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CASE CONFERENCE: Peptic Ulcer Disease

CASE CONFERENCE: Peptic Ulcer Disease. Maranion , Maria Cristina Marayag , Eric John Marcelo, 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. Admission.

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CASE CONFERENCE: Peptic Ulcer Disease

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  1. CASE CONFERENCE:Peptic Ulcer Disease Maranion, Maria Cristina Marayag, Eric John Marcelo, Pamela Marcial, KarmiMargarette

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

  3. HPI

  4. HPI

  5. HPI

  6. HPI Admission

  7. 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

  8. 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

  9. 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

  10. 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 – Adynamicprecordium, AB 5th LICS MCL, apex S1>S2, base S2>S1, (‐) murmurs

  11. PE Findings • Abdomen – Flat, no scars or striae, NABS, tympanic upon percussion, Traube’sspace not obliterated, (+) direct and rebound tenderness upper abdominal region with guarding(‐) Rovsing’ssign, (‐) psoas sign • DRE: – no skin tags seen, slight sphincteric tone, smooth rectal mucosa, (‐) palpated masses, (‐) pararectaltenderness, brown stool on tactatingfinger

  12. 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.

  13. 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

  14. Clinical Assessment • Acute abdomen secondary to perforated viscus secondary to PUD

  15. DISCUSSION: Salient Features and Pertinent Findings Subjective 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 • Positives • Epigastric pain relieved by antacid and food intake • Melena • Epigastric pain becoming generalized and refractory to omeprazole • 40 pack years of smoking hx

  16. 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

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

  18. Plans • CBC, U/A, Na, K, serum amylase and lipase • CXR, 12 L‐ECG • Emergency exploratory laparotomy, primary repair with omental bumress

  19. 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.

  20. Journal: Emergency laparoscopy – current best practice • Used to differentiate: • Trauma • Perforated PUD • Appendicitis • Gynecologic conditions

  21. 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

  22. Lab Results: CBC

  23. Lab Results: Urinalysis

  24. Lab Results: Electrolytes

  25. Lab Results: Serum Amylase and Lipase

  26. 12-Lead ECG Result • Done 05/14/09 • Normal findings

  27. CXT 5/13/09

  28. 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

  29. 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

  30. 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.

  31. Journal: Management of large perforation of duodenal ulcers

  32. 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

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