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Duodenal Ulcer Perforation


Presentation

  • Group A patients were younger (t test, P 0.01) and more likely to present with perforation, whereas patients in group B presented with a combination of symptoms (chi square, P 0.03).[ncbi.nlm.nih.gov]
  • There are very few reported cases of patients presenting with this dual pathology. CASE PRESENTATION: We report a unique case of a 53 year old Italian lady who presented with acute mesenteric ischaemia and duodenal perforation.[ncbi.nlm.nih.gov]
  • Prompt diagnosis and early therapy is needed to prevent death and prolonged serious illness, and the key to the diagnosis is an awareness of its frequent atypical presentations.[ncbi.nlm.nih.gov]
  • PURPOSE: The present study aims to provide an applicability of laparoscopic gastrectomy used in the treatment of giant duodenal ulcer perforation.[ncbi.nlm.nih.gov]
  • Abstract Here, we present the case of a 53-year-old man with a hepatothorax due to a right diaphragmatic rupture related to duodenal ulcer perforation.[ncbi.nlm.nih.gov]
Fever
  • The video shows the management of a 51-year-old woman who came to the emergency room with acute abdomen, leukocytosis, and fever. Laparoscopy showed peritonitis with apparent gastric perforation. Duodenal perforation was confirmed by endoscopy.[ncbi.nlm.nih.gov]
  • Case 2 A 11-month-old male child was admitted with 10 days history of fever, rashes, and vesicular eruptions over the body, and a probable diagnosis of measles was made.[afrjpaedsurg.org]
  • A 55-year-old man presented after 3 weeks of sharp epigastric pain radiating to the right upper quadrant, fever, and generalized weakness. He had a history of significant heroin and cocaine abuse and was currently in a methadone maintenance program.[mdedge.com]
  • In addition, other diagnostic tools include temperature measurement as elevated fevers are common and blood pressure monitoring because a drop in blood pressure is not uncommon for the affected.[stomachbloating.net]
  • Abstract We wish to report a 14-year-old male adolescent who presented with sudden onset epigastric followed by right sided abdominal pain, vomiting and fever.[jpss.eu]
Severe Pain
  • The most common sign of the deadly condition is a sudden and severe pain in your abdomen. This pain will steadily get worse. If you experience this kind of pain it is vital to see your GP as soon as possible, or dial NHS 111.[thesun.co.uk]
  • While at work I started having severe pains in my left side that radiated to my back. I was dumb enough to think that if I just went home to lie down I would be fine...and drove myself home with this mind numbing pain.[patient.info]
  • All patients came with complains of severe pain in abdomen. The pain was associated with multiple episodes of non-bilious vomiting. Surprisingly none of them presented with fever.[webmedcentral.com]
  • The patient complains of episodes of severe pain lasting for weeks, interspersed by months of remission, the pattern repeating itself over several years. The disease may burn itself out after 10–15 years.[surgwiki.com]
Respiratory Distress
  • We report a case of a 30-year-old male patient with abdominal pain and respiratory distress. Resulting from physical examination and laboratory data of the patient, acute abdomen and pneumothorax were diagnosed simultaneously.[ncbi.nlm.nih.gov]
Abdominal Pain
  • We report a case of a 30-year-old male patient with abdominal pain and respiratory distress. Resulting from physical examination and laboratory data of the patient, acute abdomen and pneumothorax were diagnosed simultaneously.[ncbi.nlm.nih.gov]
  • On admission, the patient complained of severe acute abdominal pain, with physical examination findings suspicious for a perforated peptic ulcer.[ncbi.nlm.nih.gov]
  • The patient complained of abdominal pain for the last 12 hours with two episodes of vomiting in the last five hours and complete constipation for two days.[cureus.com]
  • Materials and Methods: Three young male patients presenting with a short duration history of abdominal pain and vomiting and chest radiograph suggesting pneumoperitoneum were selected for endoscopic clipping.[jdeonline.in]
  • Abstract We wish to report a 14-year-old male adolescent who presented with sudden onset epigastric followed by right sided abdominal pain, vomiting and fever.[jpss.eu]
Epigastric Pain
  • Links: haematemesis right upper quadrant pain right iliac fossa pain (RIF) epigastric pain[gpnotebook.co.uk]
  • Figure 1 A 48-year-old man who was receiving medical treatment for peptic ulcer disease experienced intense epigastric pain, sudden in onset and without emesis, four hours before admission.[nejm.org]
  • Critical Essential Core Tested Community Questions (3) (M2.GI.13) A 75-year-old male presents with a 1-month history of severe abdominal and epigastric pain.[medbullets.com]
  • A 55-year-old man presented after 3 weeks of sharp epigastric pain radiating to the right upper quadrant, fever, and generalized weakness. He had a history of significant heroin and cocaine abuse and was currently in a methadone maintenance program.[mdedge.com]
  • Epigastric pain is a typical symptom of PUD, however, some patients may remain asymptomatic. Diagnosis occurs via direct visualization of the ulcer on esophagogastroduodenoscopy ( EGD ) and H. pylori detection (via biopsy or non-invasive testing).[amboss.com]
Acute Abdomen
  • Resulting from physical examination and laboratory data of the patient, acute abdomen and pneumothorax were diagnosed simultaneously. Laparotomy revealed duodenal ulcer perforation and a simple patch closure was performed.[ncbi.nlm.nih.gov]
  • The video shows the management of a 51-year-old woman who came to the emergency room with acute abdomen, leukocytosis, and fever. Laparoscopy showed peritonitis with apparent gastric perforation. Duodenal perforation was confirmed by endoscopy.[ncbi.nlm.nih.gov]
  • Perforated duodenal ulcer a rare cause of acute abdomen in infancy: A report of two cases. Afr J Paediatr Surg [serial online] 2008 [cited 2019 May 13];5:46-7.[afrjpaedsurg.org]
  • Although sonography is useful as a first-line diagnostic tool for acute abdomen in the emergency department, it is less helpful in the diagnosis of peptic ulcer perforation.[academic.oup.com]
  • Perforated ulcers usually present with an acute abdomen and are life-threatening unless immediately recognized and treated.[mdedge.com]
Severe Abdominal Pain
  • Severe abdominal pain in a significantly sick adolescent associated with rigid abdomen and signs of shock should prompt one to think of possible peptic perforation. Atypical and puzzling presentations have been reported [4-5].[jpss.eu]
  • Clinical features The patient presents with sudden onset of severe abdominal pain. The onset of pain is so sudden that the patient can often accurately pin-point the exact moment when the perforation occurred.[surgwiki.com]
Abdominal Distension
  • Acute ulcer in the neonate may develop with prematurity, anoxia, abdominal distension, or hyperacidity.[afrjpaedsurg.org]
  • Eight (61.54%) patients were having guarding / rigidity and four(30.77%) patients presented with abdominal distension.[webmedcentral.com]
Tachycardia
  • On examination: patient looks ill and lies unusually still in pain tachycardia shallow respiration Inspection: abdomen is flat - does not fall and rise with respiration Palpation: very tender, intense guarding & "board-like" rigidity Percussion: if air[gpnotebook.co.uk]
  • Pain was the consistent symptom while tachycardia, tenderness, and guarding were the signs present in all 70 (40%) patients. Gas under diaphragm (pneumoperitoneum) was found in 67 (95.71%).[scopemed.org]
  • On examination the child was dehydrated, anicteric, had tachycardia and tachypnoea. Abdominal examination revealed guarding and rebound tenderness suggestive of perforation peritonitis.[afrjpaedsurg.org]
  • Then presence of clinical features pain, vomiting, fever, abdominal distension, tenderness, guarding / rigidity, tachycardia, shock were recorded.[webmedcentral.com]
  • On examination, patient was unwell, pale, fe- brile, dehydrated and had tachycardia. Abdominal examination revealed guarding, rigidity and tenderness in the right side of the abdomen.[jpss.eu]
Hypotension
  • Other factors such as shock (hypotension) and comorbidities have also been described as factors contributing to poor response to conservative approach, as well as associated with higher mortality [5-6] .[cureus.com]
  • Hypotension, tachycardia or high fever are signs of gravity.[omicsonline.org]
  • Patients with bleeding ulcers may report passage of black tarry stools (melena), weakness, a sense of light-headedness or ay even pass out upon standing ( orthostatic hypotension or syncope ) and vomiting blood (hematemesis).[medicinenet.com]
  • Hypotension is a late finding as is a high fever. The abdominal findings are characteristically described as of board-like rigidity.[ncbi.nlm.nih.gov]
  • Shock was defined as persistent hypotension [systolic blood pressure as the time interval between the onset of severe acute abdominal pain, and arrival time at the hospital.[tropicalgastro.com]
Thrombosis
  • The second hypothesis is the patient developed a stress related ulcer following ischaemic bowel infarction secondary to arterial thrombosis.[ncbi.nlm.nih.gov]

Workup

  • After a brief history and physical examination in the emergency room, the patient was admitted and a thorough workup panel was requested.[cureus.com]
  • His workup revealed an elevated white blood cell count, gallstones, gallbladder wall thickening and pericholecystic fluid on his right upper quadrant ultrasound, and an upright chest xray without free air.[sages.org]
Pneumoperitoneum
  • Materials and Methods: Three young male patients presenting with a short duration history of abdominal pain and vomiting and chest radiograph suggesting pneumoperitoneum were selected for endoscopic clipping.[jdeonline.in]
  • A chest film (Panel A) showed bilateral pneumoperitoneum (arrows). An exploratory laparotomy revealed a perforated duodenal ulcer with callous borders (Panel B).[nejm.org]
  • Gas under diaphragm (pneumoperitoneum) was found in 67 (95.71%).[scopemed.org]
  • Switch off gas when desired pneumoperitoneum is created & remove the Veress needle Port location A 10mm camera port is placed in the umbilicus; this position will vary according the build of the patient.[laparoscopyhospital.com]
  • A perforated peptic ulcer is the first differential diagnosis of pneumoperitoneum, but in the socio-epidemiological context of Togo, one should also consider typhoid.[medical-dictionary.thefreedictionary.com]

Treatment

  • Simple closure, with or without H2 antagonist treatment, was the most popular management of a perforated acute duodenal ulcer.[ncbi.nlm.nih.gov]
  • These results compare favorably with reports for the elective treatment of duodenal ulcer with vagotomy and pyloroplasty.[ncbi.nlm.nih.gov]
  • Pylori positive) received postoperative H. pylori eradication treatment, and Group 2 (H. pylori negative) received only lansaprasol treatment after surgery.[ncbi.nlm.nih.gov]
  • In this study, we analysed the outcome of treatment in terms of complications, mortality and hospital stay with relevant to laparoscopy and open approach.[ncbi.nlm.nih.gov]
  • BACKGROUND: Surgery is the mainstay of treatment of patients with peptic duodenal perforation. With the advent of minimal access techniques, laparoscopy is being used for the treatment of this condition.[ncbi.nlm.nih.gov]

Prognosis

  • CONCLUSION: Early management in the intensive care unit and appropriate surgical intervention maximised the patient's chances of survival despite the poor prognosis associated with her dual pathology.[ncbi.nlm.nih.gov]
  • Figure 1: Chest radiograph suggestive of free gas under both domes of diaphragm Click here to view Discussion DUP is a common surgical emergency. [1] It has good prognosis with timely and appropriate intervention.[jdeonline.in]
  • […] medical therapy hemorrhage / perforation Zollinger-Ellison syndrome truly refractory cases consider an parietal cell vagotomy surgical approaches include: Billroth II (antrectomy with gastrojejunostomy) low recurrence but high rate of dumping syndrome Prognosis[medbullets.com]
  • Female sex, more coexisting clinical events, no evidence of chronic ulcer, and treatment by simple suture were associated with significant poor prognosis on univariate analysis.[jpss.eu]
  • Prognosis of gastric cancer stays dependent on tumour stage and seems not to be worsened by the perforation itself. Postoperative pain and rate of wound infections are lower after laparoscopic operation for perforated peptic ulcer.[thieme-connect.com]

Etiology

  • Etiology Risk factors Chronic gastritis caused by H. pylori , a curved, flagellated gram-negative rod Duodenal ulcers : up to 90% are due to H. pylori infection Gastric ulcers : up to 80% are due to H. pylori infection Chronic gastritis of other etiology[amboss.com]
  • NSAID is one of the contributing etiological factors. Early diagnosis and timely management is advocated to reduce morbidity and mortality.[webmedcentral.com]
  • Helicobacter pylori is not the predominant etiology for peptic ulcers requiring operation. Am Surg 2011; 77:1054-1060. 2. Bertleff MJ, Lange JF. Perforated peptic ulcer disease: a review of history and treatment. Dig Surg 2010; 27:161-169. 3.[ejs.eg.net]
  • The etiology of gastrointestinal perforations in the newborn. J Pediatr Surg 1969; 4: 77-80. [ PUBMED ] [ FULLTEXT ] 8. Hernandez DS, Rodrigulz AG.[afrjpaedsurg.org]

Epidemiology

  • To provide updated epidemiological data on duodenal ulcer perforation, the incidence of the disease in Norfolk, United Kingdom was determined.[ncbi.nlm.nih.gov]
  • A perforated peptic ulcer is the first differential diagnosis of pneumoperitoneum, but in the socio-epidemiological context of Togo, one should also consider typhoid.[medical-dictionary.thefreedictionary.com]
  • Epidemiology References: [1] [2] [3] [4] [5] Epidemiological data refers to the US, unless otherwise specified.[amboss.com]
  • Sonnenberg A, Sengupta A, Bauerfeind P (1988) Epidemiology of peptic ulcer disease. In: MRCP WDWRM, editor. Advances in Peptic Ulcer Pathogenesis [Internet]. Springer Netherlands; 1988: 1-31.[omicsonline.org]
  • Systematic review of the epidemiology of complicated peptic ulcer disease: incidence, recurrence, risk factors and mortality. Digestion 2011; 84:102-113. 4. Williams N, Bullstrode C, Connell RO.[ejs.eg.net]
Sex distribution
Age distribution

Pathophysiology

  • This is the first report of massive bowel ischaemia and duodenal perforation with no apparent underlying common pathophysiology leading to this presentation.[ncbi.nlm.nih.gov]
  • References: [12] Pathophysiology Clinical features Gastric ulcer Duodenal ulcer Findings common to both Dyspepsia : postprandial heaviness, early satiety , and gnawing, aching or burning epigastric pain Pain relief with antacids Potential signs of internal[amboss.com]
  • Despite better understanding of pathophysiology and medical therapy of acid peptic disease, duodenal ulcer perforation remains one of the major cause of Peritonitis. 1,2 The incidence of perforated peptic ulcer in western countries is 7 to 9 per 1,00,000[webmedcentral.com]

Prevention

  • Prompt diagnosis and early therapy is needed to prevent death and prolonged serious illness, and the key to the diagnosis is an awareness of its frequent atypical presentations.[ncbi.nlm.nih.gov]
  • CONCLUSIONS: Eradication of H. pylori prevents ulcer recurrence in patients with H. pylori-associated perforated duodenal ulcers. Immediate acid-reduction surgery in the presence of generalized peritonitis is unnecessary.[ncbi.nlm.nih.gov]
  • Doherty Lippincott Williams & Wilkins, 2006 - 826 من الصفحات This volume offers authoritative, evidence-based recommendations for preventing and managing complications in all current general surgery procedures.[books.google.com]
  • Considering the compromised state of such patients, endoscopic treatment and avoiding surgery will play a great role in preventing the further stress caused by surgery and facilitate quicker recovery.[jdeonline.in]
  • Treatment of the esophagus, stomach or duodenal ulcersaims to relieve pain, heal the ulcer, and prevent complications.[medicinenet.com]

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