Acute Abdominal Pain

1. Alonzo.Amaro.Amolenda Anacta.Andal Acute Abdominal Pain

2. Beginning Data • Male, 45 year old • Chief Complain: Severe Abdominal Pain

3. History of Present Illness • Crampy, epigastric pain • Relieved by food intake or antacids • Melena • UGI endoscopy: Erosive Gastritis • Unrecalled medications 3 years PTA • Epigastric pain • Melena • Self‐medicated: Omeprazole 1 year PTA

4. History of Present Illness A few hours PTA • Severe epigastric pain ADMISSION

5. Past Medical History (-) HPN (-) DM Family History (-) Cancer

6. Personal History • 10 pack‐years smoking • Drinks alcoholic beverage for 8 years

7. Physical Examination • Conscious, coherent, in distress • BP= 140/90, PR= 105/min, RR=26/min ,T= 37.8 C • Warm moist skin, no active dermatoses • Pink palpebral conjunctivae, anictericsclerae • Heart and Lungs: regular rate and rhythm, clear breath sounds • Abdomen : flat, hypoactive bowel sounds, 􂈗 guarding and tenderness on all quadrants • DRE: brown stool on tactating finger

9. Salient Features Pertinent Objective • PR= 105/min, RR=26/min • Abdomen : flat, hypoactive bowel sounds, (+) guarding and tenderness on all quadrants • DRE: brown stool on tactating finger Pertinent Subjective • Male, 45 y/o • Crampy, epigastric pain • Relieved by food intake or antacids • Melena • UGI endoscopy: Erosive Gastritis • 10 pack‐years smoking • Drinks alcoholic beverage for 8 years

11. Clinical Impression • Peptic Perforation

12. Initial Diagnostic Measures for Perforated PUD • Upright CXR or lateral abdominal decubitus radiography. • Upper GI contrast study with water soluble contrast.

13. Initial Therapeutic Measures for Perforated PUD • Fluid resuscitation with replacement of fluid and electrolytes. • Nasogastric decompression. • Administer broad spectrum antibiotics. • Insert Foley catheter. • Insert central venous line or Swan-Ganz artery catheter.

14. TREATMENT PLAN

15. Surgical Therapy Surgery is recommended in patients who present with the following: • Hemodynamic instability • Signs of peritonitis • Free extravasation of contrast on upper GI contrast studies

16. Preoperative Management • Fluid resuscitation • NGT insertion • Insertion of Foley catheter • Broad-spectrum antibiotics

17. Intraoperative Details • Exploratory Laparotomy • life-threatening, comorbid conditions & severe intraabdominal contamination  Graham patch using omentum • Several full-thickness simple sutures are placed across the perforation • A segment of omentum is placed over the perforation & silk sutures are secured.

18. OMENTAL PATCH

19. Intraoperative details • Minimal contamination, stable patient • highly selective vagotomy • truncal vagotomy and pyloroplasty • vagotomy and antrectomy.

20. Postoperative Details • NGT can be discontinued on postoperative day 2 or 3, depending on the return of GI function, and diet can be slowly advanced. • H. pylori infectionantibiotic regimen • Follow-up with an upper endoscopy to evaluate the area of ulcer and healing of the perforation site 4-6 weeks after surgery.

21. Possible Complications • Pneumonia (30%) • Wound infection, abdominal abscess (15%) • Cardiac problems (especially in those >70 y) • Diarrhea (30% after vagotomy) • Dumping syndromes (10% after vagotomy and drainage procedures) • Gastric outlet obstruction • Recurrent peptic ulcer

22. Laparoscopic Surgery in Peptic Perforation Closure • Comparative Study Of Laparoscopic Versus Open Peptic Perforation Closure • January 2008 • M.M. Porecha M.S., et. al. • M.P. Shah Medical College and G.G. Hospital, Jamnagar India

23. Laparoscopic Surgery in Peptic Perforation Closure • Objective: • To evaluate safety & efficacy of laparoscopoic repair for perforated peptic ulcer in routine clinical practice. • To evaluate whether it is justifiable to perform laparoscopic peptic perforation closure and to find out and evaluate whether it can stand against conventional laparotomy to treat peptic perforation. • To evaluate whether laparoscopic peptic perforation closure is better than conventional laparotomy for peptic perforation closure in terms of benefits of minimal invasive surgery

24. Laparoscopic Surgery in Peptic Perforation Closure • Study: • non – randomized and prospectivecomparative study • 50 patients with peptic perforated ulcer • 25 – 43 years old • 25 patients – open repair • 25 patients - laparoscopic

26. Conclusion • laparoscopic suture with omental patch repair is an attractive and superior alternative to conventional surgery with extraordinary benefits of minimal invasive surgery such as • Shorter operative time and reduced postoperative pain. • Lesser requirement of nasogastric aspiration and lesser wound infection. • Lesser blood loss and lesser transfusion requirement. • Shorter hospital stay and early rehabilitation. • Earlier resumption of oral feeding and lesser antibiotic requirement. • Lesser occurrence of incisional hernia and burst abdomen and lesser occurrence of pelvic abscess. • Earlier return to normal physical activity and earlier return to work.

27. Andal, Charlotte RISKS/COMPLICATIONS

28. RISKS • Elderly, chronically ill, and are taking one or more ulcerogenic drugs • Mean age is >60 y.o. • History of ulcer disease or symptoms of an ulcer is important • one-third of patients had a history of PUD • 32% of patients who presented with perforation were taking H2 blockers, antacids, or both • History of smoking, alcohol abuse, and postoperative stress

29. COMPLICATIONS • Gastric and duodenal contents may leak into the peritoneum • Gastric and duodenal secretions, bile, ingested food, and swallowed bacteria Peritonitis • Increased risk of infection and abscess formation • Third-spacing of fluid in the peritoneal cavity • Inadequate circulatory volume, hypotension, and decreased urine output

30. COMPLICATIONS • More severe cases shock • Abdominal distension as a result of peritonitis and subsequent ileus • May interfere with diaphragmatic movement, impairing expansion of the lung bases  Atelectasis