A case of Perforated Peptic Ulcer

Presented & discussed byMaj Parvesh Malik

Case Presentation

• A 34 year old serving soldier• No known co morbidities• Referred from unit MI Room• Came to SOPD at around 1100 hrs on

24/06/2013

Presenting Complaints

• Pain Upper Abdomen since 0700 hrs same day.

Pain over Epigastrium and Rt. HypochondriumRadiating to whole of abdomenSudden in onset, Colicky initially later Continuous.Constant burning sensation Aggravated by movement. Relieved by lying still

Area of Pain

• No h/o Fever, Vomiting, diarrhoea, constipation,

• No h/o Chest pain, breathlessness.

• Pt is a Chronic Smoker and chews Tobacco.• Smokes 5-6 cigarettes / day• Also gives h/o occasional Alcohol consumption.• Last night he smoked 10 – 12 cigarettes while

watching cricket match.

• No h/o similar complaints in the past.• No other significant history of past medical or

Surgical illness.

On Examination

• General ExaminationPatient average built and nourished.Alert, Conscious and well oriented.Sweating profuselyPulse : 78/min Regular, Normal VolumeBP : 154/100 mm Hg right arm supineAfebrileNo Pallor, Icterus, Cyanosis, Clubbing,

Lymphadenopathy, Pedal Edema

Systemic Examination

• Respiratory SystemChest clinically clearAirway Entry bilateral and equal

• Cardiovascular SystemS1 S2 heard, no murmurs appreciable

• Central Nervous SystemAlert, Conscious and well orientedNo neurological deficit

• Per AbdomenGuarding and Rigidity present over Rt Hypochondrium

and Epigastrium.Rt Hypochondrium and Epigastrium not moving with

respiration.Tenderness present over Rt. Hypochondrium and

Epigastrium.Rest of the abdomen soft, non tender, moving with

respiration.Not distendedNo rebound tenderness Tympanic note over whole of abdomen on percussionBowel sounds sluggish

DIFFERENTIAL DIAGNOSIS

• Perforated Peptic Ulcer• Acute Cholecystitis• Acute Pancreatitis• Ruptured Liver Abscess

Investigations(Urgent)

• Dated 24/06/2013

Hb : 14.7 g/dlTLC : 11500/cu mm P85 L10 M02 E03Platelets : 2.7 lakh/cu mmBT : 2’ 30” CT : 5’ 30”Serum Amylase : 54 U/LS. Urea / Creat : 20 / 0.8 mg/dlLFT with enzymes : WNL

X Ray Chest PA View – Free air under Diaphragm

DIAGNOSIS

• Perforated Peptic Ulcer with Peritonitis

Management Plan

• Resuscitation & Exploratory Laparotomy

During this period, he was kept NPO, on iv fluids, Continuous Ryle’s Tube aspiration, Inj Pantoprazole 40 mg 12 hrly and parenteral

antibiotics.

Operation Details

• He was taken up for Exploratory Laparotomy under General

anesthesiaSupraumbilical midline incision Operative Findings :0.5 cm Perforation present in ant aspect of first

part of duodenumPus present in Morrison's pouch and Pelvic Cavity Modified Graham Patch repair done Peritoneal Lavage done

Perforation closed with Vicryl 2-0 with omentum patch.( Modified Graham Patch Repair )

ADK placed in Morrison’s pouch.

Post operative recovery - uneventful.AfebrileVitals stableWound HealthyDrain removed on 30.06.13 ( Day 6 Post Op )Patient put on Anti H.pylori regimenStaples removed on 03.07.2013 (Day 9 Post

Op)

TIME TO CLEAR THE DOUBTS….