MANAGEMENT OF A LARGE PERFORATED DUODENAL ULCER WITH GENERALISED PERITONITIS IN A BLIND MAN- CLOSURE USING THE OMENTAL (GRAHAM)

PATCH NAME: M.L AGE: 50 YEARS SEX: MALE ADDRESS: Laling in Mikang LGA of Plateau State HOSPITAL NUMBER: 06-11-19 OCCUPATION: farming MARRITAL STATUS: MARRIED DATE SEEN: 18/06/11 PRESENTING COMPLAINT Generalized abdominal pain of 2 days duration. HISTORY OF PRESENTING COMPLAINT ML WAS apparently well until 2 days prior to presentation when he had a sudden onset of epigastric pain. The pain rapidly became generalized although occasionally it moved to the right lower quadrant and to the back. There was no previous history of dysyepsia and was not on treatment for ulcer. Pain was initially relieved by food but later was no longer relieved by food; there was no history of progressive bloating and abdominal fullness. There was a history of nausea and copious vomiting with loss of appetite and progressive weight loss. There was no history of hematemesis and no history no history of melena. There was no history of ingestion of herbal medication; there was no history of trauma to the abdomen. There was a positive history of fever that was of high grade associated with chills and rigor, relieved on taking panadol. No history of cough and no excessive nigh

sweat. He became blind at the age of 6 years following an infection to both eyes. He couldnt tell precisely the nature of the infection and how it was managed but there was no trauma to the eyes. REVIEW OF SYSTEMS There was no history of jaundice and no loss of consciousness. He had no urinary symptoms. PRE MEDICAL HISTORY There was no history of past hospital admission, he was not a known hypertensive nor diabetic. There was no history of surgeries in the past, no history of past blood transfusions. FAMILY AND SOCIAL HISTORY He was married to one wife and had 5 children; he lived with his family in a 2 bedroom apartment. Their main source of drinking water was from a well and a community bore hole, he drank alcohol occasionally but does not smoke cigarette. DRUG HISTORY He was not on any medication as at presentation. He had no known drug allergy. PHYSICAL EXAMINATION He was a middle aged man, with a dense bilateral corneal opacity, not pale, afebrile to touch with a temperature of 38.1c. There was no peripheral lymphadenopathy. He had no perception of light in both eyes. His pulse rate was 100beats per minuite, moderate volume and regular. His blood pressure was 100/60mmhg. His apex beat was on the left 5th intercostal space on the mid clavicular line with first and second heart sounds present but no added sounds or murmurs. His chest was symmetrical and moved evenly with respiratory rate of 24 breaths per minuite. He had vesicular breath sounds in both lungs.

His abdomen was distended globally with a board like rigidity on palpation and with generalized tenderness more marked at the epigastrium and periumbrical area. Guarding and rebound tenderness was also elicited. The bowel sounds were absent. The liver and spleen were not palpably enlarged and the kidneys were not ballotable. Rectal examination revealed a normal sphicteric tone, mildly enlarged prostate gland, normal non adherent rectal mucosa. Glored hand was stained with fresh brownish feaces. He was conscious and alert but restless and sweating. A provisional diagnosis of an acute abdomen with generalized peritonitis secondary to suspected perforated duodenal ulcer was made. The following differential diagnosis was also made (1) Ruptured appendicitis (2) Typhoid perforation

HOSPITAL COURSE The diagnosis and management plan were explained to him and the wife. He was then admitted into an isolated ward where an intravenous access was secured with a large- bore canula and intravenous fluids administered. He received 3 litres of dextrose water alternating with 0.9% normal saline. A nasogastric tube was inserted to empty the stomach and maintain fill bowel sounds refused. He was placed on nil per orals. A urinary catheter was passed. Blood samples were taken for complete blood count and retro vital screening ,GXM 30 OF BLOOD, there was no reagent for urea , electrolyte and creatinine estimation, urine was also taken for urinalysis. The result of the investigation were as follows, packed cell volume was 30%, total blood count was 8,500/mm; neutrophils were 60%, lymphocytes were 40%. The urinalysis was normal. He was placed on anti biotics; intravenous metronidazole 500mg every 8 hours and intravenous genticine 80mg 8 hourly and intravenous ampiclox ig 6 hourly.

The anaesthetic unit was informed and the patient was reviewed appropriately. ML and the wife signed and informed written consent for an emergency laparotomy. He was wheeled to the theatre and relatives further reassured. OPEERATIVE MANAGEMENT THE surgery was done under general anesthesia with the following intra operative findings.(1) Duodenal perforation measuring about 2x2cm (2)An inflamed appendix (3) peritoneal fluid collection of approximately 2 litres PRECEDURE: under general anaesthesia, patient abdomen was cleaned with chlorhexidene and drayed. A midline incision extending upwards to the xiphisternum was made and the abdomen entered in layers. The above finding were noted. The duodenal perforation was closed using deeply placed vicryl o sutures and reinforced with a Graham omental patch and a thorough lavage done using warm normal saline. An appendectomy was also effected with the stung ligated using chromic o after securing the mesoappendix with chromic o. the abdomen was closed en mass using nylon 1(polyamine) suture. Anaesthesia and procedure was well tolerated. He was wheeled to the ward after an hour of observation at the recovery room. He was maintained on the anti biotics that was commenced prior to surgery. 4 HOURS POST OPERATION The patient was conscious but drowsy. He was not pale, was afrible and not dehydrated. The pulse rate was 100 beats per minuite and of normal volume. The blood pressure was 100/60mmhg, he had first and second heart sounds. He was assessed to be stable and maintained on post-operative orders. POST OPERATIVE DAY 1

He was fully out of anaesthesia on physical examination, he was not pale, afebrile with a temperature of 36.7c, his pulse rate was 98beats per minuite, full volume and regular. The blood pressure was 130/80mmhg, he had 1st and 2nd heart sounds only, the abdomen was full, moved with respiration. The operation site was clean and dry with no area of undue tenderness. Bowel sounds were very scanty. The nasogastric tube was still active. Adequate hydration was maintained with an hourly time output record of 30ml/hour he was thus assessed to be stable. POST OPERATIVE DAY 2 The was no fresh complaint. His vital signs were stable. A packed cell volume was requested for which came out to be 31%. He was reassured and the relatives further educated on the course of the management and reassured as well. The catheter was removed and post of management maintained. POST OPERATIVE DAY 3 There was no fresh complaint. He had passed flatus several times.on physical examination, he was not pale, afrible with a temperature of 36.4c. the operation site was slightly soaked with serous fluid. The wound dressing was changed and the intravenous antibiotics and intravenous fluid sustained, he was commenced on graded, the NGT was removed and oral sips. POST OPERATIVE DAYS 4 TO 7 There was no fresh complaint as the patient had improved remarkable. He had moved his bowel several times. The vital signs were stable, the operation site was okay. The stitch was removed on the 7th day. The parenteral antibiotics was maintained for seven days. He was discharged home on the 8th day post operation to be seen 2 weeks thereafter. He was discharged on an oral omergrazole 30mg daily for a month, metronidazole tablets 400mg tds for a month and amoxillin--- twice daily for a month. The wife was encouraged to continue the supportive role she has been showing since the admission.

FIRST FOLLOW UP VISIT There were seen at the outpatient department after 2 weeks, there was no fresh complaint, on physical examination he was not pale, afebrile to touch. He had a respiratory of 20 cycles per minute. The pulse rate was 88 beats per minute, the blood pressure 100/70mmhg. He had 1st and 2nd heart sounds, the abdomen was flat, moved with respiration. The wound site had properly healed. There was no area of undue tenderness. He was assessed to have improved on current treatment. He was maintained on the drugs he was discharged on. They were further educated on the possible causes of the condition and prognosis with respect to recurrences. He was encouraged to feed well and continue his daily activities. The wife who is now the main bread winner of the family was encouraged to be supportive and to seek for help from her in-laws when the need arises. 2ND FOLLOW UP VISIT There were seen a month later, there was no complaints. The vital signs were stable, operation site has healed properly. They were thus discharged from the surgical point of view after satisfactory recovery. DISCUSSION