Perforated Ulcer

Question 1

X-ray to order if suspected perforated ulcer

Answer 1

Erect chest X-ray

Question 2

Surgical name for air under the diaphragm

Answer 2

Pneumoperitoneum

Question 3

Explain to examiner what u see on a erect chest X-ray showing air under diaphragm

Answer 3

This is an erect chest X-ray showing a pneumoperitoneum
You can see free intra abdominal air under the hemidiaphragm
This may be caused my a perforated viscus (E.g. peptic ulcer)
Treatment is an omental patch

Question 4

Causes of pneumoperitoneum

Answer 4

Perforated duodenal ulcer - due to prolonged NSAIDs

Perforated gastric ulcer - due to prolonged NSAIDS and marijuana use

Ruptured diverticulum- risk with increased age and history of smoking

Ruptured lower end of esophagus- due to prior history of GERD, excessive vomiting and drinking (alcoholism)

Ruptured appendix- presents with abdominal pain

Question 5

The area of the duodenum that perforates is the _______ aspect or surface of the ________ of the duodenum

Answer 5

First

Anterior wall

Question 6

Why does it perforates on the anterior wall

Answer 6

Has the highest acid concentration

Question 7

Presented of patient with a perforated ulcer

Answer 7

Sudden onset, severe abdominal pain
Pain may refer to shoulder tip (kehr’s sign)
Vomiting leading to dehydration
Patient will be in shock ( tachycardic, tachypneic, hypotensive)
Guarding and rebound tenderness-board like rigidity elicited on examination

Question 8

% of perforated duodenal ulcers have air under the diaphragm

Answer 8

70-90%

Question 9

Clinically how can you tell it is a perforated ulcer

Answer 9

Air injected into stomach through NG tube to demonstrate pneumoperitonuem

Loss of liver dullness to percussion

Upper GI endoscopy

Gastrografin In X-ray

Question 10

Blood Investigations for a perforated ulcer

Answer 10

CBC
RFT
ABG
AMYLASE 
GROUP AND CROSS

Question 11

Imagining investigations for perforated ulcer

Answer 11

• Erect chest X-ray

- Upper GI series with water soluble contrast (gastrograffin)

Question 12

Bloods and imagining done, Any other investigations?

Answer 12

Nasogastric air insufflation if no pneumoperitoneum but perforation suspected.

13C breath test for H pylori

Question 13

Prep patient with perforated ulcer for surgery as the his intern.

Answer 13

• IV access with 2 large bore peripheral IVs : fluid resuscitate to restore intravascular vol ( ringers lactate 3L/24hrs ) and electrolyte repletion
• Monitor vitals q4hrly: RR, pulse, BP, PO2
• NGT- to decompress the stomach
• Urinary Catheter: to monitor input/output
• Adequate analgesics: morphine 0.1mg/kg (for pain relief)
• Antibiotics therapy: IV cefitaxone 1g bd and IV metronidazole 500mg tds- to decrease risk of infection
• Administer proton pump inhibitors: Esomeprazole (protects the stomach mucosa from acids )
• consent the patient for surgery

Question 14

Which operation you propose your senior resident will be doing ?

Answer 14

Omental patch

Question 15

3 lines explain what would be happening in the theater room ( operation of a perforated ulcer)

Answer 15

• inspect stomach, identify duodenal perforation and an adequate size tension free patch of omental is used to cover the perforation
• omental patch is secured using 3 sutures through healthy duodenum on either side of the perforation.
• Leak test done and peritoneal cavity irrigated with saline solution to prevent contamination.

Question 16

Post op what antibiotics would you send home patient with

Answer 16

Metronidazole, amoxicillin and clarithromycin

Question 17

Operation for recurrent perforated ulcer despite taking meds

Answer 17

Selective vagotomy + partial gastrectomy + drainage procedure (gastroduodenostomy)

Additional procedures:

• Truncal vagotomy + pyloroplasty
• Highly selective vagotomy

Question 18

Ulcer erodes posterior lay what happens to the patient

Answer 18

Massive upper and lower GI bleed

Question 19

Name of two ulcers presenting at the same time

Answer 19

Kissing ulcer

Question 20

Causes that can lead to peptic ulcer disease which can then lead to getting a perforated ulcer

Answer 20

• prolonged used of NSAIDS
• prolonged used of steroids
• Marijuana and cocaine use
• H.pylori infection
• Zollinger-Ellison syndrome

Question 21

Chronic scarring of the pyloric region due to PUD lead to long term and what other pathology might cause the same effect

Answer 21

Gastric outlet obstruction

Gastric cancer

Question 22

What other two lesions can H pylori cause other than PUD

Answer 22

MALT lymphoma

Gastric adenocarcinoma

Question 23

Loop of bowel under the diaphragm is called what sign

What are the causes ?

Is it presents with abdominal pain then what is it called ?

Answer 23

Chilaiditi sign

Chronic disease - such as in lung and liver

Chilaiditi s syndrome

Question 24

Perforation clinical signs

Answer 24

Kehr’s sign - shoulder tip pain 
Hypovolemia
Severe pain
Tachycardic 
Tachypnea
Guarding and rebound tenderness- board like rigidity

Question 25

What is the difference between graham patch and an omental patch

Answer 25

Graham patch has no blood supply which increases the risk of failure and necrosis of the patch

An omental patch has its own blood supply