Case

Peritonitis e.c. gaster perforation

Perceptor: dr. Antonius Kurniawan, Sp.B FInaCS FICS

Natasya 1015009
Reyhan Hadiman 1015068
Anita Suhadi 1015069
I Komang Adi W. 1015122
Aghnia Husnayiani 1015130

Identity

Name : Tn. O
Age : 54 thn
Admission date : 20 April 2015
Room/MR : Elisa / 174104
Pre OP D/ : Peritonitis e.c hollow viscus
perforation
Post OP D/ : peritonitis e.c gastric perforation
Operation : Exploration laparotomy + gastric
suture with omentum graham patch

Anamnesis
Chief complaint: Abdominal pain
The patient came to the RSSK emergency
room with complaints abdominal heartburn
pain. The pain is felt from 6 days in
advance. Pain was felt as sore and twisting.
Complaints of abdominal pain accompanied
by nausea, but not vomiting. Patients also
complain of fever. Patients feel full and
bloated stomach looks. No complaints
diarrhea, or bloody stool or melena.

Anamnesis
the patients was already taking antacids, but then the
pain wont relieve. The patients actually fell this abdominal
pain since 4 months ago. The patients ignore the pain and
continiue farming. The patients has a gastritis history since
3 years ago.
Familial medical history: no familial history related to the
patients abdominal pain
Past medical history: abdominal pain for 4 months lately.
The patients also complaining muscle ache and consume
analgetic from the counter. Abdominal thrauma (-)
Treatment effort: antacids
Habbit: patients usually drinks jamu once in 2 or 3 weeks

Physical examination
General Appearance : Good
Consciousness
: Compos
Mentis
GCS
: 15
Height
: 168 cm
Weight
: 54 kgs
Nutritional Status : normal

Physical examination
Vital sign
Tensi : 140/90 mmHg
pulse : 88 x / menit
resp. : 18 x / menit
temp : 36,6oC
General status
head: eye: anemic conjunctiva -/-, ikteric sclera -/ neck : enlargement lymph -/- , JVP not increasing
Thorax : normal
Abdomen :
inspection: the stomach look distented
auscultation: bowel sound (+) weak
Palpation: tenderness (+), deffance muscular (+), liver and spleen are not
palpable
percussion: liver dullnes dissapear

Physical examination
Tenderness (+)

Double diagnose
Peritonitis et causa perforasi hollow
viscus
Peritonitis et causa rupture solid
organ
Peritonitis et causa bacterial infection

Laboratory findings
Nama pemeriksaan

Hasil

Satuan

Nilai normal

Hematologi rutin
Eritrosit

5.49

Juta/mm3

4.00-5.50

Leukosit

39200

/mm3

4000-10000

Trombosit

266000

/mm3

150000-450000

Hematokrit

37

40-48

Hemoglobin

11.7

g/dL

13-17

MCH

21

pg

27-31

MCV

67

fL

82-92

MCHC

32

32-37

Golongan darah

B/+

Laboratory findings
Nama pemeriksaan

Hasil

Satuan

Nilai normal

Waktu pembekuan

Menit

2-6

Waktu perdarahan

2,5

Menit

1-3

HbSAg

Negatif

Negatif

Elektrolit
Kalium

4.04

Mmol/L

3.5-5.1

Natrium

131.9

Mmol/L

136-146

92.3

Mmol/L

98-106

SGOT

20

u/L

10-35

SGPT

16

u/L

10-41

Ureum

56.9

mg/dL

10-50

Creatinin

0.9

mg/dL

0.9-1.5

GDS

131

mg/dL

50-160

Chlorida

X-Ray abdomen imaging

(20 April 2015)

Resume
Anamnesis
male 54 tahun, came with chief complaint of abdominal pain. Epigastric pain (+), soar
and twisting (+) . nausea(+), vomit(-), fever(+), dairrhea (-) blood on stool (-), melena(-). The
patients feel his belly was distented. Already taking antacids(+), prebious abdominal pain (+)
4 months earlier. Abdominal trauma (+)
Pemeriksaan fisik
Vital sign
Tensi : 140/90 mmHg
pulse : 88 x / menit
resp. : 18 x / menit
temp : 36,6oC
General status
head : eye: anemic conjunctiva -/-, ikteric sclera -/ neck : pembesaran KGB -/-, JVP tidak meningkat
Thorax : normal
Abdomen :
inspection: the stomach look distented
auscultation: bowel sound (+) weak
Palpation: tenderness (+), deffance muscular (+), liver and spleen are not palpable
percussion: liver dullnes dissapear

Resume
Laboratory findings
Leukosit: 39200 /mm3
X-Ray
Abdomen photo
conclusion : free air sub diaphragm (+)

Work Diagnosis
Peritonitis et causa perforasi hollow
viscus

Therapy
Non Medicamentose

Put NGT no.18

Fasting
Infuse
Foley kateter

medicamentose:
pre-op antibiotics (ceftriaxone 2gr,
metronidazole 500mg)

Refer to surgeon to perform exploartion

laparotomy

Prognosis
Quo ad vitam
: dubia ad bonam
Quo ad functionam : ad bonam

Operation report 20 April

2015
D/ pre-op : Peritonitis et causa
hollow viscus perforation
D/ post-op : Peritonitis et causa
gastric perforation
Operation indication: hollow viscus
perforation
Operation type: exploration
laparotomy

Operation report 20 April

2015
Aseptic and antiseptic action in the area of operation.
Midline incision is deepened through the peritoneum
Durante operationam: seropurulen 50cc liquid out, and it
looks a lot fibrin around the stomach.
There is a perforation of the antrum size of 0.6 cm.
Excision around the wound
The wound was closed with omental patch
do overhecting
The abdominal cavity was washed with 0.9% NaCl to clean
Silicon drain installed in the pelvic cavity and the area around
the perforation with railway technique
The abdomen was closed layer by layer
operation completed

post op instruction

Monitoring vital sign

Fasting until next observation
Infus RL : Dextrose = 2:2 untuk 20 gtt/mnt
therapy:
Ceftriaxone 2x2 gr,
Metronidazole 3x500 mg,
Ketolorac tromethamine 3x1ampul,
Pantoprazole 1x1 ampul,
Tranexamic acid 3x 500mg

FOLLOW UP

Follow up
Tanggal
21-04-2015

Follow-up
S: keluhan nyeri berkurang, flatus (+), BAB (-)

Order dokter
Masih puasa

O: T: 120/80 mm Hg, N: 84x/mnt, S: 37oC

Terapi lanjutkan (lihat tabel terapi

Kesadaran CM

a/r abdomen: datar, BU(+), lembut, NT (+)

Monitor input-output dan balance

drain kiri 100cc, kanan 50cc, NGT berwarna hijau Pada NGT 16 dibuka dialirkan.
22-04-2015

kental 15cc.
S: nyeri berkurang, BAB (+) cair

NGT 14 untuk feeding

Mobilisasi miring kanan-miring

O: T: 110/70 mm Hg, N: 80x/mnt, S: 36.2oC

kiri

Kesadaran CM

Terapi

a/r abdomen: datar, BU(+), lembut, NT (+),

terapi)

drain kanan kiri minimal, NGT minimal.

Monitor input-output dan balance.

I/O: balance (-) 1960 cc

Test

lanjutkan

feeding

10cc/6jam

(lihat

dengan

tabel

10%

Follow Up
Tanggal
23-04-2015

24-04-2015

Follow-up
S: nyeri berkurang, BAB (+) cair, batuk (+)

Order dokter
Mobilisasi miring kiri kanan

O: T: 110/70 mm Hg, N: 84x/mnt, S: 36,8oC

Terapi lanjutkan (lihat tabel terapi

Kesadaran CM

a/r abdomen: datar, BU(+), lembut, NT (+),

Monitor input-output dan balance.

drain kanan kiri minimal, NGT minimal.

Test

I/O: balance (-) 270 cc

25cc/6jam

S: nyeri berkurang, BAB (+) cair, batuk (+)

Mobilisasi kiri kanan

O: T: 110/70 mm Hg, N: 84x/mnt, S: 36,8oC

Terapi lanjutkan (lihat tabel terapi

Kesadaran CM

a/r abdomen: datar, BU(+), lembut, NT (+),

Monitor input-output dan balance.

drain kanan kiri minimal, NGT minimal.

NGT diklem 3:1

I/O: balance (-) 220 cc

Test

feeding

feeding

50cc/6jam

dengan

dengan

10%

peptisol

Follow Up
Tanggal
25-04-2015

Follow-up
S: nyeri berkurang, BAB (+) cair, batuk berkurang

Order dokter
Mobilisasi kiri kanan

O: T: 130/90 mm Hg, N: 88x/mnt, S: 37oC

Terapi lanjutkan (lihat tabel terapi

Kesadaran CM

a/r abdomen: datar, BU(+), lembut, NT (+),

Monitor input-output dan balance.

drain kanan kiri minimal, NGT minimal.

Test

75cc/6jam

feeding

dengan

peptisol

Aff drain kanan dan kiri

Bladder training
26-04-2015

S: nyeri sudah tidak ada, BAB (+) cair, batuk berkurang

Terapi lanjutkan (lihat tabel terapi )

O: T: 120/80 mm Hg, N: 84/mnt, S: 36.3oC

Stop kalnex

Kesadaran CM

Stop tramifen

a/r abdomen: datar, BU(+), lembut, NT (+),

Stop pantozol

drain sudah di aff

Pepsol 1x1 amp

Mucin 4x1 cth

Tanggal
27-04-2015

Follow-up
S: nyeri sudah tidak ada, BAB (+) cair, batuk berkurang

Order dokter
Terapi lanjutkan

O: T: 110/70 mm Hg, N: 88/mnt, S: 36.5oC

Kesadaran CM
a/r abdomen: datar, BU(+), lembut, NT (+),
28-04-2015

S: nyeri sudah tidak ada, BAB (+) cair, batuk hilang

Terapi lanjutkan

O: T: 110/80 mm Hg, N: 88/mnt, S: 37oC

Instruksi pulang

Kesadaran CM
a/r abdomen: datar, BU(+), lembut, NT (+),
29-04-2015

Pasien pulang

Peritonitis

Definition
Inflammation that caused by
infection of peritoneum
An emergency situation which
followed by bacteriemia and sepsis

 Surface area : 1,7

m2
Membrane
semipermeabel for 2
ways diffusion
100cc peritoneal
fluid
protein 3 g/dl
Cells :
33/mm345%
macrofag, 45%
Tc, 8% NKc, Bc,
eosinofil, and
mast cell

 Peritoneal defense mechanisms

against infection are:
1. The rapid absorption of bacteria
through the stomata diaphragm
2. Destruction of bacteria by
immune cells
3. Localization of infections as
abscesses

Etiology
Primary
Secondary
Tertier

Physiological responses determined by

several factors:
1. Virulence germs
2. The immune status and condition of
the patient
3. Environment (necrotic tissue, the
presence of blood or bile)

3. Tertier peritonitis
. End stage of peritonitis
. Obtained when clinical symptoms of
peritonitis and sepsis condition found
in patients

Clinical Manifestation

Abdominal pain
Anorexia
Vomit
Nausea
Fever
Hipocrates facies pale,
restless,cold
Shock

Physical Diagnose
Vital sign
Inspection :
Abdominal distention

Auscultation :
High pitch or none

Percussion :
Loss of liver dullness

Palpation :
Tenderness
Muscle spasm

 Laboratorium
WBC > 20.000/mm3
Shift to the left : PMN

Radiologi

Treatment
Preoperative
Fluid resuscitation
Antibiotic
Ventilator and oxygen
Intubation, catheter

Operative
Post operative

Complication
Abscess
Sepsis

Prognosis
Factors that affect prognosis:
a. the type of infection / primary
disease
b. duration / long illness before
infection
c. malignancy
d. organ failure before treatment
e. immunological disorders
f. age and general condition of patients

Gastric Perforation

Anatomy

 Function
proxymal, fundus & corpus
container of food, gastric acid and
pepsin production
Corpus wall, especially antrum is thick,
and has a strong muscle.

Vaskularisation

Innervation
Symphatetic (afferent;pain
conductor):
N. Splanchnicus majus & celiac
ganglion
Parasymphatetic: N. Vagus

Physiology

 Function: food and drinks receiver,

mixed in antrum, and early ingestion.
Motility
Relating to the storage and mixing of
food, as well as gastric emptying.
Stomach capacity: 1500 mL of being
able to adjust the size of the increase
in intraluminal pressure without
stretching the wall (arranged by n.
Vagus, lost after vagotomy)

Gastric Perforation
Definition: Penetration of part of the
wall which causes the gastric
contents from the stomach out into
the abdominal cavity, causing
bacterial contamination of the
abdominal cavity called peritonitis.

Etiology
Perforasi non-trauma:
Gastric Volvulus
Stress ulcer
NSAID consumption
Peptic ulcer
Malignancy
Foreign body (needle)

 Perforation trauma (sharp or blunt)

Iatrogenic trauma (NGT, endoscopy
Penetrating wound to the abdomen
(knife)
Blunt trauma to the stomach (bicycle
steering handle injuries, injuries from
seat belts)

Pathophysiology
Long term of NSAID
consumption
Lowering Gastric
protection
peritonitis
Chronic injury due
to gastric mucose
ulcer

H. Pylori infection

Gastric perforation

Sign & Symptoms

Symptoms: severe pain such as tingling in
the abdomen, sudden, initially in the
epigastric, then spread throughout the
abdomen
mark:
Defance muscular
absent of Liver dullness
Decreased bowel sounds / disappear
Fever
tachycardia

Workup
Abdomen x-ray (erect & LLD)
USG (to find free fluid)
CT scan

Treatment
Fix the general state
Attach the IV line, fluid therapy
Iv antibiotics pre-operative
Metronidazole 7.5 mg / kg
Gentamicin 2mg / kg
Cephalosporins

analgesics

 Immediate surgery
Goal: correction of the underlying
anatomical problem, correction causes
of peritonitis, discard foreign material in
the peritoneal cavity

Treat the underlying disease

Surgical Therapy

Vagotomy
1. Trucal Vagotomy

2. Selective vagotomy

3. Proximal / Highly selective

vagotomy

Antrectomy

Graham-Steele closure

Prevention
1. NSAID life long PPI
2. H. pylori treatment regimens
3. Excessive gastric acid secretion
Sucralfate

Complications

Damage caused by surgical wounds

septic shock
Lost of vasomotor tone
Increased capillary permeability (due to
histamine, serotonin and prostaglandins
release)
myocardial depression
Thrombocytopenia, leukopenia
Capillary endothelial damage

Prognosis
If the surgery and antibiotic treatment
immediately, the prognosis would be ad
bonam, when the diagnosis, action and
antibiotics is late;, the prognosis is ad
malam.
Factors that influence
Elderly
Previous underlying disease
Malnutrition
complication

THANK YOU