[Peptic ulcer disease] 

Perforated peptic ulcer

Indications

• Acute duodenal perforation - prevents sepsis and shit like that

Procedure: Oversew

1. GA + NGT + Antibiotics + DVT prophylaxis + Urinary catheter + supine position
2. Upper midline laparotomy
3. Identify stomach + work distally to duodenum
4. Identify perforation
   • Usually found on anterior surface of 1st part of duodenum
   • If not present there - look on posterior surface of stomach - if perforated stomach ulcer is found biospy it cause it's probably going to be a fat cancer, innit? If ulcer is large and friable, will need partial gastrectomy (as omentum just isn't man enough to do it)
5. Close perforation
   • Insert x3 absorbable sutures through duodenum on each side of perforation
   • Find mobile piece of omentum that can be mobilised into position
   • Lay across perforation and loosely tie stures over the top of omentum (do not tie tightly - may necrose omentum)
6. Wash out peritoneal cavity (remove food and shit)
7. Close as for laparotomy

Laproscopic procedure

1. Pneumoperitoneum via open method (1cm infra-umbilical incision), enter peritoneum under direct vision
2. Introduce trochar, insufflate CO2, introduce laproscope
3. 11mm port under xiphisternum
4. 5mm port in MCL R hypochondrium
5. 5mm port AAL R hypochondrium
6. Irrigate / suction peritoneal cavity
7. Repair as above
8. Close port sites

Post-op care

1. Proton-pump inhibitor
2. H.pylori eradication - (urease breath test C13): Metronidazole + clarithromycin + PPI
3. Oral fluids once flatus passed

Bleeding peptic ulcer: Under-running

Indications

• Bleeding from an ulcer that has failed to respond to conservative managment (prevents bleeding to death and shit like that) - including endoscopy + injection of sclerosants or adrenaline
• Haemorrhage requiring more than 6 units blood/24hours
• Haemorrhage unresponsive to intensive resuscitation
• High risk of re-bleeding: (1) spurting/oozing vessel on endoscopy (2) visible vessel at base of ulcer on endoscopy (3) fresh or adherent clot on endoscopy

Procedure

1. GA + NGT + Antibiotics + DVT prophylaxis + Urinary catheter + Supine position
2. Upper midline laparotomy
3. Identify stomach (distended with blood) with grey small bowel (cause of blood)
4. Insert two stay sutures on duodenum and open duodenum longitudinally (will be closed transversely - prevents stenosis)
5. Identify point of bleeding
   • Pass sucker into duodenam lumen to identify bleeding point (usually posterior wall)
   • Stuff swab into pylorus to prevent blood from being expelled from stomach
   • If cannot find blood in duodenum, look in the stomach - gastic ulcer, erosions, varices
6. Under-run gastroduodenal artery as it passess behind duodenum using 1/O absorbable suture
   • Take good bites (can miss artery otherwise)
   • Don't go too deep as will hit CBD
   • Tie sutures firmly
7. Remove swabs, evacuate blood from stomach
8. Depending on degree of ulcer-related duodenal scarring proceed to
   • pyloroplasty (close duodenum transversely with interrupted sutures)
   • gastroenterostomy
9. Close wound