Post on 05-Apr-2018
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Introduction 50 years ago perforated peptic ulcer was a disease of
young men
Today it is a problem seen mainly in elderly women
Overall incidence for admission with peptic ulcerationis falling
The number of perforated ulcers remains unchanged
Sustained incidence possibly due to increased NSAIDin elderly
80% of perforated duodenal ulcers are H. pyloripositive
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Investigations Erect plain chest radiograph
Serum amylase levels (amylase level may be elevated
but not as much as in pancreatitis) CT scan
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Management Preoperative preparations- resuscitation with fluids
and analgesia,nasogastric tube,antibiotics
Laparotomy- Upper midline incision(if the location is known) orsmall incision at umbilicus to localize the perforation
Laparoscopy
Truncal vagotomy/pyloroplasty (older method) Highly selective vagotomy(relatively safe)
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Perforation at duodenum close by several well-
placed sutures, then closing the ulcer in a transversedirection as with a pyloroplasty
Omental patch over the perforation to enhancechances of sealing the leak
Thorough peritoneal toilet with 0.9% saline
If unable to find perforation open the less sac
Remember that multiple perforations can occur
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Prepyloric ulcer behave as duodenal ulcers
All gastric ulcers require biopsy to exclude malignancy
Massive perforation-Billroth II gastrectomy
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Omental patch
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Laparoscopic closure ofperforated duodenal ulcer &
omental patching.
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Outcome Operative mortality depends on four major risk
factors:
Long period from perforation to admission
Increasing age
Coexisting medical disease
Hypovolaemia on admission