A 70-year-old man presented with progressive abdominal pain. On examination, he was found to be dehydrated, febrile, and had generalized abdominal pain with guarding and rebound tenderness. He underwent an appendectomy 10 years prior. After rehydration, an exploratory laparotomy revealed a perforated ulcer between the terminal ileum and cecum, causing peritonitis. A limited right hemicolectomy was performed to remove the diseased area. The patient's next steps included monitoring for complications, antibiotic treatment, and a post-operative diet.

1. Surgery Osce Quiz 2
http://jacknaimsnotes.blogspot.com/2010/02/surgery-osce-quiz-2.html
A 70 years old Malay man complaint of progressive abdominal pain for two weeks duration. the
pain is initially at the lower abdomen and then become generalized.
On examination, he was found to be dehydrated, febrile, ill-looking, generalized abdominal pain
with guarding and rebound tenderness at umbilicus.
He had undergone appendectomy 10 years ago.
After he was rehydrated, a laparotomy was performed to identify the problem and proceed
with necessary action. Below is the segment taken out from his stomach.
1) Identify the specimen
2) Outline your findings
3) What is your next management for this patient
For answer, click [here]

2. Notes:
After an exploratory laparatomy was performed, it is found out that this patient has perforated
ulcer at the terminal ileum to cecum which is associated with pus discharge. Therefore, it
causes this patient to develop peritonitis.
This is possibly a long standing disease which recently perforated. Therefore, a limited right
hemicolectomy is performed.
The reason why limited right hemicolectomy is performed is because the lesion is confined only
to the diseased area with no evidence of malignancy. Furthermore, other segments are healthy
and can be anastomosed.
Question 1
1. Ileum to Terminal Ileum
2. Cecum
3, ascending colon
Question 2

3. a. there is an ulcerated ulcer measuring about 2X3 cm with perforation extending from terminal
ileum to cecum. The margin is rounded, well democrated, raised edge, pus on the base of the
ulcer and surrounded by inflamed tissue.
b. There is an ulcerated ulcer measuring about 0.5X0.5 cm at the cecum-colon junction. It is
round, flat edge, and pus at the base of the ulcer. There is minimal inflammation around the
ulcer.
Question 3
Next management to this patient
a. Intra Op
1. Local lymph node for biopsy to look for any evidence of bacteria infiltration or malignancy.
2. Pus swab for culture and sensitivity
3. End to end anastomosed ( ileo-colon anastomosed)
4. There is a role of stroma; however it is not indicated in this patient provided that the
anastomosis will have a good recovery.
5. Irrigation of peritoneal cavity with at least 2 liter normal saline (or until the fluid become
clear and no more blood/pus stained)
6. Inspection to ensure that all bleeding has been secured and iatrogenic problem was repaired.
7. Put drainage tube.
8. Close up the peritoneal layer, fascia, rectus sheath and skin.
9. Sent the specimen to pathology lab to determine possible etiology of the lesion.
b. Post op
1. Put patient in recovery area for observation.
2. Consider to put patient in ICU bed if develop post op complication.
3. Keep patient Nill by mouth and gives Total Perenteral Nutrition.
4. Obtain further history from patient to elicit possible etiology like thyphoid or TB.
5. Analgesic (IV Morphine, IV Tramadol)
6. Fluid maintenance therapy.
7. Close monitoring of input/output chart.
8. Antibiotic coverage. (Change to IV Rocephine and flagyl)
9. Monitor vital sign, 15 minutes interval for 2hr post up, then every 30 minutes for 1 hour,
then hourly and 2hourly and 4 hourly.
20. Beware of any signs of surgical complication and infection
21. STO after at least D14 posts Op.