To Perforasi Gaster

TO Perforasi
Gaster
By: 2A
ANATOMY
• Most proximal abdominal organ of the
digestive tract
• Bounded: Superiorly by the diaphragm
Laterally by the spleen
Inferiorly by the duodenum,
the stomach is attached to the transverse
colon by the gastrocolic omentum.
Medially (The lesser curvature) is tethered to
the liver by the hepatogastric ligament,
Posteriorly the lesser omental bursa and the
pancreas.
Schwartz 10th ed.

Arterial and Venous Blood Supply
Celiac axis 
• The left gastric arteries  ascending and descending branch
• The right gastric arteries lesser curvature
• The right gastroepiploic arteries
• The left gastroepiploic arteries greater curvature
• Venous drainage essentially follows the arterial supply
Schwartz 10th ed.

Innervation
• Parasympathetic through the vagus
• Sympathetic originates at spinal
levels T5 through T10 and travels
through the celiac plexus
• At the GEJ the left vagus is anterior,
and the right vagus is posterior
(LARP mnemonic)
• The intrinsic or enteric nervous
system of the stomach consists of
neurons in Auerbach's and
Meissner's autonomic plexuse
Schwartz 10th ed.

Histology
1. Mucous cell  produce mucous and

bicarbonate
4 distinct layers of the gastric wall:
2. Parietal cell (oxyntic cell)  secrete
1. Mucosa (columnar epithelial cells) acid and intrinsic factor
 epithelium, lamina 3. Chief cell (zymogenic cell)  secrete
propira, muscularis mucosa pepsinogen I and II
2. Submucosa 4. Argentaffin cells  secrete serotonin
5. Granular enterochromaffin cells (G-
3. Muscularis propria (inner circular, outer cells)  secrete gastrin, ACTH-like
longitudinal)
peptide
4. Serosa Schwartz 10th ed., Haile T. Debas 6. D cell  secrete somatostatin
PHYSIOLOGY
The physiologic stimulus for acid secretion is ingestion of food
• CEPHALIC PHASE
The vagal or cephalic phase originates with the sight, smell, thought, or taste of food, which
excites neural centers in the cortex and hypothalamus increase in acid secretion to about 50% of
the maximal acid
• GASTRIC PHASE
The gastric phase of acid secretion begins when food enters the gastric lumen.
Food stimulates acid secretion by causing mechanical distention of the stomach. Gastric distention
activates stretch receptors in the stomach to elicit the long vagovagal reflex arc.
• INTESTINAL PHASE
It occurs after gastric emptying and lasts as long as partially digested food components remain
within the proximal small bowel
Schwartz 10th ed.

PEPTIC ULCER DISEASE
Peptic ulcers are focal defects in the gastric or
duodenal mucosa that extend into the
submucosa or deeper; caused by an imbalance
between mucosal defenses and acid/peptic injury
Schwartz 10th ed.

ETIOLOGY
Haile T. Debas
Pathophysiology
www.pathology-ii.2865597.n2.nabble.com/Pathophysiology-of-Peptic-Ulcer-td3032449.html
Classification
Currently, five types of gastric ulcer are
described, although the original
Johnson classification contained three
types :
• Type 1 : located near the lesser
curvature
• Type 2 and 3 : associated with normal
or inceased acid secretion
• Type 4 : occur near GE junction and
acid secretion is normal or below
normal
• Type 5 : medication induced and may
occur anywhere in the stomach
Schwartz 10th ed.

Diagnosis
• Abdominal pain, typically

nonradiating, burning in quality,
and located in the epigastrium
• A history of PUD, use of NSAIDs,
over-the-counter antacids, or
antisecretory drugs
• Nausea, bloating, weight loss,
stool positive for occult blood,
and anemia
Schwartz 10th ed., Haile T. Debas

Management
Medical Treatment :
- Resucitation
- Antibiotics
- PPI are the mainstay of medical therapy
Operative
- The indication for surgery in PUD are
bleeding, perforation, obstruction.
Schwartz 10th ed.

Surgical options
in the treatment
of duodenal and
gastric ulcer
Schwartz 10th ed.

Management of perforated peptic ulcer
• Simple patch closure, currently the most commonly performed

operation for perforated peptic ulcer, should be done in patients
with hemodynamic instability and/or exudative peritonitis signifying
a perforation >24 hours old.
• In stable patients without longstanding perforation, the addition of
HSV may be considered
Schwartz 10th ed.

Schwartz 10th ed.
http://www.curediseasecouncil.com/risk-factors-for-peptic-ulcer-disease.html
Operation technique
OPERATION TECHNIQUE
POSITION
• The patient is placed in a comfortable supine position with the feet slightly lower
than the head to assist in bringing the field below the costal margin and to keep
gastric leakage away rom the subphrenic area
OPERATIVE PREPARATION :
• The skin is prepared in the routine manner.
INCISION AND EXPOSURE

• Since the majority of perforations occur in the anterior-superior surface of the first
portion of the duodenum, a small, high, midline is made.
• Culture of the peritoneal fluid is taken & as much exudate as possible is removed by
suction
• The liver is held upward
with retractors,
exposing the most
frequent sites of
perforation.
• The easiest method of
closure consists of
placing three sutures of
fine silk through the
submucosal layer on
one side with extension
through the region of
the ulcer and then out
a corresponding
distance on the other
side of the ulcer
• Starting at the top of the ulcer, the
sutures are tied very gently to
prevent laceration of the friable
tissues. The long ends are retained
• The closure is reinforced
with omentum by
separating the long ends
o the three previously
tied sutures and placing
a small portion of
omentum along the
suture line.
• The ends of these
sutures are loosely tied,
anchoring the omentum
over the site o the ulcer
• a small biopsy of the margin of the peroration is taken because
of the possibility of malignancy
• The omentum may be anchored over the suture line
CLOSURE :
• All exudate and fuid are removed by suction. Repeated irrigation of
the peritoneal cavity with saline should be considered when there is
gross contamination by food particles.
POST OPERATIVE CARE
• The patient, when conscious, is placed in Fowler’s position.
• Nasogastric suction can be employed or the first 24 hours or as
needed.
• The fluid balance is maintained by intravenous infusions.
• Antibiotics are continued.
• Proton pump inhibitors should be given IV until PO intake is started.
• Consideration should be given to eradicate Helicobacter pylori as well
• After 3 to 4 days, the patient is started on a strict ulcer diet regimen.
Zollinger’s atlas of surgical operation

COMPLICATIONS
Gona, Soro K et al. Postoperative Morbidity and Mortality of Perforated Peptic Ulcer: Retrospective Cohort Study of Risk
Factors among Black Africans in Côte d’Ivoire. Gastroenterology Research and Practice: Hindawi. 2016
Terima Kasih

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TO Perforasi

Schwartz 10th ed.

• Venous drainage essentially follows the arterial supply

Schwartz 10th ed.

Schwartz 10th ed.

1. Mucous cell  produce mucous and

Schwartz 10th ed.

Schwartz 10th ed.

Schwartz 10th ed.

• Abdominal pain, typically

Schwartz 10th ed., Haile T. Debas

Schwartz 10th ed.

Schwartz 10th ed.

• Simple patch closure, currently the most commonly performed

Schwartz 10th ed.

INCISION AND EXPOSURE

Zollinger’s atlas of surgical operation

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