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 1^st stageà caused by rapid release of gastric juice into peritoneal cavity à thus abrupt onset of intense abdominal pain

o 2^nd 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