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VU Medisch Centrum

VU Medisch Centrum

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VU Medisch Centrum

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  1. VU Medisch Centrum Afdeling MDL Endoscopy of Peptic Perforations Chris Mulder 31 januari 2006

  2. Suspicion of perforation (oesophagus) • Pain of breathing • Subcutaneous emphysema • Localized pain • Pain and/or coughing after drinking • Pleural fluid • Stripe of air along mediastinum Wesdorp, Gastroenterology 1982

  3. Treatment • NPO • IV-fluid / antibiotics • NGT with suction

  4. Upper-GI perforations • Esophageal - dilatation - mucosal resection - reflux esophagitis - sclerotherapy • Foreign bodies • Gastric - ulcer disease - NSAID • Gastrointestinal - lymphoma

  5. Sensitivity (symptoms positive / disease positive) and specificity (symptoms negative / disease negative) of abdominal pain as a marker for ulcer disease are low. Spiro, NEJM 1974

  6. PUD complications • Hemorrhage • Perforation • Penetration • Obstruction

  7. PUD follow-up • 7% perforation • UD perforates anteriorly • UV perforates anterior lesser curvature • UD penetrates pancreas • UV penetrates left lobe liver

  8. Incidence of operations for perforated peptic ulcer decreased >> 50% Sanchez-Bueno, Dig Surg 2001

  9. PUD perforation • Abdominal X-ray (< 80%) • Spiral CT • Endoscopy

  10. PUD perforation • NG-aspiration • IV-fluids • IV-PPI / antibiotics • Sealing (Berne TV, 1989) • Clipping ??? << 1 cm ?? • Surgery Treatment of Choice (laparoscopic / classical) Berne TV, Arch Surg 1989 Donovan A, Arch Surg 1998 Gul YA, Ir J Med Sci

  11. Risk of perforation in PUD • Heater probe • Gold probe • Laser therapy (not documented) • APC erbe (not documented)

  12. Where to clip ? How to clean the peritoneal cavity ?

  13. PUD perforation 200 MDL-artsen gemailed 10 januari 2006 2004-2006 • 1 MDL-arts: 2x geclipt: 2x mislukt • 2 MDL-arts: 3x glue: 1x gelukt • Verder vele meldingen over clippen van colon-perforaties en clippen van PEG openingen ++ Berne TV, Arch Surg 1989 Donovan A, Arch Surg 1998 Gul YA, Ir J Med Sci

  14. Applikation eines Ovesco-Clips zum Verschluß einer Perforation im Dickdarm Quelle: Ovesco Endoscopy GmbH (see Google)

  15. PUBMED No articles about successfull clipping of PUD Chr. J. Mulder 30-01-2006

  16. Nothing is mentioned about endoscopic therapy of PUD perforations

  17. Cases of perforated duodenal ulcer treated in College of Medical Sciences, in Bharatpur.Laparoscopy followed by simple closure of perforation reinforced with pedicled omental patch is treatment of choice Kathmandu Univ Med Journal Gupta et al, 2003;1:166-9