CASE CONFERENCE:Peptic Ulcer Disease

Maranion, Maria CristinaMarayag, Eric JohnMarcelo, Pamela

Marcial, Karmi Margarette

General Information

• J.D., 49 y/o, M• Filipino, Roman Catholic• Married• Jeepney Driver• Chief Complaint: Abdominal Pain

HPI

HPI

HPI

HPI

History• Past medical History– (-) HPN, DM, Asthma– (-) previous surgeries or BT

• Family History– (-) HPN, DM, Asthma

• Personal and Social History– Smoker (40 pack yrs)– Occasional alcoholic beverage drinker – Diet: mixed – Denies illicit drug use

ROS• No fever, no weight loss, no weakness, no anorexia• No rashes, no increased pigmentation• No visual dysfunc4on, no redness, no itchiness, no eye pain, excessive

lacrima4on• No deafness, no tinnitus, no aural discharge• No epistaxis, no nasal discharge• No gum bleeding, no throat soreness• No dyspnea, no shortness of breath, no chest pain, no palpita4ons• No diarrhea, no cons4pa4on, no nausea, no vomi4ng, no heartburn, (+)

melena• No dysuria, hematuria, incontinence• No limita4on of movements, joint pains and swelling of joints• No heat or cold intolerance, no polyphagia, polydipsia, polyuria• No convulsions, no headache, no sleep disturbances

PE Findings• General

– conscious, coherent, not in cardiorespiratory distress• Vital Signs:

– BP: 140/90 mmHg– PR = 90 bpm, regular– RR = 22 cpm– T = 37.6 oC

• Skin– Warm, moist– no active dermatoses

PE Findings• HEENT

– pink palpebral conjunctivae, anicteric scelrae, no nasoaural discharge, moist buccal mucosa, tonsils not enlarged, nonhyperemic posterior pharyngeal walls– Supple neck, no palpable cervical lymph nodes, thyroid not enlarged

• Thorax– symmetric chest expansion, ( ) retractions, resonant on ‐both lung fields, equal and clear breath sounds

• Cardiovascular– Adynamic precordium, AB 5th LICS MCL, apex S1>S2, base S2>S1, ( ) murmurs‐

PE Findings• Abdomen

– Flat, no scars or striae, NABS, tympanic upon percussion, Traube’s space not obliterated, (+) direct and rebound tenderness upper abdominal region with guarding ( ) Rovsing’s sign, ( ) psoas ‐ ‐sign

• DRE:– no skin tags seen, slight sphincteric tone, smooth rectal mucosa, ( ) palpated masses, ( ) ‐ ‐pararectal tenderness, brown stool on tactating finger

PE Findings• Extremities

– Pulses were full and equal, no cyanosis, no edema, no limitation of movement in all extremities were noted.

• Neurological Examination– Conscious, coherent, oriented to 3 spheres– Cranial nerves: pupils 2 3 mm ERTL, EOMs full and ‐equal, V1V2V3 intact, can clench teeth, can raise eyebrows, can close eyes slightly, can smile, can frown, can puff cheeks, no facial asymmetry, no hearing loss, can turn head from side to side with resistance, can shrug shoulders, tongue midline on protrusion.

PE Findings

• Neurologic Exam– Motor: MMT of 5/5 on all extremi4es– Cerebellar: can do FTNT & APST– DTR’s: ++ on all extremities– No sensory deficit– ( ) Babinski‐– ( ) nuchal rigidity‐

Clinical Assessment

• Acute abdomen secondary to perforated viscus secondary to PUD

DISCUSSION: Salient Features and Pertinent Findings

Subjective• Positives

– Epigastric pain relieved by antacid and food intake

– Melena– Epigastric pain becoming

generalized and refractory to omeprazole

– 40 pack years of smoking hx

Objective• Positives

– T = 37.6 oC– RR = 22 cpm– BP: 140/90 mmHg– (+) direct and rebound

tenderness upper abdominal region with guarding

• Negatives– ( ) Rovsing’s sign, ( ) psoas ‐ ‐

sign

Journal: Risk Factors for PUD – a population based prospective cohort study comprising 2416 Dasnish

adults• S Rosenstock, T Jørgensen, O Bonnevie, L

Andersen• Gut 2003;52:186–193

Journal: Risk Factors for PUD – a population based prospective cohort study comprising 2416 Dasnish

adults

Plans

• CBC, U/A, Na, K, serum amylase and lipase• CXR, 12 L ECG‐• Emergency exploratory laparotomy, primary

repair with omental bumress

Journal: Emergency laparoscopy – current best practice

• Oliver Warren, James Kinross, Paraskevas Paraskeva, Ara Darzi

• World Journal of Emergency Surgery 2006 Volume 1:24; August 31, 2006

• Emergency laparoscopic surgery allows both the evaluation of acute abdominal pain and the treatment of many common acute abdominal disorders.

Journal: Emergency laparoscopy – current best practice

• Used to differentiate:– Trauma– Perforated PUD– Appendicitis– Gynecologic conditions

Patient’s Course in the Ward

• 5/14/09– Admimed to MSW– Requested for CBC, U/A, CXR, Na, K, 12 L‐ECG, serum amylase and lipase– Scheduled for OR on the same day

Lab Results: CBCDate 05/14/09 Results Ref. Range

HGBHCTPlateletWBCNeutLymph.

1360.41332 12.70.830.17

120-1700.37-0.54150 – 4504.5 – 10.000.50 – 0.700.20 – 0.40

Lab Results: Urinalysis

Date 05/14/09ColorTransparencypHSp. GravityAlbuminSugarRBCWBC

Dark yellowSl. Turbid6.01.020Negative++0-3/hpf 0-3/hpf

Lab Results: Electrolytes

Date 05/14/09

Result Ref. Range

Sodium

Potassium

136

3.5

137-147

3.5-5.1

Lab Results: Serum Amylase and Lipase

Date 05/14/09 Results Ref. RangeAmylase 65.0 10-130 IIU/LLipase 31.8 13-60 IU/L

12-Lead ECG Result

• Done 05/14/09• Normal findings

CXT 5/13/09

CXR 5/13/09

• There is a linear lucency noted in the subdiaphragmatic area suggestive of pneumoperitoneum

• Suspicious infiltrates are seen in the right apex and right infraclavicular area.

• The heart is not enlarged• The right hemidiaphragm is slightly elevated• Sulci are intact

Journal: Management of large perforation of duodenal ulcers

• Sanjay Gupta, Robin Kaushik, Rajeev Sharma and Ashok Attri

• BMC Surgery 2005, 5:15; 25 June 2005

Journal: Management of large perforation of duodenal ulcers

• The case files of 162 patients who underwent emergency laparotomy for duodenal ulcer perforations over a period of three years (2001 – 2003) were retrospectively reviewed and sorted into groups based on the size of the perforations – small, large, giant.

• These groups of patients were then compared with each other in regard to the patient particulars, duration of symptoms, surgery performed and the outcome.

Journal: Management of large perforation of duodenal ulcers

Post-op

• Findings– 1x1.5 cm perforation at the anterior portion of the 1st part of the duodenum and minimal amount of purulent peritoneal fluid noted

• Patient was given D5 NR• Patient was put on pantoprazole 40 mg/IV OD

and sulperazone (sulbactam+cefoperazone) 1.5 g/IV q8 hours