VU Medisch Centrum Afdeling MDL Endoscopy of Peptic Perforations Chris Mulder 31 januari 2006.
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Transcript of VU Medisch Centrum Afdeling MDL Endoscopy of Peptic Perforations Chris Mulder 31 januari 2006.
VU Medisch Centrum
Afdeling MDL
Endoscopy of Peptic PerforationsEndoscopy of Peptic Perforations
Chris Mulder
31 januari 2006
Suspicion of perforation Suspicion of perforation (oesophagus)(oesophagus)
• Pain of breathing• Subcutaneous emphysema• Localized pain• Pain and/or coughing after drinking
• Pleural fluid• Stripe of air along mediastinum
Wesdorp, Gastroenterology 1982
TreatmentTreatment
• NPO
• IV-fluid / antibiotics
• NGT with suction
Upper-GI perforationsUpper-GI perforations
• Esophageal - dilatation
- mucosal resection
- reflux esophagitis
- sclerotherapy
• Foreign bodies • Gastric - ulcer disease
- NSAID
• Gastrointestinal - lymphoma
Sensitivity (symptoms positive / Sensitivity (symptoms positive / disease positive) and disease positive) and specificity (symptoms specificity (symptoms
negative / disease negative) of negative / disease negative) of abdominal pain as a marker for abdominal pain as a marker for
ulcer disease are low.ulcer disease are low.
Spiro, NEJM 1974
PUD complicationsPUD complications
• Hemorrhage
• Perforation
• Penetration
• Obstruction
PUD follow-upPUD follow-up
• 7% perforation
• UD perforates anteriorly
• UV perforates anterior lesser curvature
• UD penetrates pancreas
• UV penetrates left lobe liver
Incidence of operations for Incidence of operations for perforated peptic ulcer perforated peptic ulcer
decreased >> 50%decreased >> 50%
Sanchez-Bueno, Dig Surg 2001
PUD perforationPUD perforation
• Abdominal X-ray (< 80%)
• Spiral CT
• Endoscopy
PUD perforationPUD perforation
• NG-aspiration• IV-fluids• IV-PPI / antibiotics• Sealing (Berne TV, 1989)
• Clipping ??? << 1 cm ??
• Surgery Treatment of Choice
(laparoscopic / classical)Berne TV, Arch Surg 1989
Donovan A, Arch Surg 1998Gul YA, Ir J Med Sci
Risk of perforation in PUDRisk of perforation in PUD
• Heater probe
• Gold probe
• Laser therapy (not documented)
• APC erbe (not documented)
Where to clip ?How to clean the peritoneal cavity ?
PUD perforationPUD perforation
200 MDL-artsen gemailed 10 januari 2006
2004-2006• 1 MDL-arts: 2x geclipt: 2x mislukt• 2 MDL-arts: 3x glue: 1x gelukt• Verder vele meldingen over clippen van colon-
perforaties en clippen van PEG
openingen ++ Berne TV, Arch Surg 1989Donovan A, Arch Surg 1998
Gul YA, Ir J Med Sci
Applikation eines Ovesco-Clips zum Verschluß einer Perforation im Dickdarm Quelle: Ovesco Endoscopy GmbH (see Google)
PUBMEDPUBMED
No articles about successfull
clipping of PUD
Chr. J. Mulder 30-01-2006
Nothing is mentionedabout endoscopic therapy of PUDperforations
Cases of perforated duodenal ulcer Cases of perforated duodenal ulcer treated in College of Medical treated in College of Medical Sciences, in Bharatpur.Sciences, in Bharatpur.
Laparoscopy followed by simple Laparoscopy followed by simple closure of perforation reinforced closure of perforation reinforced with pedicled omental patch is with pedicled omental patch is treatment of choicetreatment of choice
Kathmandu Univ Med JournalGupta et al, 2003;1:166-9