abdominal pian 20080102

檢傷主訴：今早開始呼吸喘spo2;100%.胸痛到腹部痛.
Abdominal pain, sudden onset, this morning

from epigastragic region to entire abdomen
病患自己描述瞬間從上腹部往肚臍和整個肚子痛下去
associated with severe nausea sensation and tenesmus

ask for pain control 來的時候非常痛，要求趕快止痛，

tarry stool passage for several days(+)

rebounding pain(+) diffusely, muscle guarding: moderate --> 從這樣的主訴，很直接就會想到是PPU

結果CXR 並沒有看見subphrenic air，怎麼辦？病患的臨床症狀就是像，只好切CT 了，































看完影像之後，再看看operative findings

1.0.5 cm perforation over pylorus was noted. Turbid ascites about 1000 ml was noted. Culture was done
2.Umbilical hernia was noted

operative procedure:


The patient is put supine on the operating table. A upper median abdominal incision is made for exposing the peritoneal cavity. It is irrigated copiously with warm saline and the perforated hole is identified. Traction sutures of 000 silk are placed at the superior and inferior margin of pyloric ring. A longitudinal incision is made approximately 2 to 3 cm on each side of pyloric ring through all layers of anterior wall. A row of 000 silk Gambee sutures are placed transversely with one end on the gastric wall and the other end on the duodenal side. The pyloroplasty is closed thereafter. The soft tissue plane around the esophago-gastric junction is entered and the distal esophagus is surrounded by a nelaton tube. It is tracted caudally and two cord-like vagus nerves are identified respectively on the anterior and posterior sides of esophagus. The nerves are divided and ligated. Sections of trunk are sent for pathology. The peritoneal cavity is irrigated again. Three J-P drain tubes are placed in the Morrison`s pouch and left subphrenic space. Umbilical hernia was repaired. The wound is closed in layers.

所以簡而言之，就是

Vagotomy and pyloroplasty
Repair of ventral hernia without bowel -resection