Dr Emad
General surgery session.
**
Hx of vomiting brown color(1t/day):coffee ground,
constipation then diarrhea,but he is continuously having
repeated vomiting and fatigue fever.
DDx:-
1-complicated peptic ulcer
2-gastritis
3-gastric ca
4-pancreatitis
Management
-admission to hospital.
-resuscitation (IVF).
-analgesia " we avoid NSAIDS,we give opiods with
buscopan(leads to relaxation) to avoid the spasm of
sphinecter of oddi caused by opiods ".
What investigations you send ?
1)Lab :-
-CBC
-WBC count.
-s.electrolytes(hypokalemiaileus).
-ESR (up to 20 normal, if more than 90 malignancy is
suspected).
-CRP
-RFT.
-LFT(malignancy or metastases).
-pancreatic enzymes"lipase:more specific,amylase".
*S.amylase :- not specific as it raises at early time then return
back to normal.
2)imaging studies:-
-X ray:-to see air under diaphragm , basal
pneumonia,calcification,gas shadow of stomach.
-US:-for gall stones "pancreatitis ",splenomegaly.
-OGD:always with biopsy randomly taken from the lesion.
-CT scan with contrast:to see necrotic tissue,calcified
tissue,any mass,fluid,abscess.
-endoscopic features of an ulcer
1.clot covers it.
2.visible vessel in the ulcer base.
Notes :-
Post.duodenal ulcer mostly bleed .
Ant.duodenal ulcer perforate.
--------------------------------
Surgical Rx indicated in :-
1.large volume of bleeding initially.
2.active bleeding ulcer.
3.rebleeding .
.
GRAHAM patch
Treated as suturing the bleeding ulcer with
Rx medical & surgical .
a)medical:-
-PPI.
-H2 antagonist.
-tranexamic acid.
b)minimally invasive:-
-therapeutic endoscopy.
-injection:epinephrine.
-laser.
-electrocoagulation,thermal(bipolar diathermy).
-another DDx:-pancreatitis :
Most common cause :- bile duct stones, alcohol.
Pt comes more dehydrated than PU patient, if not
treatedpancreatic pseudocyst (within 2-3wks).
Treatment
Admission to hospital , ivf rehydration ,analgesia , broad
spectrum antibiotics(meropenem, imipenem)
O2 mask or ventilation.
Surgery is done in pancreatic pseudocyst (drainage to stomach
or jejunum :-cystogastrostomy), (pancreatic abscess).
Excision of necrotic tissue from the pancreas.