[12] Perforated Peptic Ulcer

Question 1

What kind of PU most commonly perforates?

Answer 1

DU

Question 2

Why are DUs the most common PU to perforate?

Answer 2

Because the first part of the duodenum has the highest acid concentration

Question 3

What might an anterior perforation of a DU lead to?

Answer 3

Air under the diaphragm

Question 4

What might a posterior perforation of a DU lead to?

Answer 4

Can erode into gastroduodenal artery, leading to bleed

Question 5

What proportion of the duodenum is retroperitoneal?

Answer 5

3/4

Question 6

Is there air under the diaphragm if a DU perforates in a retroperitoneal part of the duodenum?

Answer 6

No

Question 7

How do perforated peptic ulcers present?

Answer 7

Sudden onset severe pain, beginning in epigastrum then becoming generalised
Vomiting
Peritonitis

Question 8

What are the differential diagnoses for perforated peptic ulcers?

Answer 8

Pancreatitis
Acute cholecystitis
AAA
MI

Question 9

How are perforated peptic ulcers investigated?

Answer 9

Bloods
Urine dipstick
Imaging

Question 10

What bloods are done in perforated peptic ulcer?

Answer 10

FBC
U&E
CRP
G&S
Clotting

Question 11

When is an ABG required in perforated peptic ulcers?

Answer 11

If there is ?mesenteric ischaemia

Question 12

What imaging is done in perforated peptic ulcers?

Answer 12

Erect CXR

AXR

Question 13

How long must a patient be standing before taking an erect CXR?

Answer 13

15 mins

Question 14

What % of patients with perforated peptic ulcers will have air under the diaphragm on erect CXR?

Answer 14

70%

Question 15

What might give a false positive on erect CXR?

Answer 15

Chailadti’s sign

Question 16

What might be seen on AXR in perforated peptic ulcers?

Answer 16

Rigler’s sign

Question 17

What is Rigler’s sign?

Answer 17

Air on both sides of bowel wall

Question 18

What are the options in management of perforated peptic ulcers?

Answer 18

Conservative

Surgical

Question 19

What is involved in resuscitation in perforated peptic ulcers?

Answer 19

NBM
Aggressive fluid resuscitation
Analgesia
Abx
NGT

Question 20

What analgesia is given in perforated peptic ulcers?

Answer 20

Morphine 5-10mg/2hour max, with or without cyclizine

Question 21

How is fluid balance monitored in perforated peptic ulcers?

Answer 21

Urinary catheter, maybe a CVP line

Question 22

What Abx may be given in perforated peptic ulcers?

Answer 22

Cef and met

Question 23

When might conservative management of perforated peptic ulcers be considered?

Answer 23

If the patient isn’t peritonitic

Question 24

What is involved in the conservative management of perforated peptic ulcers?

Answer 24

Careful monitoring
Fluids
Antibiotics

Question 25

What makes conservative management for perforated peptic ulcers possible?

Answer 25

The omentum may seal the perforation spontaneously, preventing operation

Question 26

What technique is used in the surgical management of perforated peptic ulcers?

Answer 26

Laparotomy

Question 27

How is a perforated DU managed surgically?

Answer 27

Abdominal washout and omental patch repair

Question 28

How is a perforated GU surgically repaired?

Answer 28

Excise ulcer and repair defect

Question 29

What surgical option may rarely be required in perforated PU?

Answer 29

Partial or complete gastrectomy

Question 30

What should be done if a gastrectomy is performed for perforated PU?

Answer 30

Send specimen for histology to exclude cancer

Question 31

What % of perforated PUs are associated with H. Pylori infection?

Answer 31

90%