1. CASE CONFERENCE: Peptic Ulcer Disease Maranion, Maria Cristina Marayag, Eric John Marcelo, Pamela Marcial, Karmi Margarette

2. General Information J.D., 49 y/o, M Filipino, Roman Catholic Married Jeepney Driver Chief Complaint: Abdominal Pain

3. HPI 13 years PTA Patient experienced gnawing, non- radiating pain, grade 2-3/10, in the RLQ Relieved by the intake of antacids, aggravated by heavy meal intake Sought consult at a local clinic, given Buscopan with unrecalled dosage

4. HPI 2 days PTA Patient experienced one episode of melena, no consult was done

5. HPI 7 hours PTA Patient experienced severe, non-radiating, epigastric pain, graded 9/10 Sought consult at a local clinic and was advised to take clarithromycin and omeprazole which afforded temporary relief

6. HPI 6 hours PTA Patient still experienced severe, non‐radiating, epigastric pain, grade 9/10. The pain then became generalized all over the abdomen. Due to persistence of symptoms, the patient was rushed to the USTH ER

7. History Past medical History – (-) HPN, DM, Asthma – (-) previous surgeries or BT Family History – (-) HPN, DM, Asthma Personal and Social History – Smoker (40 pack yrs) – Occasional alcoholic beverage drinker – Diet: mixed – Denies illicit drug use

8. ROS No fever, no weight loss, no weakness, no anorexia No rashes, no increased pigmentation No visual dysfunc4on, no redness, no itchiness, no eye pain, excessive lacrima4on No deafness, no tinnitus, no aural discharge No epistaxis, no nasal discharge No gum bleeding, no throat soreness No dyspnea, no shortness of breath, no chest pain, no palpita4ons No diarrhea, no cons4pa4on, no nausea, no vomi4ng, no heartburn, (+) melena No dysuria, hematuria, incontinence No limita4on of movements, joint pains and swelling of joints No heat or cold intolerance, no polyphagia, polydipsia, polyuria No convulsions, no headache, no sleep disturbances

9. PE Findings General – conscious, coherent, not in cardiorespiratory distress Vital Signs: – BP: 140/90 mmHg – PR = 90 bpm, regular – RR = 22 cpm – T = 37.6 oC Skin – Warm, moist – no active dermatoses

10. PE Findings HEENT – pink palpebral conjunctivae, anicteric scelrae, no nasoaural discharge, moist buccal mucosa, tonsils not enlarged, nonhyperemic posterior pharyngeal walls – Supple neck, no palpable cervical lymph nodes, thyroid not enlarged Thorax – symmetric chest expansion, (‐) retractions, resonant on both lung fields, equal and clear breath sounds Cardiovascular – Adynamic precordium, AB 5th LICS MCL, apex S1>S2, base S2>S1, (‐) murmurs

11. PE Findings Abdomen – Flat, no scars or striae, NABS, tympanic upon percussion, Traube’s space not obliterated, (+) direct and rebound tenderness upper abdominal region with guarding (‐) Rovsing’s sign, (‐) psoas sign DRE: – no skin tags seen, slight sphincteric tone, smooth rectal mucosa, (‐) palpated masses, (‐) pararectal tenderness, brown stool on tactating finger

12. PE Findings Extremities – Pulses were full and equal, no cyanosis, no edema, no limitation of movement in all extremities were noted. Neurological Examination – Conscious, coherent, oriented to 3 spheres – Cranial nerves: pupils 2‐3 mm ERTL, EOMs full and equal, V1V2V3 intact, can clench teeth, can raise eyebrows, can close eyes slightly, can smile, can frown, can puff cheeks, no facial asymmetry, no hearing loss, can turn head from side to side with resistance, can shrug shoulders, tongue midline on protrusion.

13. PE Findings Neurologic Exam – Motor: MMT of 5/5 on all extremi4es – Cerebellar: can do FTNT & APST – DTR’s: ++ on all extremities – No sensory deficit – (‐) Babinski – (‐) nuchal rigidity

14. Clinical Assessment Acute abdomen secondary to perforated viscus secondary to PUD

15. DISCUSSION: Salient Features and Pertinent Findings Subjective Positives – Epigastric pain relieved by antacid and food intake – Melena – Epigastric pain becoming generalized and refractory to omeprazole – 40 pack years of smoking hx Objective Positives – T = 37.6 oC – RR = 22 cpm – BP: 140/90 mmHg – (+) direct and rebound tenderness upper abdominal region with guarding Negatives – (‐) Rovsing’s sign, (‐) psoas sign

16. Journal: Risk Factors for PUD – a population based prospective cohort study comprising 2416 Dasnish adults S Rosenstock, T Jørgensen, O Bonnevie, L Andersen Gut 2003;52:186–193

17. Journal: Risk Factors for PUD – a population based prospective cohort study comprising 2416 Dasnish adults

18. Plans CBC, U/A, Na, K, serum amylase and lipase CXR, 12 L‐ECG Emergency exploratory laparotomy, primary repair with omental bumress

19. Journal: Emergency laparoscopy – current best practice Oliver Warren, James Kinross, Paraskevas Paraskeva, Ara Darzi World Journal of Emergency Surgery 2006 Volume 1:24; August 31, 2006 Emergency laparoscopic surgery allows both the evaluation of acute abdominal pain and the treatment of many common acute abdominal disorders.

20. Journal: Emergency laparoscopy – current best practice Used to differentiate: – Trauma – Perforated PUD – Appendicitis – Gynecologic conditions

21. Patient’s Course in the Ward 5/14/09 – Admimed to MSW – Requested for CBC, U/A, CXR, Na, K, 12 L‐ECG, serum amylase and lipase – Scheduled for OR on the same day

22. Lab Results: CBC Date 05/14/09ResultsRef. Range HGB HCT Platelet WBC Neut Lymph. 136 0.41 332 12.7 0.83 0.17 120-170 0.37-0.54 150 – 450 4.5 – 10.00 0.50 – 0.70 0.20 – 0.40

23. Lab Results: Urinalysis Date05/14/09 Color Transparency pH Sp. Gravity Albumin Sugar RBC WBC Dark yellow Sl. Turbid 6.0 1.020 Negative ++ 0-3/hpf

24. Lab Results: Electrolytes Date 05/14/09 ResultRef. Range Sodium Potassium 136 3.5 137-147 3.5-5.1

25. Lab Results: Serum Amylase and Lipase Date 05/14/09ResultsRef. Range Amylase65.010-130 IIU/L Lipase31.813-60 IU/L

26. 12-Lead ECG Result Done 05/14/09 Normal findings

27. CXT 5/13/09

28. CXR 5/13/09 There is a linear lucency noted in the subdiaphragmatic area suggestive of pneumoperitoneum Suspicious infiltrates are seen in the right apex and right infraclavicular area. The heart is not enlarged The right hemidiaphragm is slightly elevated Sulci are intact

29. Journal: Management of large perforation of duodenal ulcers Sanjay Gupta, Robin Kaushik, Rajeev Sharma and Ashok Attri BMC Surgery 2005, 5:15; 25 June 2005

30. Journal: Management of large perforation of duodenal ulcers The case files of 162 patients who underwent emergency laparotomy for duodenal ulcer perforations over a period of three years (2001 – 2003) were retrospectively reviewed and sorted into groups based on the size of the perforations – small, large, giant. These groups of patients were then compared with each other in regard to the patient particulars, duration of symptoms, surgery performed and the outcome.

31. Journal: Management of large perforation of duodenal ulcers

35. Post-op Findings – 1x1.5 cm perforation at the anterior portion of the 1st part of the duodenum and minimal amount of purulent peritoneal fluid noted Patient was given D5 NR Patient was put on pantoprazole 40 mg/IV OD and sulperazone (sulbactam+cefoperazone) 1.5 g/IV q8 hours