Peforated Peptic Ulcer

PEFORATED PEPTIC ULCER
BY A.C MBULO.
PERFORATED PEPTIC ULCERS
(a) Draw a well labeled Diagram illustrating the sites of ulcers
 Gastric ulcers lesser curvature , body, fundus, antrum.
 Deodenal ulcers
 Oesophageal ulcers 15%
(b) State five (5) clinical features of perforated peptic ulcers 15%
1.Severe upper abdominal pain throughout the abdomen transmitted by
the abundant visceral and parietal peritoneal pain receptors.
2.Shoulder pain due to stomach or deudenal spillage into peritoneal
cavity causing irritation to the phrenic nerve.
3.Rigid and tender abdominal muscles (quarding) as an attempt to protect
the abdomen from further injury
4.Shallow, rapid respirations
5.Absent bowel sounds
6.Nausea and vomiting – rare
C. Pre –operative surgery as for an emergency Surgery.

(d) post operative management up to discharge. 50%
1st 24 Hours.
• The patient is nursed in acute bay in supine position with the head tilted
to one side to facilitate drainage of secretions until patient fully recovers
from anaesthesia and is propped up on pillows.
• The Intravenous line is secured and 5% dextrose 1 litre may be

alternated with 2 litres of Normal saline in 24th hours. Catheter is
secured and urine output and input is monitored and is recorded on a
fluid balance chart. Abdominal drains are secured and drainage bag.
OBSERVATIONS:
• Temperature is done 4 hourly. Subnormal temperature may denote
shock or hypothermia with a high temperature indicating infection.
• Respirations are taken ½ hourly until patient’s condition stabilizes and

then changed to hourly, 2 hourly and 4 hourly.
• I’ll observe patient for Dyspnoea which may indicate poor recovery and
respiratory distress.
• I’ll observe for Cyanosis of lips and extremeties indicate low oxygen
body content
• Pulse is taken ½ hourly to monitor cardiac function and circulatory
system together with blood pressure.
• Rapid feeble pulse with a low blood pressure may indicate shock.
These vital signs are graduated to hourly, 2 hourly and 4 hourly as they
stabilize.
• I’ll also observe abdominal dressing for soiling which may indicate
internal haemorrhage
• if initial re-enforcement of dressing fails surgeon is informed.
• I’ll also observe the patient for the Presence of abdominal distension
which is an indication of internal hemorrhage.
• Blood transfusion may be given if necessary. 10%

PAIN RELIEF:
• I’ll administer the prescribed pain killers such as Pethidine IMI 100 mg 6 hourly x 3
doses is given. 2%
NUTRITION:
• I’ll keep the patient nil orally therefore I’ll commence 5% dextrose to supply
glucose nutrient and normal saline or Ringers lactate to replace lost electrolytes. Sips
of water may be started if bowel sounds present and abdomen is soft.
• Intravenous may be removed if these are scanty fluid drainage.
• I’ll consider 2 hourly NG Tube aspirations and continuous drainage to decompress

the GIT and facilitate healing.
PSYCHOLOGICAL CARE:
• When fully conscious, I’ll tell the patient the operation was done to
allay anxiety and fear. 24 Hours – 72 Hours.
• I’ll also explain the expected procedures to be done.
• To add on I’ll answer questions the patient is going to ask and refer
some questions to my colleague or the surgeon to answer .
• I’ll also reassure the patient and care taker to enhance co-operation to
treatment and care and relieve anxiety.
Hygiene
1st wound dressing is removed by the surgeon followed by daily aseptic

dressing. Abdominal drain may be removed or shortened if corrugated.
• On the 2nd day post-operative, bed bath is given and asisted oral toilet is
done.
• I’ll do cannula care, 4 hourly catheter toilet aseptically to prevent

ascending infection.
• i’ll also keep on performing general hygienic procedures such as dump

dusting patient’s unit, changing dirty linen and advising patient not to
cover an incision site with dirty cloth or material.
Exercises
• Day 1 post-operative, the patient is encouraged to do deep breathing
and coughing exercises while splinting or surpoting the abdomen to
prevent aspiration pneumonia.
• I’ll as well do some passive exercises especially of patient’s joints in

order to improve blood circulation.
• Early ambulation is encouraged and patient sits in a chair.

MEDICATION:
• Pain is relieved by analgesia e.g panadol 500 mg TDS. Antibiotics are given as
prescribed.
72 HOURS UP TO DISCHARGE
• Assisted baths until patient can bath on her own.
• Oral fluids are given if tolerated IV fluids are discontinued , light and then normal
diet given.
• Alternate sutures are removed and if wound union is good all sutures are removed.
Abdominal drainage tube is removed and sterile dressings done until area is healed.
• Drugs are given as prescribed.
Health Education
• Stress Management
• DIET: Bland diet without spices, coffee, cigarette smoking, caffeine

stimulates gastric acid secretion. Caffeine stimulated gastric acid
secretion.
• Prevention of stress ulcers by avoiding severe injury, burns and

hypotension.
• Importance of seeking medical attention early when seek and sings
and symptoms of peforated peptic ulcers.
• Importance of going for review so that her recovery is monitored
• To continue taking prescribed drugs.

E. State four (4) complications following partial gastrectomy their
management.
1.Dumping syndrome:
• This is a direct result of surgical removal of a layer portion of the

stomach and the pyloric sphincter due to reduction in the reservoir
capacity of the stomach its characterized by feeling of generalized
weakness, sweating, palpitations and dizziness attributed to sudden
decrease in plasma volume.
• Patient also complains of abdominal cramps, nausea,bloating and
diarrhea and the urge to defecate. This could be controlled by having
six small dry feedings daily that are low in carbohydrate, restricted in
refined sugars
• The feed should contain moderate amount of protein and fat. Fluids be
taken between meals but not with meals as this will quicken the
dumping of food into the small stomach.
2.Postprandial Hypoglycemia:
• This is as a result of uncontrolled gastric emptying of bowels of fluid

high in carbohydrate into the intestine. This leads to hyperglycaemia
and consequently the excess release of insulin into the circulation. This
leads to a secondary hypoglycaemia. Advise the patient to take low
carbohydrate diet as a preventive measure.
3.Billous vomiting: This is a sudden discharge of bile from the proximal
duodenum into the stomach via the gastrojejunestomy. This leads to
gastritis. Treatment with cholestyramine and antacids are used to prevent
this. Frequent small meals may also help.
4.Malnutrition: Anaemia, Vitamin deficiency e.g B12, gross weight loss
and even Osteoporosis. The patient is put on cyancobalamin for life.
• Advise the patient to take a gluten free diet. Iron supplements are
also encouraged. Give 4% for each to make 16%.
5.Recurrence is < 1%. Where it occurs H2 receptor antagonists may be
• given in reduced maintenance dose.

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PEFORATED PEPTIC ULCER

4.Shallow, rapid respirations

5.Absent bowel sounds

6.Nausea and vomiting – rare

C. Pre –operative surgery as for an emergency Surgery.

• The Intravenous line is secured and 5% dextrose 1 litre may be

• Respirations are taken ½ hourly until patient’s condition stabilizes and

• Pulse is taken ½ hourly to monitor cardiac function and circulatory

system together with blood pressure.

• if initial re-enforcement of dressing fails surgeon is informed.

• Blood transfusion may be given if necessary. 10%

• Intravenous may be removed if these are scanty fluid drainage.

• I’ll consider 2 hourly NG Tube aspirations and continuous drainage to decompress

• I’ll also explain the expected procedures to be done.

1st wound dressing is removed by the surgeon followed by daily aseptic

• I’ll do cannula care, 4 hourly catheter toilet aseptically to prevent

• i’ll also keep on performing general hygienic procedures such as dump

• I’ll as well do some passive exercises especially of patient’s joints in

• Early ambulation is encouraged and patient sits in a chair.

• DIET: Bland diet without spices, coffee, cigarette smoking, caffeine

• Prevention of stress ulcers by avoiding severe injury, burns and

• Importance of going for review so that her recovery is monitored

• To continue taking prescribed drugs.

• This is a direct result of surgical removal of a layer portion of the

• This is as a result of uncontrolled gastric emptying of bowels of fluid

5.Recurrence is < 1%. Where it occurs H2 receptor antagonists may be

• given in reduced maintenance dose.

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