Answer
1) Findings of X-ray
- This is a full erect chest x ray in PA view
- There is a bilateral minimal collection of gas under diaphragm
- Opacity of the lung field (hilar) that is most likely not indicate serious pathology.
2) Provisional diagnosis is Peritonitis secondary to Perforated Viscous, most likely from Gastric Ulcer.
- Patient has symptoms of peptic ulcer
- Chronic smoker
- Minimal gas under diaphragm. Even though no gas under diaphragm, differential diagnosis of perforated viscous still could not be excluded as 10% of the cases do not have these findings. the most common perforation site is anterior part of the stomach.
- In middle age
- Men to women ration for perforated peptic ulcer is 2:1
- Generalized pain with board like rigidity indicates irritation to the peritoneum.
3) Management to this patient
a) Resuscitation
- Give 02 100%, 3L/min via nasal prong
- Obtain two large bore IV access
- Fluid therapy with 5 pints crystalloid (3 pints NS, 2 pints D5%)
- Analgesic, Tramadol 50mg IV stat followed with infusion.
- Keep nil by mouth
- Insert Ryle’s tube
- Monitor the vital sign.
b) Immediate management
- Blood investigation (FBC, BUSE/Creat, VBG)
- Insert CBD for I/O monitoring
- IV Pentaprazole
- Start antibiotic (Ciprobay, flagyl)
- Insertion of central venous line to measure CVP.
c) Definitive management which is emergency laparatomy
I) Pre operative management
o Obtain full history to anticipate high risk candidate for surgery.
o Obtain consent for laparatomy.
o Keep nil by mouth
o 12 lead ECG
o Blood investigation (FBC, GSH, RFT, LFT, baseline clotting screening i.e PT/aPTT and INR)
o Vital sign
o Pre medication for surgery
II) Intra OP management
o The surgery is perform under GA
o Identify the perforated part and take swab for C&S
o Close the perforation with omental patches (Graham’s technique)
o Peritoneal irrigation with 10L warm normal saline.
III) Post Operative management
o Monitor patient in recovery area for satisfactory ABC (Airway, breathing, circulation), acute complication of surgery (bleeding, complication from GA, loss of distal circulation), pain management
o Monitoring of vital sign every 15 minutes for one hour, hourly for 2 hours and 4 hourly.
o Transfer patient once stable
o Do not inspect the surgical wound for at least 48 hours but the surroundings of the dressing should be inspect for any sign of inflammation.
o Continue the analgesic infusion
o Cover with antibiotic.
o Encourage early movement to prevent risk of DVT
o Monitor I/O chart. Urine output should be at least 0.5 ml kg-1 h-1
o Keep nil by mouth. After at least 6H or no nausea and vomiting, can allow clear fluid.
o Review the patient at least three times per day.
o The suture can be removed at least after 2 weeks if no complication.
o Then patient can be discharged with appointment.