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04-24-2008, 08:44 AM
m Incidence: 15-20% of cases of peptic ulcers. More common in duodenal ulcer. Males more than females & anterior more than posterior.
m Predisposing factors:
1- Stress conditions « acidity.
2- Heavy meal « overstretched stomach.
3- Prolonged fever « destruction of gastric wall.
4- Using NaCO3 as antacid « production of ­ CO2 increase size of
stomach « perforation.
m Pathology:



Gastric Perforation

Duodenal Perforation
















In both cases: 3 stages will occurs:
1- Stage of perforation « contamination of peritoneum.
2- Stage of chemical peritonitis: irritation by the acidity « Exudation of fluid to dilute the acidity.
3- Stage of septic peritonitis:
Generalized. Localized.

mClinical Picture:
1- Stage of perforation:
Usually during work.
Sudden agonizing pain referred to the shoulder.
Collapse with tachycardia and vomiting.
Board-like rigidity is characteristic.
2- Stage of peritoneal reaction " peritonism":
False improvement due to dilution of acidity by exudate.
Pain lessen.
Tenderness and rigidity diminish But, persist.
i.e, Symptoms disappear but the signs persist.
3- Stage of bacterial peritonitis.
Usually after 6 hours. Fever, tachycardia, repeated vomiting.
Marked tenderness and rigidity. Later on abdominal distention.
m Investigation:■■■
Plain x-ray in erect position. « Gas under diaphragm.
In Shocked patient; x-ray is done on the left lateral position « gas in axilla.
m Treatment:
1) Simple closure (sealing) of perforation using an omental graft. « best results with lowest mortality. 30% definitive cure.
2) If the patient diagnosed early (before peritonitis).
Some surgeons perform definitive surgical measures for treatment of the ulcer as vagotomy with drainage operation or partial gastrectomy but high mortality recommend simple closure.
SOURCE: DR. AYMAN SALEM'S BOOK
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