Shock Hypoxia and

Perforated duodenal ulcer

Okeke Ngozi E.Amaka
Team 3
Shock and Hypoxia are two important life threatening conditions found in
medicine. Shock is defined as failure of cellular function due to inadequate
tissue perfusion and consequent cellular hypoxia resulting from reduction in
the effective circulating blood volume while hypoxia is defined as a
pathological condition in which the body as a whole(generalized hypoxia)or a
region of the body is deprived of adequate oxygen supply. Their similarities
include:

 They are both as a result of decreased effective circulation

 They both result in inadequate oxygen perfusion to tissues
 They both ultimately result in cellular injury and ultimately function
 They equally cause metabolic derangement..e.g metabolic acidosis
 They both long term result in multiple organ dysfunction
 In terms of their clinical presentation they may present with
breathlessness , disorientation ,may become comatose
 On examination patients with shock and hypoxia may have pallor
,cyanosis, tachycardia and respiratory embarrassment(in their bid to
increase oxygen intake)

In terms of their differences

1) Shock is as a result of reduction in the effective circulating volume whilst

hypoxia is as a result of deoxygenation of tissues /or a reduction in the
carrying capacity of the tissues.
2) Shock is consequence of acute blood loss(haemorrhage),plasma and fluid
loss (hypovolaemic shock e.g in peritonitis, intestinal obstruction)while
hypoxia results from conditions like high altitudes, diving underwater using
closed circuit rebreather systems.
3) Clinically a patient in shock usually may present with cold clammy
extremities in addition to the pallor cyanosis and tachycardia in the late
stages as opposed to seizures and coma in hypoxia
4) The definitive management for shock is rescuscitation with intravenous
fluids like Normal Saline and Ringers lactate to expand the extravascular
volume while hypoxia is managed with oxygen administration.
5) Shock is traditionally classified into hypovolaemic cardiogenic and
distributive shock whilst hypoxia is classified into hypoxemic hypoxia and
histotoxic hypoxia.

PATHOGENESIS OF THE POSSIBLE TYPES OF SHOCK IN A 25 YEAR OLD MALE

WITH A PERFORATED DUODENAL ULCER WHO PRESENTS TO THE
EMERGENCY ROOM IN SHOCK.

Perforation in duodenal ulcer is one of the serious complications of peptic

ulcer. The possible types of shock experienced include
hypovolaemic shock
haemorrhagic shock
septic shock

In perforation there’s erosion of the gastrointestinal wall by the ulcer

leading to spillage of intestinal contents into the peritoneal cavity causing
an acute peritonitis;which is initially chemical and later bacterial. This could
present with severe vomiting and subsequent dehydration from copious
vomiting and loss of fluid from extravascular compartment could lead to
hypovolaemic shock.

Secondly there could be scarring and stenosis from the ulcer leading to
narrowing of the pyloro-duodenal region leading to gastric outlet
obstruction and subsequent vomiting.

In perforation, there might be erosion into a big vessel leading to

haemorrhage and whole blood loss and subsequent decrease in the
effective circulating volume causing haemorrhagic and hypovolaemic shock
The last but not the least type of shock could result from spillage of
intestinal bacteria into the systemic circulation causing sepsis, release of
vasoactive and pro-inflammatory substances, complement activation and
the coagulation cascade which will lead to vasodilation and hypotension
and subsequent shock.

MANAGEMENT PROTOCOL FOR THIS PATIENT

A perforated duodenal ulcer is a surgical emergency. Management requires

prompt rescuscitation of the patient investigations definitive treatment and
follow up.
Rescuscitation involves securing intravenous access and taking blood for
necessary investigations ( full blood count ,blood for grouping and cross
matching to transfuse if indicated, haemoglobin levels, sickling status and
blood urea and electrolytes) placing two wide bore cannulae and
administering crystalloids to expand extravascular volume and correct
electrolyte derangement.
A nasogastric tube is inserted to decompress the stomach and rest the
bowel;a urethral catheter is inserted to monitor urine output; volumes of
(30-50mls/hr) will show there’s adequate perfusion of the kidneys. When
there’s adequate urine output, potassium chloride is then administered to
replenish depleted potassium levels.
Antibiotics are administered to control the sepsis and usually the targeted
bacteria are the gram negative E. coli and the anaerobes e.g
bacteriodes.Proton pump inhibitors are also admistered to reduce acid
secretion and prevent further perforation. Patient is then ready to undergo
surgery; the definitive surgery is placing an omental patch over the lesion
and thorough peritoneal lavage.
Furthermore counselling and follow up is important in this patient
considering his age as stress ulcers are common in this age group.