after careful evaluation
2007 October 31
Your patient is in acute distress, showing all the symptoms of acute shock. After careful evaluation you suspect a duodenal ulcer has perforated the posterior wall of the first part of the duodenum. Hemorrhage is probably from which of the following arteries?
A. Splenic artery
B. Superior mesenteric artery
C. Gastroduodenal artery
D. Left gastric artery
E. Right hepatic artery
now what exactly is “careful evaluation”? Past Hx of duodeonal ulcers? Long term usage of NSAIDS? H.pylori infection?
Educate me, please, because i seem to think this is a great anatomical question (Ans is C) but just not very realistic…
Firstly, a clarification: erosion of an ulcer into a solid organ is traditionally known as penetration. Perforation usually refers to creation of an opening into a free surface (ie the peritoneum).
In the presence of shock and a typical sounding history, an important adjunct to initial resuscitation is insertion of a nasogastric tube. In the presence of blood in the NGT aspirate and signs of haemodynamic compromise, the most common/important diagnoses to consider would be bleeding varices, bleeding gastric ulcer, bleeding duodenal ulcer. In a young person without known liver disease or risk factors for gastric ulcer (NSAIDs/steroids, increasing age) duodenal ulcer would by far be the most common diagnosis.
I don’t know how you’d distinguish a 1st/2nd part of the duodenum ulcer, though.
thanks hildy!
so in the presence of blood in NGT aspirate, after ddx considerations, the next steps in mx would be?
to the OR to clamp of the gastroduodenal artery? (yea, another question i came across was if this was clamped, what structures would NOT be compromised? Ans was greater curvature of the stomach because the left gastroepiploic artery anastomoses with the right so its all good)
Your patient is in acute distress, showing all the symptoms of acute shock. After careful evaluation you suspect a duodenal ulcer has perforated the posterior wall of the first part of the duodenum. Hemorrhage is probably from which of the following arteries?
A. Splenic artery
B. Superior mesenteric artery
C. Gastroduodenal artery
D. Left gastric artery
E. Right hepatic artery
First, note that perforation of the duodenum typically occurs on the anterior surface of the duodenal bulb just beyond the pylorus.
The gastroduodenal artery descends directly behind the first part of the duodenum to the left of the bile duct before dividing at the upper border of the pancreas into terminal branches there (superior pancreatico-duodenal and right gastroepiploic arteries). Bleeding is due to perforation through the duodenal wall and thus the arteries directly supplying that part of the duodenum.
As the coeliac trunk branches out, the gastroduodenal artery follows the duodenum towards the right while the splenic artery goes to the spleen on the left. The superior mesenteric artery branches out from the abdominal aorta way below (past the pancreas), so is in no immediate danger of perforation.
Remember that the left gastric artery supplies the lower part of the esophagus, and so is way high up (besides, it’s on the left).
The right hepatic artery is of common origin with the gastroduodenal artery (i.e. common hepatic artery) but instead branches of the common hepatic artery heads upwards towards the liver into the right and left hepatic arteries and the cystic artery, and so is too high up for direct erosion of the arterial wall as would be expected.
The next step as a house officer should be immediate resuscitative measures as this will directly sustain the patient’s life if the patient is already in shock. Start 2 large bore infusions of normal saline 0.9% fast and ensure A, B, C in case the patient goes into shock, all the time checking vital signs. If not immediately in shock, get important labs done such as full blood count, urea/electrolytes, and especially group and cross match in case of need for blood transfusion. Do an erect chest X-ray as well to check for free air under the diaphragm to confirm perforation. Also start the patient on IV Rocephine (Ceftriaxone) and metronidazole because the former covers for gram positive as well as wide gram negative bacteria, while the latter covers for anaerobes. Arrange an Emergency OT and send the OT chit (in Singapore at least) to inform them that you’re coming. Inform at least the Registrar on call as well.
In the OT, a peritoneal toilet is performed to remove fluid and food in the peritoneal cavity. If the perforation is not anterior but posterior, the lesser sac should be opened along the greater curve. Classic operation is the Bilroth 1 gastrectomy (gastroduodenostomy) for perforated gastric ulcer, but a Roux-en-Y gastrojejunostomy might be necessary in the event of removal of the duodenum.
Perforation usually occurs just beyond the pyloric bulb (i.e. the first part of the duodenum). The second part of the duodenum is retroperitoneal, so signs and symptoms of retroperitoneal involvement can be expected in perforation of the second part.
One last thing: be aware that not all perforated peptic ulcers will have a history, and may be asymptomatic. There will be board like rigidity of the abdominal walls and involuntary guarding. Rebound tenderness indicates peritonitis. The patient may paradoxically get better after a few hours due to dilution with peritoneal fluid, but this is a sign that the patient will enter shock and become hemodynamically unstable.
Hmzz.. when i first read the question, I was thinking of more like the perforation of the supraduodenal artery which in most cases branches off the gastroduodenal artery to supply the superior flexure of the 1st part of the duodenum… not sure if any bleeding form this branch will actually lead to a shock though.. anyone?
thanks tianhong for the educational post for readers!
to add, left gastric artery also supplies the lesser curvature of the stomach.
if u typed that off your head whilst u’re already in clinical years, woah! you have my respect; i think i probably will forget the exact branches of these unless i revise them consciously or sth. no photographic memory
the next part of clinical medicine was great. thanks for the mini-tutorial
what clinical books do you use? i heard med at glance is popular amongst nus medics?
Hey no sweat Jeff.
Um… I suppose that if you keep revising your work with clinical significance in mind, you’ll find that you’ll be able to remember quite a lot of things (it’ll come as a handy little data packet). It helps that one revises before going to observe an operation at the OT, cos that REALLY revises anatomy and makes it come alive. I think the trick is to build up knowledge around a patient, and not knowledge around a subject.
I currently use Kumar and Clark for clinical Medicine, Bailey and Love for surgery (i love this book), Baliga’s 250 cases (all time favourite), Mont Reid as a pocket guide for surgery. For emergency med (my area of interest), I rely on Emergency Medicine by Peter Manning and Shirley Ooi (a locally produced book — geared towards Singapore). Ortho I use Apley’s concise system of ortho, paediatrics I use a combination of Rudolph and Nelson. I’m using Llewellyn Jones for ObGyn. Yup, won’t really mention the other smaller sub specialties here. Haven’t used the book you mentioned though (don’t know if it’s popular amongst us here in Singapore).
Oh I forgot one last thing in my last comment: if found to be Helicobacter pylori positive, then one should institute triple therapy and follow up at an outpatient’s clinic. Avoid NSAIDS, corticosteroids…etc.
With regard to the gist of your post which was your question about what “careful evaluation” should mean, I doubt the person who came up with this question thought much about it. It’s an anatomy question that appears to be trying too hard to be clinically-oriented, as you rightly alluded to.
yeap.. on that note, i’m glad next year i’m going to be learning what “careful evaluation” actually means. first hand.