VU Medisch Centrum

Afdeling MDL

Endoscopy of Peptic PerforationsEndoscopy of Peptic Perforations

Chris Mulder

31 januari 2006

Suspicion of perforation Suspicion of perforation (oesophagus)(oesophagus)

• Pain of breathing• Subcutaneous emphysema• Localized pain• Pain and/or coughing after drinking

• Pleural fluid• Stripe of air along mediastinum

Wesdorp, Gastroenterology 1982

TreatmentTreatment

• NPO

• IV-fluid / antibiotics

• NGT with suction

Upper-GI perforationsUpper-GI perforations

• Esophageal - dilatation

- mucosal resection

- reflux esophagitis

- sclerotherapy

• Foreign bodies • Gastric - ulcer disease

- NSAID

• Gastrointestinal - lymphoma

Sensitivity (symptoms positive / Sensitivity (symptoms positive / disease positive) and disease positive) and specificity (symptoms specificity (symptoms

negative / disease negative) of negative / disease negative) of abdominal pain as a marker for abdominal pain as a marker for

ulcer disease are low.ulcer disease are low.

Spiro, NEJM 1974

PUD complicationsPUD complications

• Hemorrhage

• Perforation

• Penetration

• Obstruction

PUD follow-upPUD follow-up

• 7% perforation

• UD perforates anteriorly

• UV perforates anterior lesser curvature

• UD penetrates pancreas

• UV penetrates left lobe liver

Incidence of operations for Incidence of operations for perforated peptic ulcer perforated peptic ulcer

decreased >> 50%decreased >> 50%

Sanchez-Bueno, Dig Surg 2001

PUD perforationPUD perforation

• Abdominal X-ray (< 80%)

• Spiral CT

• Endoscopy

PUD perforationPUD perforation

• NG-aspiration• IV-fluids• IV-PPI / antibiotics• Sealing (Berne TV, 1989)

• Clipping ??? << 1 cm ??

• Surgery Treatment of Choice

(laparoscopic / classical)Berne TV, Arch Surg 1989

Donovan A, Arch Surg 1998Gul YA, Ir J Med Sci

Risk of perforation in PUDRisk of perforation in PUD

• Heater probe

• Gold probe

• Laser therapy (not documented)

• APC erbe (not documented)

Where to clip ?How to clean the peritoneal cavity ?

PUD perforationPUD perforation

200 MDL-artsen gemailed 10 januari 2006

2004-2006• 1 MDL-arts: 2x geclipt: 2x mislukt• 2 MDL-arts: 3x glue: 1x gelukt• Verder vele meldingen over clippen van colon-

perforaties en clippen van PEG

openingen ++ Berne TV, Arch Surg 1989Donovan A, Arch Surg 1998

Gul YA, Ir J Med Sci

Applikation eines Ovesco-Clips zum Verschluß einer Perforation im Dickdarm Quelle: Ovesco Endoscopy GmbH (see Google)

PUBMEDPUBMED

No articles about successfull

clipping of PUD

Chr. J. Mulder 30-01-2006

Nothing is mentionedabout endoscopic therapy of PUDperforations

Cases of perforated duodenal ulcer Cases of perforated duodenal ulcer treated in College of Medical treated in College of Medical Sciences, in Bharatpur.Sciences, in Bharatpur.

Laparoscopy followed by simple Laparoscopy followed by simple closure of perforation reinforced closure of perforation reinforced with pedicled omental patch is with pedicled omental patch is treatment of choicetreatment of choice

Kathmandu Univ Med JournalGupta et al, 2003;1:166-9