Manajemen Perforasi Gaster

Introduction
• Peptic ulcer disease is common with a lifetime prevalence in the
general population of 5-10% and an incidence of 0.1–0.3% per year.  
• The lifetime prevalence of perforation in patients with PUD is about
5%
• PPU carries a mortality ranging from 1.3% to 20%. Thirty-day
mortality rate reaching 20% and 90-d mortality rate of up to 30% have
been reported.
Anatomy
Physiology
Etiology
• NSAIDs, 
• Helicobacter pylori (H. pylori),
• physiological stress,
• smoking,
• corticosteroids
• and previous history of PUD are
risks factors for PPU
Clinical Feature
• Symptoms of PUD include abdominal pain, upper abdominal
discomfort, bloatedness and feeling of fullness. 
• The classic triad of sudden onset of abdominal pain, tachycardia and
abdominal rigidity is the hallmark of PPU.
The clinical manifestation
• The initial phase within 2 h of onset, epigastric pain, tachycardia and
cool extremities are characteristic.
• In the second phase (within 2 to 12 h), pain becomes generalized and
is worse on movement. Typical signs such as abdominal rigidity and
right lower quadrant tenderness (as a result of fluid tracking along the
right paracolic gutter) may be seen.
• In the third phase (more than 12 h), abdominal distension, pyrexia
and hypotension with acute circulatory collapse may be evident.
Imaging and laboratory finding
• chest X-ray
• serum amylase/lipase
• CT scan is recommended as it has a diagnostic accuracy as high as
98%
• Leukocytosis and raised C-reactive protein
• Elevated creatinine, urea and metabolic acidosis
BOF
Management
• PPU is a surgical emergency associated with high mortality if left
untreated.
• Fluid resuscitation,
• intravenous antibiotics,
• analgesia,
• proton pump inhibitory medications,
• nasogastric tube,
• urinary catheter and
• surgical source control.
Scoring
Scoring
• Small grade I and II perforations can be closed
primarily in one or two layers.
• Large (grade III) injuries near the greater curvature
can be closed by the same technique or by the use of
a GIA stapler.
• A pyloric wound may be converted to a pyloroplasty
to avoid possible stenosis in this area.
• Extensive wounds (grade IV) may be so destructive
that either a proximal or a distal gastrectomy is
required. Reconstruction with a Billroth I, Billroth II,
or Roux-en-Y anastomosis is dictated by the presence
or absence of an associated duodenal injury.
• In rare cases, a total gastrectomy and a Roux-en-Y V
esophagojejunostomy is necessary for severe injuries
(grade V)
Operative management

Graham Patch Cellan-jones repair plugging

Pylaroplasty
Billroth I and II
Roux-en-Y gastrojejunostomy
Surgical Management
Post Operative complication
• surgical site infection,
• pneumonia,
• intra-abdominal collection/abscess,
• wound dehiscence,
• enterocutaneous fistula,
• peritonitis,
• incisional hernia and ileus