PERITONITIS EC GASTRIC PERFORATION

IDENTITY
Name : Mrs. EH
Gender : female
Age : 57 yo
MR : 00181219
Address : JL. Nawaripi
Origin : Sorong
Religion : Kristen Protestan
Education : High School
Ward : Mambruk
Date of admission : November, 24-2020

SUBJECTIVE
Main Complaint
Sudden onset of abdominal pain.

Current medical history

A 57-years-old female had presented to Emergency unit of RSUD Mimika with sudden onset of
abdominal pain since 3 hours earier. The pain was epigastric; severe, deep-seated, progressive, non-
radiating, not relieved by food intake and vomiting and not associated with diarrhea. Her condition
worsened an hour to presentation with generalized abdominal pain and abdominal wall rigidity and
distension. There was no history of change in bowel habit, no blood in the stool, no associated fever,
weight loss, alcohol binge or trauma.

Past medical history

There was history of diabetes mellitus, hypertension, SNH and using NSAIDs for almost 3 years due to
gout arthritis

Medication history
She was not on any medication for her ailments at the time of presented to the hospital.

Habit history
Not smoke, not drink alcohol. She reported had a history of frequently consumed non-standardized
herbal.

OBJECTIVE
Clinical status : Painful distress
Consciousness : Compos Mentis (E4V5M6)

Vital sign
BP : 140/80 mmHg
Pulse : 83 bpm
T : 37,5oC
RR : 24 bpm

General Status
Head and neck : Normal limits

Thorax
Pulmo
Inspection : Symmetrical, no retraction
Palpation : Normal vocal fremitus
Percussion : Resonant sound
Auscultation : Vesicular breath sound, Ronchi (-/-), Wheezing (-/-)

Cardio : Normal limits

Abdomen
Inspection : Distended, symmetrical
Auscultation : Peristaltic sound decreased
Palpation : No mass palpable, defense muscular and tenderness on all abdominal regions,
hepatomegaly (2 cm below arcus costae), lien is impalpable
Percussion : Hypertimpany

Extremities : Good perfusion, not cyanosed, no pitting edema

Digital Rectal Examination

Increased abdominal pain, tonus M. Sphingter ani decreased, ampula recti fulled with air
Handscoon : blood (-), Feces (+)

Local Status
Mc.Burney sign (-), Rovsing sign (-), Obturator sign (-), Psoas sign (-)

NGT: initial gastric drainage: cloudy +/- 50cc

Laboratory Findings
HB: 9,1
WBC: 14.030
NEU%: 72%

Radiology Findings
Thorax x-ray: “Pneumoperitoneum”
Abdominal x-ray: “Free intraperitoneal air; Air fluid level”
Abdominal USG: “Ascites”

ASSESSMENT

Peritonitis is inflammation of the peritoneal cavity and is most commonly the result of gastrointestinal
rupture, dehiscence, or perforation. Perforation of the stomach is a full-thickness injury of the wall of
the organ. Perforation of the wall creates a communication between the gastric lumen and the
peritoneal cavity. If the perforation occurs acutely, there is no time for an inflammatory reaction to wall
off the perforation, and the gastric content is free to enter the general peritoneal cavity, causing
chemical peritonitis.

Clinical signs in patients with peritonitis may be mild to severe and are often nonspecific.
Signs and symptoms can include refusal to feed, vomiting, and decreased activity. The most
common presenting manifestation is a sudden onset of abdominal distension and pain. These are the
same as those found in the case. Patients with perforation invariably complain of acute onset of severe
abdominal pain. The patients often note the exact time of onset of pain. Many of them will seek medical
attention with the onset of pain but a few will present in a delayed fashion (may present with sepsis).
Irritation of the diaphragm may occur leading to pain radiating to the shoulder. Sepsis can be the initial
presentation of perforation.

The majority of patients will have tachycardia, tachypnea, fever, and generalized abdominal tenderness.
Bowel sounds may be absent and rebound and guarding are likely to be present.

The overall peripheral white blood cell counts typically fall within normal limits. A marked neutrophilia
with a left shift is the predominant hematologic finding, although a normal or low neutrophil count may
be present. An increasingly left-shifted neutrophilia (or neutropenia) paired with clinical signs of
peritonitis. Furthermore, acid-base and electrolyte abnormalities may be noted. Hypoproteinemia may
be a result of the loss of protein within the peritoneal cavity. Patients with a concurrent septic process
may be hypoglycemic. Hepatic enzymes, creatinine, and blood urea nitrogen may be elevated, indicating
primary dysfunction of these organs or perhaps reflecting a state of decreased perfusion or dehydration.

Diagnosis usually confirmed by radiological imaging showing a pneumoperitoneum and free

intraperitoneal air which are suggest perforation of a hollow viscous organ. Another reported suggestive
sign is the lack of an air-fluid level in the stomach in a horizontal beam view and a relative paucity of gas
in the distal bowel.

Initial management consists of agressive resuscitation, oxygen therapy, intravenous fluids, and broad-
spectrum antibiotics. A nasogastric tube should also be placed. Intravenous analgesia and PPIs should be
given as necessary. A urinary catheter enables close monitoring of urine output. 
Broad-spectrum antibiotics have been shown to reduce the risk of wound infection. Metronidazole and
either a cephalosporin or an aminoglycoside will suffice.
Surgical management is the mainstay of treatment for most stomach perforations. Emergency surgical
repair (open or laparoscopic) is indicated in nearly all cases.

Working Diagnosis
Generalized Peritonitis ec suspect Hollow Viscous Organ Perforation dd Gastric Perforation
+ Ascites + HHD + DM Type 2 + Bronchopneumonia suspect Covid-19

Definitive Diagnosis
Generalized Peritonitis ec Gastric Perforation + Ascites + HHD + DM Type 2 + Bronchopneumonia
suspect Covid-19

PLAN
Pre-opereration therapy
Fasting
Flow NGT, production of NGT observed
Set Foley catheter, urine ouput observed
IVFD RL 1500 ml/24h
Inj. Meropenem 1g/8h/iv
Inj. Omeprazole 40mg/12h/iv
Drip. Paracetamol 1g/24h/iv
Plan CITO laparatomy
Ready PRC 2 bag

Post-opereration therapy
IVFD RL + Analgetic from TS Anestesi
IVFD RL 1500 ml/24h
Inj. Meropenem 1g/8h/iv
Inj. Metronidazole 500 gr/8h/iv
Inj. Omeprazole 40mg/12h/iv
Fasting
Observation of NGT production
Observe abdominal drain production
Wound care/day

ABSTRACT
Background: Peritonitis is inflammation of the peritoneal cavity and is most commonly the result of
gastrointestinal rupture, dehiscence, or perforation. Gastric perforation is a surgical emergency in
routine practice. The causes and predisposing factors for gastric perforation vary from traumatic to
benign conditions like inflammatory processes. Early detection, intensive care, stabilization and
prompt surgery yield positive outcome. Early diagnosis is important for better prognosis. Objective:
To report the case of peritonitis ec gastric perforation encountered at ER of RSUD Mimika.
Materials and Method: Case report. Case presentation/report: We present a 57-years-old female
had presented to Emergency unit of RSUD Mimika with sudden onset of abdominal pain since 3 hours
earlier. Plain abdominal X-ray revealed pneumoperitoneum. Emergency laparotomy was performed
where a gastric perforation was found measuring 1.5 by 1.5 cm located on the antrum of the
gastric. The patient underwent successful surgical intervention and recovered well.

KEYWORD:
Peritonitis, Gastric, Perforation