This is a presentation of journal regarding gastroduodenal perforation

1. AN OVERVIEW OF
GASTRODUODENAL
PERFORATION
A JOURNAL CLUB PRESENTATION BY
DR.SAI LIKHITHA
2ND YR POST GRADUATE
UNIT 2
UNDER GUIDANCE OF MY PROFESSOR-
DR. Y. KIRAN KUMAR.MS GENERAL
SURGERY

2. INTRODUCTION
• GASTRO INTESTINAL PERFORATION, WITH LEAK OF ALIMENTARY CONTENTS
INTO PERITONEAL CAVITY ,IS A COMMON SURGICAL EMERGENCY AND MAY
HAVE LIFE THREATENING SEQUELAE.
• MAY BE SPONTANEOUS OR TRAUMATIC.

3. • FACTORS IMPLICATED IN PEPTIC ULCERATION
• THE INCIDENCE OF PEPTIC ULCER DISEASE IS ESTIMATED TO BE 1.5-3 %
• THE LIFE TIME PREVALENCE OF PERFORATION IS 5%
• MORTALITY RANGES FROM 1.3- 25%
• <40YRS AGE: DUODENAL ULCERS>GASTRIC ULCERS.
MEN>WOMEN
• <1% GASTRIC ULCERS ARE PREMALIGNANT
• PERCENTAGE OF CANCER IN GASTRIC PERFORATION IS 9%

4. MALIGNANT VS BENIGN GASTRIC ULCERS
BENIGN MALIGNANT
CRITERIA

5. SPONTANEOUS PERFORATION:
• DUODENAL AND GASTRIC PERFORATIONS REMAIN THE 2 MOST COMMON
PERFORATIONS OF GASTROINTESTINAL TRACT
• DUODENAL ULCERS – 1ST PART OF DUODENUM
ON ANTERIOR PART-PERFORATE
ON POSTERIOR PART- CAUSE BLEEDING
• LIFE TIME RISK OF BENIGN GASTRODUODENAL PERFORATION IS 10%
• 30-50% ASSOCIATED WITH NSAIDS
• MORE COMMON IN ELDERLY
• PEPTIC ULCER AND ITS PERFORATION- HELICOBACTER PYLORII

6. • ONLY 1/3 RD OF PPU HAVE HISTORY OF PEPTIC ULCER.
• 60-70% ARE DUODENAL AND 17% ARE GASTRIC
• PRESENTATION OF GASTRIC PERFORATION.
• RADIOLOGICAL AND LABORATORY INVESTIGATIONS
1. ERECT CHEST XRAY
2. PLAIN ABDOMINAL XRAY-RIGLER’S SIGN,FOOTBALL SIGN, CLEAR LIVER
EDGE,AIR UNDER DIAPHRAGM
3. CECT ABDOMEN- PNEUMOPERITONUEM, PNEUMATOSIS INTESTINAL
IS,PERIHEPATIC FREEFLYID, AIR POCKETS AROUND STOMACH, THICK REACTIVE
INTESTINAL WALLS
4. SR.AMYLASE,LIPASE,RFTS,

7. • MANAGEMENT
OPERATIVE OR NONOPERATIVE
1. OPERATIVE:
DEFINITIVE ULCER PREVENTING SURGERIES – VAGOTOMY AND GASTRECTOMY
( CAN BE PERFORMED IN VHRONIC DUODENAL ULCER PREVIOUSLY H.OYLORI
NEGATIVE AND THOSE WITH RECURRENT ULCERS DESPITE TRIPLE THERAPY)
MAJORITY ARE SMALL AND EASILY CLOSED AS SHOWN IN THE FIGURE

8. PROCEDURES:
1. CELLES-JONES
2. GRAHAM’S PATCH REPAIR
3. MODIFIED GRAHAM’S PATCH REPAIR
4. FINNEYS PYLOROPLASTY
5. BILLROTHS 2 GASTRECTOMY AND RECONSTRUCTION

11. • FACTORS WHICH INCREASED MORTALITY.
AGE>60YRS
DELAYED TREATMENT
SHOCK AT ADMISSION
CONCOMITANT DISEASES
• 6% MORTALITY RATE IN PERFORATION <5MM
• 19% IN 5-10MM
• 24% IN>10MM

12. ROLE OF LAPAROSCOPIC SURGERY
• 1990
• FALCIFORM LIGAMENT
• MORTALITY-5.8%
• COVERSION RATE-12.4%

13. • OTHER METHODS
USING GELATIN SPONGE PLUG WITH FIBRIN GLUE SEALING
ENDOSCOPIC CLIPPING TECHNIQUES
SELF EXPANDABLE METALIC STENTS AND DRAINAGE

14. 2. NONOPERATIVE:
ASYMPTOMATIC AND UNFIT PATIENTS
ALTHOUGH IN 1935 WANGENSTEEN (1, 26, 84) REPORTED A CASE SERIES OF 7
PATIENTS WHO RECOVERED FROM PERFORATED ULCERS BY SELF-HEALING,
HERMAN TAYLOR IN 1946 (26, 84) FIRST REPORTED 28 PATIENTS WITH
PERFORATED ULCERS TREATED CONSERVATIVELY BY NASOGASTRIC ASPIRATION,
INTRAVENOUS (IV) F LUIDS AND SERIAL ABDOMINAL X-RAYS (NOW KNOWN AS
TAYLOR’S METHOD) WITH A MORTALITY OF 10%.
DASCALESCU ET AL. (84) WHO WITH THE ADDITION OF BROAD SPECTRUM
ANTIBIOTICS AND ANTI-SECRETORY DRUGS REPORTED A SUCCESS RATE OF 89%
US/CT GUIDED PERCUTANEOUS DRAINAGE IS AN OPTION FOR HIGH RISK PATIENTS
WHO CANNOT TOLERATE MAJOR SURGICAL TREATMENT

15. • THE MORTALITY RATE FOR NON-OPERATIVE MANAGEMENT IN PATIENTS WITH A
SEALED PERFORATION WAS 3% AS OPPOSED TO 6.2% WHERE EMERGENCY
SURGERY WAS PERFORMED FOR PPU
• THIRTY PERCENT FOR WHOM NONOPERATIVE TREATMENT IS INITIATED
PROCEED TO SURGERY, PARTICULARLY IF AGE IS >70 (92). OTHER FACTORS
SUCH AS SHOCK (HYPOTENSION) AND COMORBIDITIES HAVE ALSO BEEN
DESCRIBED AS FACTORS CONTRIBUTING TO THE
POORRESPONSETOCONSERVATIVEAPPROACHANDASSOCIATEDHIGHER
MORTALITY
• PERFORATION OF AN ADVANCED GASTRIC CANCER MAY BE ANOTHER
INDICATION FOR PURSUING A CONSERVATIVE COURSE.

16. • PROBLEMS INCLUDE:
THE HIGH RATE OF MORTALITY
PROLONGED HOSPITAL STAY
PERFORATED GASTRIC CANCER IS DIFFICULT TO DIAGNOSE AND WILL USUALLY
NOT RESPOND,
A COLONIC PERFORATION IS DIFFICULT TO EXCLUDE AND A FREE PERFORATION
WILL DO BADLY WITH CONSERVATIVE TREATMENT
GASTRIC PERFORATION RESPONDS LESS LIKELY THAN DUODENAL PERFORATION