CASE PRESENTATION

PERFORATED GASTRIC ULCER

NAME:NORSHAHIDAH BT ZAINAL
STUDENT ID:SD012017-04-002565
DEFINITION

Perforated gastric ulcer: Perforated gastric ulcer refers to an open sore or erosion of
the stomach lining that generally results in upper gastrointestinal bleeding or
hemorrhage.
PATHOPHYSIOLOGY

• Damage to the mucusal with alcohol abuse,smoking and use of NSAIDs

• Infection of Helicobacter Pylori
• Erosions of mucuous membrane
• Low function of mucusal cell and low of mucous
• Erosive gastritis
• Mucusal ulcerations
• Severe ulcerations:sign and symptoms
• epigastric pain
• Hemathemesis
• Pale
• pyrosis
SIGN AND SYMPTOM:
• Upper abdominal pain
• belching,
• vomiting,
• weight loss,
• poor appetite

CAUSES:
• Helicobacter pylori,
• NSAID
• Tobacco smoking
• Crohn disease
DIAGNOSTIC:
– BLOOD TEST
– XRAY
– CT SCAN
– STOOL CULTURE
– UFEME

TREATMENT:
 Stop smoking
 Stop NSAIDs
 Stop alcohol
 Medications : Proton pump inhibitor,
:H2 blocker
:Antacid
:Antibiotics
 Surgery:Laparoscopic
:Endoscopy
PATIENT PARTICULAR

• MEDICAL RECORD:1260726
• NAME:MRS.CHAN SEW YING
• DATE OF ADMITTED: 10/9/2017
• GENDER:FEMALE
• AGE:56 YEARS OLD
• ETHNIC:CHINESE
• OCCUPATION:FACTORY WORKER
• DIFFERENTIAL DIAGNOSIS:TRO appendicitis
• DIAGNOSIS: Perforated gastric ulcer

VITAL SIGNS:

B/P:107/60mmHg
PR:90bpm
RR:19bpm
TEMP:37C
• 56 years old female presenting with :
 abdominal pain x 2/7
 vomiting x 1/7 ,2 episode
 Pain at RIF
 Radiating to lower part of abdomen
PMHx:Hypertension,on Amlodipine ,follow up Klinik Kesihatan
Klang.
:Endomentrial CA stage 1,TAHBSO done,follow up
hospital Kelantan.

PSHx:Total Abdominal Hysterectomy with Bilateral Salpingo-

Oophorectomy(TAHBSO) at JUNE 2016

:Compeleted radiotherapy in NOV 2016,follow up at

Institut Kanser Negara.
• PHYSICAL EXAMINATION

Vital sign:

 BP:107/60
 PR:90
 RR:19
 T:37 c

Abdomen:

Guarded,not distended,generalized tenderness

Previous Scar,well healed,no hernia
Soft
No mass
Rebound negative
Bowel sound present,not hyperactive
DIFFERENTIAL DIAGNOSIS

• Possible acute appendicitis

• Possible costipation pain
• Perforated appendicitis
• Perforated Diverticulitis
INVESTIGATION

• BLOOD TEST:
 fbc:HB 12,WBC 12.16,PLT 294,HCT 40
 Rp:NA 139,K 3.7,UREA 4.4,CREAT 43
 Lft:TP 76,A/B 45,ALT 39,ALP 75,TW 10.1
 Vbg:PH 7.35,PLO 43.4,HW 22.61
 Lact:3.3

• UFEME:Negative
• AXR:fecal loaded,no dilated bowel
• CXR AP sitting:no air under diaphragm
• PR:Brownish stool,no impacted stool
• CT abdomen:Perforated@pylorus
• Scan finding:no mass,no free fluid
• IMP:PERFORATED GASTRIC ULCER
MANAGEMENT
10/9/2017 10/9/2017@6pm
IV cefobid 2g stat & 1g BD For GXM 4 pints-2 pints to OT
IV Flagyl 500mg stat & TDS -2 pints reserve
Keep NBM 4 pints:2 pints normal Repeat VBG
saline
Call OT once 2 pints packed cell
:2 pints Destrose is ready
IV pantoprazole 40mg OD
IV tramadol 50mg OD
For PGU repair today
CT abdomen
Chest Xray
ECG
To post case for repair PGU KIV bowel
resection
To insert RYLE'STube Free Flow and
aspirate 4 hourly
Continue antibiotic
Start IV pantoprazole stat 40mg & ON
Keep NBM with IV drip 4 pints normal
saline
11/9/2017
Patient post laparotomy with
perforated gastric ulcer repair under
GA
Patient intubated ETT 7.0mm
Observation taken and recorded:
– BP:99/66mmhg
– PR:102
– SPO2:100%
IVD 1 pint havt
IV ivoadrenaline
Tripple lumen at right
subclavian(inserted in OT)
2 silicone drain size 8
CBD inserted
Ryle's tube free flow
Specimens:Peritoneal fluid for c&s
:Ulcer edge for HRL
Send patient to icu
Management/progress in ICU
– Post op:Laparotomy and PGU repair
– Saturating well under NPO2
– DXT stable
– Tolerating clear fluid 50cc/3h on
fentanyl
Condition on discharge from ICU
– GCS:eye opening-4
– :Verbal response-5
– :Motor response-6
– BP:180/70mmHg
– HR:87bpm
– RR:14bpm
• SPO2:100% under NPO2
Post ICU discharge plan:
– Medication:T.Bizoprolol 1.25mg OD
– :T.Amlodiphine 10mg OD
– IV vitamin K 5mg OD x3/7
– Oxygen therapy:NPO2
– IV fluids:QSDI 60cc/h
– Feeding:clear fluid 50cc/3h
12/9/2017
– Wound inspection
– Cont ABX
– Reeducate PT
– Chest physio and incentive spirometry
– Neb saline 4 hourly
– Keep all drain
– Drain charting per shift
– TED stocking
HEALTH EDUCATION:
Stop smoking
Beware of NSAIDs
Stop drink alcohol
Eat a diet rich in fruits and vegetables
Manage stress
SUMMARY

Mrs.Chan Sew Ying is 56 years old,female who presents to

HTAR with abdominal pain x2/7 since 9/9/2017@6pm and
vomiting x1/7,2 episode.She describes pain at Right Illiac Forsa
radiate to lower part at abdomen.She has history of hypertension
with vital sign BP:107/80,PR:90,RR:19,T:37c.Differential
diagnosis is appendicitis ,continue investigation with blood test,
UFEME,AXR,CT abdomen.Result
perforated@pylorus.IMP:perforated gastric ulcer continue
management and surgery.
summary
Classically, when a patient's peptic ulcer perforates, it floods his peritoneum
with the acid contents of his stomach, and gives him a sudden agonizing pain.
Sign and symptom is pale, sweating, and hypotensive, with a fast pulse
(usually), a normal temperature, and a stomach which is not distended.
Typically, his abdomen has a board-like rigidity, unlike that in any other
disease, which may be so complete that you cannot elicit tenderness, except
when you examine him rectally.