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Acute Abdomen > Perforated viscous > Flashcards

Perforated viscous Flashcards

1
Q

What is the estimated lifetime risk of perforation in peptic ulcer patients?

A

2-10%

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2
Q

Which of the following is NOT a risk factor for peptic ulcer disease?

1) NSAIDS
2) Smoking
3) H. Pylori
4) Marginal ulcer after bariatric surgery
5) Fasting
6) Low fibre diet
7) Crack cocaine, cocaine, methamphetamines
8) Gastrinoma
9) Critical illness
10) Steroids
11) High salt diet
12) EtOH
13) Chemotherapy with bevacizumab

A

6) Low fibre diet

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3
Q

In patients treated surgically with peptic ulcer perforation, what proportion confirmed H.Pylori infection on biospy?

A

70%

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4
Q

What is the recurrence rate of peptic ulcer disease if not treated for with eradication therapy at 1 year?

A

5.2% for eradication therapy and 35.2% for no eradication therapy

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5
Q

What should patients take who are on a long term NSAID?

A

PPI

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6
Q

Introduction of which medication class has helped reduced the number of NSAID related perforations?

A

COX-2 inhibitors

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7
Q

What are the preoperative factors that increase the risk of mortality after operation for perforated peptic ulcer?

A 
AKI
ASA 3-5 
Comorbidity 
Diabetes 
Low albumin 
Malignancy 
NSAID 
Old age 
Shock 
Steroids 
Surgical delay
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8
Q

Roughly what proportion of perforated peptic ulcer patients spontaneously seal at the time operation?
(from case series)

A

50%

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9
Q

Is there a link between time to surgery and mortality in patients with perforated peptic ulcers?

A

No. The UK National Emergency Laparotomy Audit (NELA) of over 2000 patients showed no link between 30-day mortality and time to surgery

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10
Q

What is the difference in outcomes between laparoscopic and open omental repair of perforated peptic ulcer?

A

Randomised studies and systematic reviews confirmed there is little benefit in terms of mortality, morbidity, or hospital stay. Strong evidence the laparosocpic approach takes longer and may be associated with more morbidity.

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11
Q

When should you do an open repair over a laparoscopic repair for perforated peptic ulcers?

A

Inexperienced laparoscopic surgeon
Larger perforations
Significant peritoneal contamination

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12
Q

Whats an alternative to open or laparoscopic repair of perforated peptic ulcer?

A

Endoscopic repair - stent, endoscopic clips, suturing, transluminal replication of omental patch

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13
Q

What are the surgical management options for a giant duodenal ulcer?

A

1) Attempt to close the defect and leave a drain to control a leak if it occurs
2) Controlled duodenal fistula using a foley catheter or T-tube duodenostomy
3) Finney pyloroplasty
4) Omental plug
5) Distal gastrectomy

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14
Q

What infusion can be considered in patients requiring pancreatic suppression with high risk of duodenal leak or fistula?

A

Octreotide

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15
Q

Why should all gastric ulcers be biopsied?

A

Malignancy

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16
Q

What surgical strategies can be employed for suspected perforated gastric carcinomas?

A

1) Biopsy ulcer and omental patch repair.
2) Resection of complete ulcer in specialist centre
3) Wedge gastrectomy (small and appropriate)

17
Q

What is the primary management of gastric lymphoma?

A

Non surgical

18
Q

What type of cultures in upper GI perforations are associated with a worse prognosis?

A

Fungal cultures

19
Q

When would you consider anti-fungal therapy in upper GI perforations?

A

1) Delayed diagnosis
2) Use of steroids
3) Acid suppressive medications

20
Q

What factors should be considered in patients post operative for repair of upper GI perforation?

A

1) NG aspirates for likely ileus
2) All should receive eradication therapy
3) PPI 6-8 weeks post
4) Check H.pylori at 6-8 weeks with breath or stool
5) Follow up endoscopy (malignancy) (13% of gastric perforations are malignant)

21
Q

What is the most common cause of oesophageal perforation?

A

Iatrogenic - diagnostic and therapeutic endoscopy, neck/thoracic procedures (cervical spine surgery, parathyroid, neck dissection, endoscopic aortic valve replacement,

22
Q

What is the best management of endoscopic oesophageal perforation?

A

Early diagnosis and aggressive treatment

1) endoscopic closure
2) simple gut rest
3) antibiotic therapy

23
Q

What are the main causes of oesophageal rupture?

A

1) Iatrogenic
2) Spontenous rupture (Boerhaave’s syndrome)
3) Caustic injury

24
Q

What is the mortality of oesophageal perforation?

A

18%

25
Q

What time of chemical ingestion is at high risk of causing oesophageal rupture?

A

Alkali (rare with acidic)

26
Q

What percentage of oesophageal ruptures are due to spontaneous rupture (Boerhaave’s syndrome)?

A

15%

27
Q

Which of the causes of oesophageal rupture has the highest mortality rate due to mediastinal and pleural contamination?

A

Boerhaave’s syndrome

28
Q

What is the best mode of treatment for oesophageal rupture in patients who score low in severity scoring system (Pittsburgh)?

A 
Non operative (less aggressive) 
(Antibiotics and gut rest)
29
Q

What are the options to control a oesophageal leak?

A

1) Endoscopic therapy
2) Thoracotomy or thoracostomy and direct repair
3) Isolation of the oesophagus and direct repair
4) Oesophageal resection

30
Q

What are the components of endoscopic therapy for oesophageal perforation?

A

1) Stent deployment (self expanding and covered)
(controls the leak and re-establishes early oral intake)
*stent migration is problematic, so stent removal is important
2) Endoscopic vacuum therapy (requires multiple endoscopies with changes every few days)
* reports of haemorrhagic deaths

31
Q

What are the components of surgical repair for oesophageal perforation?

A

1) Simple suture repair after excision of necrotic tissue is what is required.
? pleural wrap for reinforcement though increase risk of stricture formation
2) Creation of a formed fistula with a T tube may be necessary
3) Surgical jejunostomy required for enteral nutrition

32
Q

What are the types of retroperitoneal perforations that can occur during ERCP?

A 
Type 2 (sphincter of Oddi perforation) 
Type 3 (Bile duct perforation) 
Type 4 (retroperitoneal gas)

Acute Abdomen (4 decks)

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