Gastrointestinal perforations clinical study and management

Karuppasamy, M (2007) Gastrointestinal perforations clinical study and management. Masters thesis, Tirunelveli Medical College, Tirunelveli.


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INTRODUCTION: Gastro Intestinal Tract Perforations represent one of the most common acute abdominal emergencies in the surgical field and is still a dreaded condition having a high morbidity and or mortality. Differences in the clinical presentation of Gastro Intestinal tract perforations vary from the typical severe acute abdominal pain at one end, to subtle or no symptoms in the hospitalized patients for unrelated illness at the other end1. The various atypical presentations that mimic other abdominal conditions throw a real challenge over the diagnosis to the emergency surgeon. A careful clinical history, methodical clinical examination and radiological study plays a major role in the early diagnosis of this acute abdominal emergency. There are multiple factors that influence the prognosis and outcome of the patient. Preoperative resuscitation, appropriate administration of broad-spectrum antibiotics and good postoperative care are the mainstay in the management of Gastro Intestinal Perforations. The operative management depends upon the cause of perforations. Surgeons must continually reassess standard method of treatment and be receptive to new ideas. AIM OF THE STUDY: 1. To study the presentation of various Gastrointestinal perforations admitted in the General Surgical Department of Tirunelveli Medical College Hospital. 2. To analyse the etiology & clinical features of Gastrointestinal perforations. 3. To compare the reliability of physical findings versus radiological signs in cases of Gastrointestinal perforations. 4. To study various types of managements of gastrointestinal perforations and merits & demerits of them. 5. To study the mortality, morbidity in various groups followed in the management of these cases ,with ref to their manifestation. MATERIALS AND METHODS: This study was conducted in the Department of General Surgery, Tirunelveli Medical College Hospital, Tirunelveli for a period of 21 months from November 2004 to August 2006. 127 cases of gastro intestinal perforations were studied during the period. The diagnosis was established by the Duty surgeon provisionally based on the clinical presentation. Definitive diagnosis established at the time of operation. As pre operative evaluation following investigation done. 1. Relevant biochemical tests, 2. Blood grouping typing, 3. X-ray chest , Abdomen, 4. USG (Ultra Sonogram), 5. E.C.G, 6. Abdominal paracentesis whenever warranted. Peroperative finding: Operative details included the 1. Site of the perforation, 2. Size of the perforation, 3. nature and quantity of peritoneal fluid & soiling, 4. The gross appearance of the bowel bearing the perforation, 5. The nature of surgical procedure performed, 6. Tissue biopsies for histologic confirmation were taken in appropriate cases. Post Operatively: Morbidity was analysed in terms of associated complications following surgery and duration of hospital stay. Following details were observed from the clinical course and recorded in case records. 1. Patients name, age, sex, inpatient number (pt identity). 2. Clinical features and abdominal findings. 3. Delay in hours between symptoms and surgery. 4. Operative findings. 5. Procedures done. 6. Post operative complications. 7. Duration of hospital stay. All case included in this study were observed / assisted /operated by the presentor. Inclusion criteria: All cases admitted with signs of peritonitis included irrespective of etiology. Exclusion Criteria: 1. Cases of Oesophageal rupture 2. Cases of perforations of hepatobiliary system 3. Cases of iatrogenic perforation during laparotomy 4. Cases of delayed presentation with shock and septicemia whose general condition did not warrant any operative management even after all resucitative measures. CONCLUSION: • Duodenal ulcer perforation was the commonest cause of gastrointestinal perforation with a male preponderance. • More common in the fourth and fifth decade of life. • Smoking and alcohol were the main aggravating factors. • Perforation was the first manifestation of peptic ulcer disease in a small percentage of patients. • The role of nonsteroidal anti-inflammatory drugs as the cause of perforation was little in this study group. • Radiological evidence of pneumoperitoneum could not be established 10% cases. • Ultrasonogram – useful diagnostic tool to establish free fluid in acute abdomen. • Simple closure with omental patch with thorough peritoneal toileting was very much effective. • Definitive ulcer surgery was not warranted in the emergency and treatment with H2 blockers and H. Pylori eradication achieved good control over the disease in the follow up period. • The prognostic indicators were early hospitalization, adequate fluid replacement and absence of co-existing medical illness. • Gastric perforations were common in the fifth & sixth decade. • The role of biopsy in gastric perforation was established with a case proving positive for malignancy. • Delayed hospitalization was the major cause of perforation in appendicitis. • Jejunal perforations were rare and trauma was the single major cause of jejunal perforation. • Closure in two layers was very much effective in small bowel perforations. • Inspite of recent advances in duodenal perforation - closure by laparoscopy, still simple closure with omental patch is widely practiced in this study group. • The most common post-operative complication was wound infection. • Deaths were due to septicemia, renal failure or cardiac arrest. • The actual mortality was higher than the mortality in the study group since cases of delayed presentation with shock and septicemia did not warrant anesthesia and were excluded from the study group.

Item Type: Thesis (Masters)
Uncontrolled Keywords: Gastrointestinal perforations ; management ; clinical study.
Subjects: MEDICAL > General Surgery
Depositing User: Devi S
Date Deposited: 09 Jun 2018 17:01
Last Modified: 09 Jun 2018 17:01

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