postoperative stress

24. COMPLICATIONS  Gastric and duodenal contents may leak into the peritoneum Gastric and duodenal secretions, bile, ingested food, and swallowed bacteria Peritonitis Increased risk of infection and abscess formation  Third-spacing of fluid in the peritoneal cavity Inadequate circulatory volume, hypotension, and decreased urine output

25. COMPLICATIONS  More severe cases  shock  Abdominal distension as a result of peritonitis and subsequent ileus May interfere with diaphragmatic movement, impairing expansion of the lung bases  Atelectasis