RAMSAY SIME DARBY HEALTHCARE COLLEGE

DIPLOMA IN MEDICAL ASSISSTANT

SEMESTER 4

INDIVIDUAL ASSIGNMENT

INTAKE: DMA SEPT 2015

SUBJECT CODE:

SUBJECT NAME: SURGICAL

NAME:NORSHAHIDAH BINTI ZAINAL

ID: SD01-201704-002565

ACADEMIC FACILATOR: Ms. ROSMARINA BT SEKOF

DEFINITION
Perforated ulcer disease is defined as an ulcer occuring in a region that touches gastric
acid and pepsin and usually refers to gastric ulcer or duodenal ulcer.Ulcers average between
one-quarter and one-half inch indiameter. They develop when digestive juices produced inthe
stomach, intestines, and digestive glands damage thelining of the stomach or duodenum. Gastric and
duodenal ulcers are two kinds of peptic ulcers. A peptic ulcer is a sore that’s on the inside of
the stomach lining (gastric) or the upper part of the small intestine (duodenal).A person can
have one or both ulcers at the same time. Having both types is known as gastroduodenal.

TYPES OF PEPTIC ULCERS

Gastric ulcers: A common type of ulcer, these occur on the inside of the stomach.
Duodenal ulcers: These are located at the beginning of the small intestine (called the
small bowel or duodenum).
Esophageal ulcers: These occur inside the esophagus (the tube that carries food from
your throat to your stomach).

PATHOPHYSIOLOGY

 Damage to the mucusal with alcohol abuse,smoking and use of NSAIDs

 Infection of Helicobacter Pylori
 Erosions of mucuous membrane
 Low function of mucusal cell and low of mucous
 Erosive gastritis
 Mucusal ulcerations
 Severe ulcerations:sign and symptoms
 epigastric pain
 Hemathemesis
 Pale
 pyrosis

CAUSES OF PERFORATED GASTRIC ULCER

1.H. pylori
 A major causative factor (60% of gastric and up to 50–75%[18] of duodenal ulcers) is
chronic inflammation due to Helicobacter pylori that colonizes the antral mucosa. The immune
system is unable to clear the infection, despite the appearance of antibodies. Thus, the bacterium
can cause a chronic active gastritis (type B gastritis). Gastrin stimulates the production of gastric
acid by parietal cells. In H. pylori colonization responses to increased gastrin, the increase in acid
can contribute to the erosion of the mucosa and therefore ulcer formation.
2.NSAIDs
 Another major cause is the use of NSAIDs, such as ibuprofen and aspirin. The gastric mucosa
protects itself from gastric acid with a layer of mucus, the secretion of which is stimulated by
certain prostaglandins. NSAIDs block the function of cyclooxygenase 1 (COX-1), which is
essential for the production of these prostaglandins. COX-2 selective anti-inflammatories (such
as celecoxib ) preferentially inhibit COX-2, which is less essential in the gastric mucosa, and
roughly halve the risk of NSAID-related gastric ulceration.
3.Stress
 Stress due to serious health problems such as those requiring treatment in an intensive care unit is
well described as a cause of peptic ulcers, which are termed stress ulcers.While chronic life stress
was once believed to be the main cause of ulcers, this is no longer the case. those with other
causes such as H. pylori or NSAID use.
4.Diet
 Dietary factors such as spice consumption, were hypothesized to cause ulcers until late in the
20th century, but have been shown to be of relatively minor importance. Caffeine and coffee, also
commonly thought to cause or exacerbate ulcers, appear to have little effect.Similarly, while
studies have found that alcohol consumption increases risk when associated with H.
pylori infection,

RISK FACTOR OF PERFORATED GASTRIC ULCER

 Drinking too much alcohol
 Regular use of aspirin, ibuprofen, naproxen, or other nonsteroidal anti-inflammatory
drugs (NSAIDs). Taking aspirin or NSAIDs once in a while is safe for most people.
 Smoking cigarettes or chewing tobacco
 Being very ill, such as being on a breathing machine
 Having radiation treatment
SIGN AND SYMPTOM OF PERFORATED GASTRIC ULCER
 abdominal pain, classically epigastric strongly correlated to mealtimes. In case of
duodenal ulcers the pain appears about three hours after taking a meal;
 bloating and abdominal fullness;
 waterbrash (rush of saliva after an episode of regurgitation to dilute the acid in
esophagus - although this is more associated with gastroesophageal reflux disease)
 nausea and copious vomiting;
 loss of appetite and weight loss;
 hematemesis (vomiting of blood); this can occur due to bleeding directly from a gastric
ulcer, or from damage to the esophagus from severe/continuing vomiting.
 melena (tarry, foul-smelling feces due to presence of oxidized iron from hemoglobin);
 rarely, an ulcer can lead to a gastric or duodenal perforation, which leads to acute
peritonitis, extreme, stabbing pain, and requires immediate surgery.

DIAGNOSTIC

 Blood test: The presence of certain infection-fighting cells could mean you have an
H. pylori infection.
 Stool culture: A stool sample is sent for lab testing. H. pylori bacteria will grow over
the course of a few days, if present.
 Urea breath test: A urea breath test involves swallowing a pill that contains carbon
and breathing into a bag that’s sent to a lab. High levels of carbon dioxide can
indicate presence of H. Pylori.
 An esophagogastroduodenoscopy (EGD): a form of endoscopy, also known as
 a gastroscopy, is carried out on people in whom a peptic ulcer is suspected

TREATMENT

1.Younger people with ulcer-like symptoms are often treated with antacids or H2
antagonists before endoscopy is undertaken.
2.People who are taking nonsteroidal anti-inflammatories (NSAIDs) may also be prescribed
a prostaglandin analogue (misoprostol) in order to help prevent peptic ulcers.
3.Acid reducing medication:H2 antagonists or proton-pump inhibitors decrease the amount of acid in
the stomach, helping with healing

PROTON PUMP INHIBITORS DRUG :Drug that block acid production and promote healing of ulcer

 Omeprazole (Prilosec, Zegerid)

  Lansoprazole (Prevacid)
 Rabeprazole (Aciphex)
 Pantoprazole (Protonix)
 Esomeprazole (Nexium)

Acid reducers, also called H2 blockers, reduce acid production and relieve ulcer pain.

 Cimetidine (Tagamet)
 Ranitidine (Zantac)
 Famotidine (Pepcid)
 Nizatidine (Axid)
4.Antibiotic
 When H. pylori infection is present, the most effective treatments are combinations of 2
antibiotics (e.g. clarithromycin, amoxicillin, tetracycline, metronidazole) and a proton-pump
inhibitor (PPI), sometimes together with a bismuth compound. In complicated, treatment-
resistant cases, 3 antibiotics (e.g. amoxicillin + clarithromycin + metronidazole) may be used
together with a PPI and sometimes with bismuth compound. An effective first-line therapy for
uncomplicated cases would be amoxicillin + metronidazole + pantoprazole .

5.Surgery

 Perforated peptic ulcer is a surgical emergency and requires surgical repair of the perforation.
Most bleeding ulcers require endoscopy urgently to stop bleeding with cautery, injection,
or clipping.
 Laparoscopy

Laparoscopy allows the surgeon to explore and wash out the entire peritoneal cavity. The
benefits of less postoperative pain, shorter length of hospital stay and earlier return to
work after laparoscopic surgery for perforated peptic ulcer may offset the costs needed
for performing laparoscopic repair.Laparoscopic repair also offers the advantage of better
cosmesis.Laparoscopic approach to hemodynamically stable patients with free air at X-
ray and/or CT for diagnostic purposes.t laparoscopic repair of PPU in stable patients with
PPU <5mm in size and in presence of appropriate laparoscopic skills

 Open surgery
Open surgery in presence of septic shock or in patients with absolute contraindications
for pneumoperitoneum.We suggest open surgery in presence of perforated and bleeding
peptic ulcers, unless in stable patients with minor bleeding and in presence of advanced
laparoscpic suturing skills

COMPLICATION

Surgical complications include the following:

 Pneumonia (30%)

 Wound infection

 Abdominal abscess (15%)

 Cardiac problems (especially in those younger than 70 years)

 Diarrhea (30% after vagotomy)

 Dumping syndromes (10% after vagotomy and drainage procedures)

HEALTH EDUCATION

Life styles changes:

 Diet:
 Stop smoking:If you smoke, you are already at increased risk for getting an
ulcer.ulcers take longer to heal in smokers and that the ulcer medication you are
taking may be less effective.
 Beware of NSAIDs:NSAIDs, such as aspirin, ibuprofen, and many others, are taken
for pain and fever, but can cause an ulcer if used too often.
 Stop drink alcohol: Stop drinking alcohol if you want to completely reduce your
risk of additional ulcers and help your body heal.
 Eat a diet rich in fruits and vegetables: A comprehensive review of published
studies related to ulcer prevention shows that eating a lot of fiber from fruits and
veggies may help reduce your risk of ulcer.
 Manage stress: Most ulcers are caused by H. pylori or NSAIDs, but for a small
group of people, stress does appear to have a connection to ulcers.nd in many
vegetables, may also be helpful

PATIENTS PARTICULARS:
1. MEDICAL RECORD:
2. NAME:MRS.CHAN SEW YING
3. GENDER:FEMALE
4. AGE:56 YEARS OLD
5. ETHNIC:CHINESE
6. OCCUPATION:FACTORY WORKER
7.

Chief complaint:
Mrs.Chan Sew Ying is 56 years old,female who presents to HTAR with abdominal pain
x2/7 since 9/9/2017@6pm and vomiting x1/7,2 episode.She describes pain at Right Illiac
Forsa radiate to lower part at abdomen.

History of present illness:

1.Abdominal pain x2/7
 Colicky pain in nature
 Sudden onset
 Initially at Right Illiac Forsa radiate to lower part at abdomen
2.Vomiting x1/7
 2 episodes
 Fluid content
 No Bilions,no blood

Otherwise:BO normal
:No fever
:PU normally
:No URTI/UTI
:No LOA/LOW
:No altered bowel habit
:No sob,chest pain,palpitation
:No diarhea
O/E:Alert,tachypniec
BP:107/60
PR:90
RR:19
T:37 c

Mrs.Chan Sew History

 Past medical history(PMHx):Hypertension,on Antihypertension ,follow up Klinik

 Kesihatan Klang.
:Endomentrial CA stage 1,TAHBSO done,follow up hospital Kelantan.
 Past Surgical History(PSHx):Total Abdominal Hysterectomy with Bilateral Salpingo-
Oophorectomy(TAHBSO)-JUNE 2016
:Compeleted radiotherapy in NOV 2016,follow up at Institut Kanser
Putrajaya
 Medication:Amlodipine 10g OD
 Social history:Married with 1 child
:Work as factory worker
:Non smoker,non alcoholic
 Family History:Father had lung CA
 Menstrual History:Previously claimed regular period with occasional dysmenorrhea.

PHYSICAL EXAMINATION

Head to Toe(oral,throat,ear,eye and nasal):

 Oral hygiene was good
 No discharge from ear and nasal
 The eye shows no sign of ptosis,conjuctiva was not pale

Neck:
 No swelling
 No lump

Chest region:
Heart:
 Normal heart sound (lub dub sound)
 Regular rhythm and good good volume
 No palpation

Lungs:
 Breathing normally
 Clear lung
 Chest symmentry during respiration not asymmetrical
 No crepitation
 No chest deformities

Abdomen:
 Guarded,not distended,generalized tenderness
 Previous Scar,well healed,no hernia
 Soft
 No mass
 Rebound negative
 Bowel sound present,not hyperactive

Nervous system:
 Sensation normal
 Patient was alert and concious

Upper&lower limbs:
 No upper limb swelling
 Patient can walk

Genital&rectum:
 Normal bowel habit(x1 day)
 PR:brownish stool,no impacted stool

Investigation

BLOOD INVESTIGATION:
 fbc:HB 12,WBC 12.16,PLT 294,HCT 40
 Rp:NA 139,K 3.7,UREA 4.4,CREAT 43
 Lft:TP 76,A/B 45,ALT 39,ALP 75,TW 10.1
 vbg:PH 7.35,PLO 43.4,HW 22.61
 Lact:3.3

UFEME:Negative
AXR:fecal loaded,no dilated bowel
CXR AP sitting::no air under diaphragm
PR:Brownish stool,no impacted stool
CT abdomen:Perforated@pylorus
Scan finding:no mass,no free fluid

MANAGEMENT PLAN

10/9/2017
 IV cefobid 2g stat & 1g BD
 IV Flagyl 500mg stat & TDS
 KNBM 4 pints:2 pints normal saline
:2 pints Destrose
 IV pantoprazole 40mg OD
 IV tramadol 50mg OD
 CT abdomen
 Chest Xray
 For ecg
 To post case for repair PGU KIV bowel resection
 To insert RTFF and aspirate 4 hourly
 Continue antibiotic
 Admit 3A
 Start IV pantoprazole stat 40mg & ON
 KNBM with IV drip 4 pints normal saline

10/9/2017@6pm
 For 6xm 4 pints-2 pints to OT
-2 pints reserve
 Repeat VBG
 Call OT once 2 pints pc is ready
 For PGU repair today

11/9/2017
 Patient post laparotomy with perforated gastric ulcer repair under GA
 Patient intubated ETT 7.0mm
 Onservation taken and recorded:
BP:99/66mmhg
PR:102
SPO2:100%
 IVD 1 pint havt
 IV ivoadrenaline
 Tripple lumen at right subclavian(inserted in OT)
 2 silicone drain size 8
 CBD inserted
 Ryles tube free flow
 Specimens:Peritoneal fluid for c&s
:Ulcer edge for HRL
 Send patient to icu
12/9/2017
 Wound inspection
 Cont ABX
 Reeducate PT
 Chest physio and incentive spirometry
 Neb saline 4 hourly
 Keep all drain
 Drain charting per shift
 TED stocking

Management/progress in ICU
Post op:Laparotomy and PGU repair
Saturating well under NPO2
DXT stable
Tolerating clear fluid 50cc/3h on fentanol

Condition on discharge from ICU

GCS:eye opening-4
:Verbal response-5
:Motor response-6
BP:180/70mmhg
HR:87
RR:14
SPO2:100% under NPO2

Post ICU discharge plan:

Medication:T.Bizoprolol 1.25mg OD
 :T.Amlodiphine 10mg OD
IV vitamin K 5mg OD x3/7
Oxygen therapy:NPO2
IV fluids:QSDI 60cc/h
Feeding:clear fluid 50cc/3h

HEALTH EDUCATION
 Take NSAIDs with meals or medications that protect your stomach lining, if you
need NSAIDs.
 Avoid or limit caffeinated drinks and alcohol. They may worsen your symptoms.
 Refrain from smoking, as it can slow healing.
 Take all of your antibiotics, if prescribed, for H. pylori infections. Not taking the
entire amount can bring the infection back.
 Take steps to reduce the stress in your life. , reducing stress can keep gastric and
duodenal ulcer symptoms from getting worse.