5) Perforated Peptic Ulcer & Chronic Stenosis скачать в хорошем качестве

5) Perforated Peptic Ulcer & Chronic Stenosis

Perforated Peptic Ulcer = men are more affected than women. Male Female ratio are 12 : 1 Pathology – 1) Acute Perforation- Stage- I) Stage of Peritonism- -Acid peptic juices, bile & pancreatic juices come out in to peritoneal cavity. -Peritoneal irritation . Stage II) Stage of reaction – Chemical injury –to burn of the peritoneum. -Peritoneum reacts –secreting peritoneal fluid copiously –gives relief of pain for short time. -This stage losta for 3-6 hous Stage III) Sage of peritonitis – -Diffuse bacterial peritonitis –Acid secretion of stomach is abolished. -No acid barrier, the bacterial invasion becomes easy . -starts 12 hours of perforation. 2) Sub Acute perforation – (leaking peptic ulcer) peritonal cavity becomes contaminated by leakage –occurs due to various factors a) small size of perforation , b) adhesions around the ulcer, c) emptiness of stomach, d) Plugging /sealing off the opening by omentum. 3)Chronic perforatation – -when an ulcer perforates but the area is walled off by adhesions / by viscera or -when a gastric ulcer perforates into the lesser sac with a sealed omental formen, a chonic abscess may form -usually present with an abd. mass. Clinical features – 1) Primary stage or the stage of Peritonism- Acute agonizing pain in epigasrium or Rt. Hypochondrium. may / may not vomit - signs of dehydration (Tongue dry) - Temp. slightly subnormal (950 To 960 F) - Pulse is increased On palpation –Tenderness- Board like rigidity -Rebound tenderness is charastically present On Auscultation-Abd is silent - there is definite absence of normal peristaltic sound of intestine. Rectal examination - will reveal pelvic tenderness. 2)Secondary stage or the stage of reaction – -Stage of illusion or delusion -Fire continues under the ashes (worst stage of peritonitis is on the way) -Pulse –high. -Temp. –gradually rises. P/A –Distended,Tender & rigidity less marked. -No bowel sound. 3)Tertiary stage or stage of peritonitis- -Diffuse peritonitis develops -Patients looks toxic (facies hippocratica ) with pallor, sweating, pinched face, anxious look. -Extrimities cold, vomiting is now frequent, c/o-insatiable thurst -Pulse –very high small & thready -Patient is in shock -Resp. shallow & rapid , Temp. –shoots up P/A –Gross distention, accumulation of gas & fluid in paralysed intestine. On palpation –no lnger board like, but muscle still guarded. Treatment –Rx is surgery. Pre-operative management- -Mandatory to resuscitate prior to operation i)Rest & sedation, ii)NBM & RT Aspi. 1 hourly, iii)I/V fluids started immediately, iv)Blood investigations, v)For shock if serve –plasma expanders –Dextran, vi)Broad spectrum antibiotic by parenteral route, vi)Catheterization, i)I/O TPR charting Surgery –Simple suture operation - Peritoneal toilet –Drainage Chronic Stenosis- 3 types of stenosis as complications of peptic ulcer - 1)Pyloric stenosis, 2) Hour Glass stomach, 3)Tea pot stomach. 1)Pylonic stenosis – not due to ulcer of the pylorus of the stomach but mostly due to chronic cicatrization of chronic D.U. -Scar at the chronic DU contracts & gradually narrow the lumen. Clinical features- Onset is slow & silient, 1)Pain –loses it’s definite relationship with food - Sensation of fullness. 2)Vomitting –classical symptom - capious projectile & foul vomitus is characteristic - vomitus contains undigested food - vomitus gives considerable relief. 3)Periodicity is lost. 4)Constipation is also complained. 5)Loss of weight. On examination – 1) Visible peristaltic waves passing from lt. to Rt. 2) Succussion –splash (heard on shaking the patient) 3) On ausculto –percussion the greater curvature delineated & stomach found grossly distended. Special investigations- 1)Gastric function test- low acid, absence of bile, copious amount of mucus due to chronic gastritis. 2)Ba-meal examinations – shows a large & low stomach -presence of barium even after 6 hours. Management – Due to continuous vomiting- massive loss of H+ & Cl-(Hypochloraemic alkalosis along with hypocalcaemia) -Gastric juice contains 10 mEq. / lit. of K , so pottassium deficiency is also. -I/V RL is replaced. -R.T. Aspi. Definitive Rx- Sx –Trunkal Vagotomy (Antrectomy / G.J. stomy) -Pyloroplasty 2)Hour Glass Stomach- due to cicatricial contraction of a saddle shaped ulcer of the lesser curvature. the stomach is almost devided in two chambers. Clinical features – always & almost seen in women. -Periodicity is lost . -Vomitting, is quite common. Investigations- Ba meal X-ray + OGD Scopy. Rx- Billroth- I- Gastrectomy. 3)Tea –pot stomach - longitudinal shortening of the long standing gastric ulcer at the lesser curvature will produce. -pylorus pulled up.