Case Report

Clerk 許哲元
2019/11/05
Case Report

Patient’s History

2
Basic data

病歷號 : 1262063
姓名 : 張宗榮
性別 : 男
生日 : 50/12/29 ( 57 y/o )
住院時間 : 2019/10/31

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Personal History

• Allergy history: NKA

• Systemic disease: Schizophrenia ( 靜和醫院 )

• Surgery history : nil

• Smoking: nil / Alcohol: nil / Betel nut: nil

• Family history: nil

• TOCC: nil
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Chief Complaint

• Fever with chest pain for 1 day

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 Present illness
2019/10/31 中山附醫 ER
• T / P / R : 38.1° C / 106 / 22
• BP : 154 / 69
• SpO2 : 97%
• Denied : rhinorrhea, cough, sore throat,
vomiting, diarrhea, dysuria, frequency

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 Present illness
2019/10/31 中山附醫 ER
• T / P / R : 38.1° C / 106 / 22
• BP : 154 / 69
• SpO2 : 97%
• Denied : rhinorrhea, cough, sore throat,
vomiting, diarrhea, dysuria, frequency
• PE : Chest : coarse breath sound
Abdomen : diffuse tenderness

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ER ( 10 / 31 4 PM )
血液

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ER ( 10 / 31 4 PM )
生化

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ER ( 10 / 31 3 PM )
鏡檢

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ER ( 10 / 31 6 PM )
血液 & 血庫

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CXR

• free air over bilateral

subphrenic spaces; hollow
organ perforation should be
considered.

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EKG - RBBB

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 CT

• intrapertioneal free air and

fluid accumulation.

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CT
• Focal wall defect in gastric antrum/pylorus.

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Abdominal Sono

• GB polyps.

• Increase corticoechogenicity of right kidney with suspect

minimal perirenal fluid.

• Echoic debris with mild thickened wall of urinary bladder.

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 Clinical course
2019/10/31
ER : Diagnosis : pyrexia, PPU
Treatment : N/S, Brosym, Lyacety

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 Clinical course
2019/10/31
ER : Diagnosis : pyrexia, PPU
Treatment : N/S, Brosym, Lyacety
2019/10/31 Admission
6 pm

10 pm Operation

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• Pyloroplasty + omentum patch + excisional biopsy of prepylorus ulcer
 Clinical course
2019/10/31 Post – operation ICU care
• drainage condition
• pain relief
• chest care

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 Clinical course
2019/10/31 Post – operation ICU care
• drainage condition
• pain relief
• chest care

2019/11/03 Transfer to ward

• iv nutrition support
• abx with Tazocin
• consult to Psy Dr.

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Case Report

Discussion
Perforated Peptic Ulcer

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 Outline

• Clinical manifestations

• Diagnosis

• Management

• Surgery vs Conservative management

• Postoperative care

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 Clinical manifestations
< 2 Hr abdominal pain
tachycardia, a weak pulse,
cool extremities, and a low temperature

2 ~ 12 Hr

> 12 Hr

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 Clinical manifestations
< 2 Hr abdominal pain
tachycardia, a weak pulse,
cool extremities, and a low temperature

2 ~ 12 Hr abdominal pain may lessen

liver dullness ↓
RLQ tenderness

> 12 Hr

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 Clinical manifestations
< 2 Hr abdominal pain
tachycardia, a weak pulse,
cool extremities, and a low temperature

2 ~ 12 Hr abdominal pain may lessen

liver dullness ↓
RLQ tenderness

> 12 Hr abdominal distention ↑

Temperature ↑
hypovolemia 26
 Diagnosis

• Plain x-rays : free air

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Dome sign Reverse V sign Falciform ligment sign
 Diagnosis

• Plain x-rays : free air

• CT with oral contrast : leakage

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• extravasation of oral contrast through a hole in the duodenum 
• inflammatory thickening of the duodenal wall
 Management

• IV PPI

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Benefit of PPI

H2-R antagonist
Omeprazole (19)
(11)

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Benefit of PPI

H2-R antagonist
Omeprazole (19)
(11)
Mortality : 64% 11%
=>PPI promotes sealing 33
 Management

• IV PPI

• Antibiotics : enteric G (-) + anaerobes + mouth flora

=> + beta lactamase inhibitor : Augmentin, Tazocin

or 3rd cephalosporin + metronidazole

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 Management

• IV PPI

• Antibiotics : enteric G (-) + anaerobes + mouth flora

=> + beta lactamase inhibitor : Augmentin, Tazocin

or 3rd cephalosporin + metronidazole

• Surgery
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Surgery vs Conservative

NG + abx + H2 blocker

Conservative ( 29 + 11 ) Laparoscopic ( 43 )

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Surgery vs Conservative

fail to improve after 12 Hr

Conservative ( 29 + 11 ) Laparoscopic ( 43 )

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Surgery vs Conservative

Conservative ( 29 + 11 ) Laparoscopic ( 43 )
• not differ in morbidity and mortality
• hospital stay was 35% longer
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Surgery vs Conservative

delayed presentations → persistent leak→ peritoneal contamination

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 Surgery vs Conservative

delayed presentations → persistent leak→ peritoneal contamination

=> peritoneal drainage, especially for who are not good surgical candidates

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 Postoperative

• Wound care

• Remove NG tube : return of GI function on post-op d 2 or 3

• Diet : slowly advanced

• Antibiotic : Patients with H pylori infection

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 Follow up –
Upper endoscopy
at least > 2 wks, prefer to 6 ~ 8 wks

• evidence of malignancy,
• biopsy for H. pylori
• assessment for ulcer healing

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 Back to the patient

• Symptoms : ( abdominal pain ) → chest pain, tachycardia, tenderness

• Diagnosis : CXR ( Dome sign ), CT (without oral contrast?)

影
43
 Back to the patient

• Symptoms : ( abdominal pain ) → chest pain, tachycardia, tenderness

• Diagnosis : CXR ( Dome sign ), CT (without oral contrast?)

• pre-op : Pantoloc ( PPI )

Brosym ( 3rd Cepha + beta lactamase inhibitor )

• post-op : JP drainage, Tazocin, NG tube, IV nutrition, foley(?)

• Follow up : EGD (?) 影

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Case Report

Take home message

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 PPU

• Diagnosis : • Management :
• Plain x-rays • IV PPI
• CT with oral contrast • Antibiotics
• Surgery

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 References

• UpToDate
• PubMed

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Case report

Thank you for your attention

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RBBB : 電訊號無法由右傳入右心室，必須靠來自左心室的訊號活化
寬 QRS

V1 雙 R

V6 的 S 寬