Case study 1: (taken from medscape student)
47 yr-old gentleman
A/E admission
P/C : waking up with severe abdominal pain
HoPC :
- Over past week
- Intermittent
- Gas-like epigastric pain
- Sensation ‘like I need to burp’.
As of this morning
- Pain acutely worsened
- Radiating in a bandlike pattern throughout the patient’s upper abdomen and to his back
- Intense when lying flat on his back
- Slightly better when sitting upright
Associated symptoms
- Mild nausea but no vomiting
- No fever / chills
- No diarrhoea
RFs:
- No NSAIDs
PMHx:
- No chronic medical conditions
Meds: Nil
Allergy: NKDA
SHx:
- Drinker - ~6-8 beers daily
System review:
- No chest pain
- No SOB
- No palpitation
O/E:
General appearance :
- Thin
- Slightly emanciated man
- Uncomfortable
- Distressed
- Diaphoretic and writhing around
Vital signs:
- Temp: 35.4
- Pulse: 87bpm
- Resp. Rate : 28 breaths/min
- BP : 111/62 mm Hg
- O2 sat : 98% (room air)
HEENT
- Sclera is anicteric (normal)
- Oropharynx clear with slight dry mucus membrane
CVS:
- Regular rhythm
- No murmurs
- Lungs clear
Abdo:
- Tenderness in epigastric and bilateral upper quadrant regions with focal rebound tenderness and guarding
- No tenderess or palpable masses in lower abdomen
- Rectal exam : heme-negative, brown stool
Mx:
- Cardiac monitor
o ECG:
§ normal sinus rhythm at ventricular rate of 88bpm
§ non specific ST flattening
- IV line – normal saline
- 2 doses of IV hydromorphone (pain killer) – but no significant improvement in his pain / abdo tenderness
- CXR – Normal, no air visualized under the diaphragm
- Abdo USS – no evidence of gallstones or biliary wall thickening, kidney and liver appear normal
- CBC (complete blood count/ FBC), metabolic panel, hepatic panel with lipase, tropnonin --> within normal limits
- CT abdomen + pelvis
Comments of CT abdo:
- Free air under diaphragm à consistent with a perforated viscus
- Also fluid in region of distal antrum/pylorus with small pocket of air in this fluid
- Pt’s hx of alcohol à pointed to perforated gastric ulcer
DDx:
- Cardiovascular etiology (eg. ACS, aortic dissection)
- GI (eg. Mild esophagitis and gastritis
- Gallbladder diseases (eg. Mild biliary colic to acute cholecystitis)
- Liver (eg. Acute hepatitis, masses, gonococcal or chlamydial perihepatitis, acute cholangitis)
- Acute pancreatitis
- Acute appendicitis (may first present with upper abdo/mid abdo pain before localizing to right lower quadrant)
- Pulmonary processes (eg. Pneumonia) – must be considered even in absence of cough/SOB
The workup:
- Based on age and risk factors
- Characteristics and assoc. symptoms of each potential diseases
- Hx and physical examination
*CXR upright à no evidence of perforation
Uncomplicated PUD
- 90% DU, 75% PUD caused by H.pylori infection
- Second cause : NSAIDs
o Risk / complications are proportional to daily dose taken
- Others: anticoagulant, steroids, alcohol, smoking, infection
- DUD : majority occurs at anterior wall of duodenal bulb
Perforated ulcers:
- 3 classical stages:
o 1st stageà caused by rapid release of gastric juice into peritoneal cavity à thus abrupt onset of intense abdominal pain
o 2nd stage à spontaneous improvement in symptoms à as result of fluid pouring out of injured intraperitoneal tissues à causes buffering of acidic gastric juice
o Final stage à frank peritonitis à characterized by increased pain and signs of systemic inflammatory response.
- CT scan : higher sensitivity of visualizing free air and may show evidence suggesting location of perforation
- C/I : endoscopy à because of air insufflations
- Thus, alternative : water-soluble contrast agent
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