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1. Surgery
Case
Presentation
ADITYA DINESH - 180101218
ADITIJ DHAMIJA - 180101220

2. Scenario
•A 60 year old man presents with severe abdominal pain since 1 day. On examination, pulse is
120bpm.
•There is diffuse guarding of abdomen.
•Chest X-ray shows free air under right hemidiaphragm.

3. Demographic Details
•Name – Salman Khan
•Age – 60 years
•Sex – Male
•Occupation – Driver
•Address – Bandra, Mumbai

4. Chief Complaints
•Severe abdominal pain since 1 day which is recalcitrant to over the counter pain medication
•Palpitations

5. History of Present Illness
•The patient was apparently normal 3 days back when started feeling mild upper abdominal pain which
occurred 3 hours after meal.
•The pain was insidious in onset following the meal and was associated with symptoms of bloating,
abdominal fullness and nausea. Patient reported early satiety.
•The pain was relieved on taking antacids.
•1 day ago patient developed sudden severe and diffuse abdominal pain with palpitations.
•Pain began in the evening and worsened before dissipating completely.
•Then a more constant pain developed insidiously which has progressively increased, the pain also radiates
towards the right shoulder.
•There was blackish discoloration of stools.

6. Past History
There is history of chronic back pain which is relieved by NSAIDs.

7. Treatment History
Patient has been taking NSAIDs daily for the past 6 months due to chronic back pain.

8. Personal History
•There is history of constipation
•Bladder habits are normal
•Patient reported waking up at 1-2AM in the past 3 days.
•The patient was anorexic
•Diet – Mixed

9. Family History
There is no history of any similar complaints in any other family members

10. Differential Diagnosis

11. Causes of Diffuse Abdominal Pain

12. Differential Diagnosis
Peptic ulcer perforation
Acute pancreatitis – Pain, rigidity but no fever.
Functional dyspepsia – Pain and early satiety
Gastroparesis – Post prandial fullness
Acute myocardial infarction – No previous heart symptoms
Acute mesenteric ischemia – Post prandial pain
Adrenal insufficiency
Spontaneous bacterial peritonitis
Colorectal cancer

13. General Physical Examination
Patient has reduced body build, conscious and oriented to time, place and person.
Vitals:
Pulse – 120 / min
BP – 120/82 mm Hg
Temperature – 100 F
Respiratory rate – 16 breaths/ minute
Slight pallor is seen. No icterus, cyanosis, clubbing, cervical lymphadenopathy and edema seen.
Abdominal facies was seen.

14. Local Examination
•The patient was made to lie flat on his back with legs extended. The whole abdomen from the nipples
above down to the saphenous openings was exposed.
Inspection:
1. Distension of abdomen was observed with scaphoid appearance.
2. Restricted abdominal movement on respiration was seen.
3. Discomfort on gently coughing.
Swelling, Discoloration of skin absent. No scars or sinuses seen.
No superficial veins are seen over the abdomen.

15. Palpation:
1. There was rigidity of abdominal wall
2. Tenderness was elicited on light palpation over the epigastrium region.
3. Rebound tenderness is seen.
No palpable mass found in the abdomen.
There was no enlargement of Liver or Spleen.
Pain on abdominal percussion.
No significant findings on Auscultation.

16. Provisional
Diagnosis
PERFORATED PEPTIC ULCER LEADING TO PNEUMOPERITONEUM

17. Peptic Ulcer
ETIOPATHOGENESIS:-
It can be caused due to:
1. H. pylori infection
2. Consumption of NSAIDS
3. Increased acid production in case of gastrinomas such as Zollinger-Ellison syndrome
Cigarette smoking is a risk factor.
Peptic ulcer can lead to malignancy in the stomach.

18. Clinical features
1. Intermittent pain in the epigastrium is seen, which may radiate to the back.
2. Symptoms may disappear and appear after weeks or months due to spontaneous healing of ulcer.
3. Vomiting
4. Weight loss
5. Melena or Hematemesis can be seen due to bleeding.
6. Epigastric tenderness
7. Bloating sensation and nausea

19. Complications (Peptic
Ulcer)
•Haematemesis, melena, hematochezia, orthostatic hypotension
•Gastric outlet obstruction
•Gastrocolic or duodenocolic fistulas
•Perivisceral abscess
•GI haemmorhage
•Choledochoduodenal fistula
•Pancreatic duct fistula
•Perforation of peptic ulcer

20. Investigations
For pneumoperitoneum:
Erect x-ray chest – Gas bubble below diaphragm
If patient can’t stand, take X-ray in lateral decubitus
Best investigation is contrast enhanced CT which
can detect gas bubbles missed by X-ray.

21. Treatment
•Broad spectrum antibiotic therapy is initiated based on site of perforation
•There is little role of conservative management except in patients with contained perforation,
gastrointestinal fistula formation, or limited contamination as judged by imaging, in those who have
no signs of systemic sepsis antibiotic therapy combined with drainage (effusion, abscess), provision
for nutritional support (eg, gastrostomy, feeding jejunostomy), or stent placement may be an
appropriate initial management strategy.

22. Surgical Management
•The most common surgery performed for perforated peptic ulcer is oversewing the ulcer or the use of
a Graham’s patch (healthy omentum) which is used because suturing of an inflamed ulcer can be
difficult or impossible. Endoscopic gastric closure may be achieved via Natural Orifice Trasluminal
Endoscopic Surgery technique.

23. Thank You