Distal Gastric perforation in a 15

year old adolescent

- a case report
Dr. M. Rajesh Menon
MS Post Graduate
S1, Prof. R. Vasuki’s unit
Assts: Dr. N. B. Thanmaran, Dr. A.K. Kalpana Devi and Dr. P.S. Arun.
Department of General Surgery
KMCH- Chennai
 Presentation
• 15 year school boy,
• Sudden onset abdominal pain, since last night
• Initially at the epigastrium and right hypochondrium
• Intermittent dull ache initially later became severe and
continuous, spreading across the abdomen
• Associated with vomiting since morning, couple of
episodes, non projectile, mainly undigested food
particles with bile.
• No history of trauma, fever, abd distention
• No history of yellowish discoloration of sclera
• No history of hematemesis or malena
 History contd
• No similar complaints in the past
• Irregular food habits present
• Bowel and bladder normal.
• No significant co-morbidities
• No past surgeries or procedures
• Active student life
• Socially adept
• No history of alcoholism or smoking
• No similar complaints in the family
 On examintaion
• Thin built and average nourishment
• Conscious
• Dehydrated with poor GC
• Temperature- 99 F
• PR: 100/mt
• BP: 130/80
• SPO2 – 98%
• RR: 18/mt
• Patient was in severe pain
 Systemic examination
• Cardiovascular and Respiratory system was
within normal limits
• Per abdomen, on inspection, abd scaphoid
• On palpation, rigid abdomen with voluntary
and involuntary guarding, more in the supra
colic compartment.
• Tender over epigastrium, right hypochondrium
and right illiac fossa
• Hernial sites were free
 Examination contd
• On percussion, no obvious obliteration of liver
dullness
• No clinical evidence of free fluid
• On auscultation, the bowel sounds were
absent.
• External genitalia and PR was within normal
limits
 Work up
• A provisional diagnosis of Acute abdomen was
made probably due to
– ? Peritonitis post appendicular perforation,
– ? Acute pancreatitis
• Patient was immediately put on NPO, RTA and
CBD.
• IV fluid, PPI, Antiemetics and
• Antibiotics started.
 Investigations
• X Ray CXR PA view and Abdomen erect
showed gas under the diaphragm.
• USG showed: Bulky pancreas with mild peri-
pancreatic inflammation. Free fluid in the
abdomen.
• TC was 5400 cells /cu mm
• With 75% Polymorphs
• Sr. Amylase was around 300
Air under the diaphragm on the right side
 Emergency laparotomy and proceed
planned
Findings:
• 150 ml of pus mixed with bile and undigested food particles
• Perforation of size around 2 cms was noticed at the distal
gastric antrum anteriorly
• Bile was seen coming out from the opening.
• Flakes all around the peritoneum with slough over the
small bowel segments
• Appendix was mildly dilated and enlarged with engorged
veins over it
• There were multiple lymph node enlargements of varying
sizes through out the mesentry
• Solid organs were normal
 Procedure done
• Thorough wash given with warm saline.
• Initially appendectomy was done after serial
clamping cutting and ligation. Specimen for HPE.
• Biopsies were taken
• from the perforated wall
• mestentric lymph node.
• Perforation was closed with GRAHAMS LIVE
OMENTAL PATCH CLOSURE.
• Sub Hepatic and pelvic drain were kept
• Abdomen closed in layers.
P
e
r
f
o
r N
a o
t d
i e
o s
n
 Post op period
• Uneventful
• Passed motion on 3rd POD
• Orals started on 5th POD
• Left drain removed 6th POD
• Right drain next day
• Suture removal 10th day.

Post op picture with drain removed

 HPE report (KMCH)
• Wedge biopsy from wall of the perforation
showed fibromuscular tissue with acute
inflammatory infiltrate.
• Mesentric lymph nod biopsy reported as reactive
lymphoid hyperplasia
• Appendectomy specimen showed normal
histology with lymphoid hyperplasia, serosal
congestion and inflammation s/o early
appendicitis.
• CBNAAT of peritoneal fluid- negative for TB.
Discussion- Gastric/DU perforation
• Perforation is one of the well established and dreaded
complication of Peptic ulcer disease.
• DU perforation common and mainly anterior wall.
• Gastric perforations mostly near distal antrum/Lesser
curvature, may be malignant.
• Incidence is reducing
• Change in age and gender patterns
• Compared to yester years it is common past middle age
• Increasing seen in females, esp in elderly
Male to female ratio may approach 2:1
 Presentation and findings
• Sudden onset generalized abd pain (due to peritoneal
irritation caused by acid)
• Classically, Peritonitis and its features predominate in
late presentations (pyrexia, tachycardia, toxic state,
board like rigidity of the abdomen, immobile patient)
• But seldom clear now a days- esp in elderly with NSAID
abuse.
• Peritonitis features are less in small perforations,
sealed perforations and in perforation to lesser sac.
• Bleeding is common in Posterior Du perforations
 Investigations
• Chest X ray shows gas under the diaphragm in
around 70% of cases.
• CT is more accurate but reserved for equivocal
cases
• Neutrophilic leucocytosis is common
• Serum amylase is useful to differentiate from
acute pancreatitis
• However gold standard is CT when in doubt.
 Treatment overview
• Decontamination if the peritoneum with closure of the
perforation.
• Graham’s omentopexy is commonly done after taking
biopsy of the wall if gastric.
• Now a days procedures to reduce gastric acid secretion
are less common.
• Abdominal wash given and wound closed after DT
placement.
• Post op antibiotics
• Role of H pylori is to be assessed (serology/ Co2 breath
analyser, OGD with Bx for HPE- urease) and eradication
treatment regime started.
 Contd’
• Gastric ulcers should, if possible, be excised
and closed, so that malignancy can be
excluded.
• For perforations more than 3 cms, simple
closure is impossible
• Billroth II gastrectomy or subtotal gastrectomy
with Roux-en-Y reconstruction are useful
operations then.
Various methods of closure

A, primary suture; B primary

suture with pedicled omental
flap; C, pedicled omental flap
sutured into the perforation
(Cellan–Jones repair); D, free
omental plug sutured into the
perforation (Graham patch);
E, use of three long-tailed
sutures to close the
perforation and buttress with
a pedicled omental flap; F,
use of tacking sutures around
the perforation (for example
when friable edges or a large
perforation may not allow
approximation of wound
edges)
 Laparoscopic approach
• The same objective can be satisfied
laparoscopically
• The laparoscopic procedure has the benefit of
less pain, early mobility and reduced
morbidity.
• Problems: Longer time and higher incidence
of re- leakage.
• Modified Graham’s repair for peptic ulcer perforation: reassessment study
Bhavinder K. Arora1*, Rachit Arora2 , Akshit Arora3
Role of conservative management
• Surgery is the treatment of choice
• However for patients who have small leaks
from a perforated peptic ulcer and relatively
mild peritoneal contamination, who may be
managed with intravenous fluids, NG suction
and antibiotics.
• However the literature is vary about this
approach.
• Not routinely resorted to.
 Perforation in children and
adolescents
• Not very common in children/adolescents
• Cause mostly unknown.
• Spontaneous perforation is also reported (in literature)
• Most studies and literature is related to Adult PPU
disease. (very little on children)
• Incidence not clear (compared to 10% in Adults)
• More than 80% were male and 90% were adolescents
between the ages of 14 to 18.
• Around 70 % had dyspepsia but without overt
symptoms of PUD.
• In 25 % PPU was the presenting feature.
 Special characteristics
• Peptic ulceration and H pylori infection may be common in
Asians and Low socio economic class.
• In Neonates: congenital defects of the gastric wall,
mechanical disruption, stress ulceration secondary to
neurogenic disorders, and ischemia of the gastric wall
secondary to vascular shunting.
• 5-18 years: very uncommon: peptic ulceration, trauma,
aerophagia, or drug administration. Seen associated with
Burkitts lymphoma. Iatrogenic causes are reported
• Other causes may be ZES, Sickle cell Anaemia, NSAID abuse
and stress ulcerations (Head injury/ burns)
• Majority had perforation of the ant wall in pre- pyloric
than duodenum.
 Investigations and treatment
• X ray is diagnostic of pneumoperitonium
• CT is accurate and only done if required
• Neutrophilic leucocytosis
• Amylase was not helpful
• Treatment principles are same as adult.
• Simple suture to ometopexy.
• Emergency as delay leads to morbidity
• Laparoscopic exploration and mgt in experienced centers.
• Definitive acid reducing procedures not well studied or
documented.
• Better prognosis compared to adults
• Follow up to check H Pylori.
• Eradication regimen for 14 days.
 References
• Perforated peptic ulcer in the pediatric population: A case report and literature review:
Sara Morrison, Peter Ngo, Bill Chiu.

• Spontaneous Gastric Perforation in Two Adolescents , 1 Amaka Akalonu , 2 Mona

Yasrebi , Zarela Molle Rios; Division of Gastroenterology, Hepatology and Nutrition,
Alfred I. duPont Hospital for Children, Wilmington, DE, U.S.A.

• Perforated Peptic Ulcer in Children: A 20-year Experience Man-Chin Hua, yMan-Shan Kong,
yMing-Wei Lai, and zChih-Cheng Luo; Divisions of Pediatric Critical Care and Emergency
Medicine, {Gastroenterology, and {Department of Pediatric Surgery, Chang Gung Children’s
Hospital, Chang Gung Memorial Hospital,Chang Gung University College of Medicine,
Taoyuan, Taiwan

• Lithuanian Surgery, 2015, 14 (1), p. 38–45. Perforated peptic ulcer in children: diagnosis
and treatment. Jūratė Baltrūnaitė1, Kęstutis Trainavičius, 1 Vilnius University, Faculty of
Medicine, M. K. Čiurlionio Str. 21, LT-03101 Vilnius, Lithuania, 2 Children’s Surgery Centre,
Children’s Hospital, Affiliate of Vilnius University Hospital Santariskiu Klinikos, Santariskiu
Str. 7, LT-08406 Vilnius, Lithuania
 References cont’d
• Jan 2014; British Journal of Surgery- Strategies to improve the outcome of
emergency surgery for perforated peptic ulcer
• The management of perforated gastric ulcers; Matthew Fraser Leeman et al,
Department of Surgery, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old
Dalkeith Road, Edinburgh EH16 4SA, United Kingdom
• Modified Graham’s repair for peptic ulcer perforation: reassessment study
Bhavinder K. Arora1*, Rachit Arora2 , Akshit Arora3
• E Medicine – Omental patch techniques
• Maingot Abdominal operations - 12th edition
• Sabiston -20th edition
• Baliey and Love- 26th Edition
• Schwartz - 10th edition
Dr. M. Rajesh Menon
MS Post Graduate
S1, Prof. Vasuki’s unit
Asst: Dr. N. B. Thanmaran, Dr. A.K. Kalpana Devi and Dr. P.S. Arun.
Department of General Surgery
KMCH- Chennai