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Perforating Gastric Ulcer Simulating Appendicitis Dr Richard H Harte

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PERFORATING GASTRIC ULCER SIMULATING APPENDICITIS.

DR. RICHARD H. HARTE reported the following case. A man, thirty-one years of age, was admitted to the Pennsylvania Hospital, stating that he was perfectly well up to the day before admission, when he was taken with sharp abdominal pains. There was no vomiting or diarrhoea. He was treated at home, but the pain became worse, so that the ambulance was sent for and he was taken to the hospital. When seen his temperature was slightly elevated, features pinched and anxious, tongue coated, and he complained greatly of abdominal pain. On examination, the abdomen was slightly distended, very hard, and there was a great deal of muscular rigidity and exceeding tenderness on slightest pressure. The point of tenderness was decidedly over the region of the appendix.

With this imperfectly elicited history, the diagnosis of per forated appendicitis was made and an operation advised imme diately. In less than an hour from the time of his admission he was etherized and an incision made over the region of the appen dix. Immediately on opening the peritoneal cavity there escaped a considerable amount of gas, together with considerable yellow ish fluid containing flakes of organized lymph. There were no adhesions to speak of. The appendix was soon exposed and a small ulcerated portion at its extreme tip was found ; otherwise it seemed fairly normal. It was ligated and excised, and the ab domen thoroughly flushed with hot normal salt solution and a two way drainage tube introduced and the wound closed. During the operation the patient's condition was almost in extremis. The tube was flushed out frequently, and on the next day the patient expressed a certain amount of relief ; the pain was greatly diminished ; but he had frequent attacks of vomiting of dark reddish material which unquestionably was blood. The diagno sis was then made of ruptured gastric ulcer, causing the perito nitis from which the patient was suffering rather than the pri mary trouble in the appendix. These symptoms lasted for the next forty-eight hours, when the abdomen became much dis tended, the pulse failed, and the patient died. A post-mortem examination was made through the abdominal wound, and with difficulty the stomach was removed and several small ulcers were found, one of which had perforated. Everywhere else in the abdominal cavity there were evidences of peritonitis. The stomach contained a considerable amount of bloody mucus.

From this case the reporter drew some practical deductions : First, in the matter of diagnosis, the history was misleading, the patient stating that he had never suffered from any gastric dis turbance or from any abdominal pain, even of appendiceal char acter. Even if it had been possible to interrogate the patient before he became so engrossed with his present distressed con dition, some points might have been elicited which would have materially assisted in making a more accurate diagnosis, espe cially in determining the cause of the peritonitis from which it was very apparent that he was suffering. The sudden escape of gas on opening the abdominal wound is almost significant of perforation from either gastric or duodenal ulcer owing to the rapid fermentative changes that occur in the visceral contents of this region, rather than to a ruptured appendix or gall-bladder, and under these circumstances it will be always well to seek for the trouble in the upper part of the abdomen rather than waste time in attempting to find a perforation lower down.

It has been advised by medical authorities that some coloring matter, as methylene blue, may be administered by the mouth and its escape through the perforation into the peritoneal cavit) will then facilitate the location of the ulcer after the abdomer has been opened. This may hold good in ulcer of the stomach where the fluid would naturally pass out quickly without and digestive changes having taken place ; although this procedure will hardly lend itself to the practical surgeon any more than the puncture of the abdomen with a hypodermic needle in the hop that gaseous bacteria and cellular evidences of perforation cat be aspirated. Unfortunately in this class of patients, before operative procedure has been determined on, the general condition has become so grave that the time spent in prolonged search ii the different parts of the abdomen will militate very materiall: against a favorable result.

The ordinary signs of perforated peritonitis are well known namely, (a) pain, which is often misleading as to its position (b) great muscular rigidity, (c) a flat abdomen, and (d) at time the disappearance of liver dulness, especially when due to gaseou distention from the escape of the stomach's contents.

Again, the sex may be of some assistance in unravelling the diagnosis, perforating gastric ulcer being more common ii women ; according to Weir's tables 8o per cent. being thus of fected, and in perforated duodenal ulcers the figures are abou reversed, showing that men are much more liable to duodena ulceration than women.

It is hardly necessary to say that the surgical treatment of perforated peritonitis cannot be too prompt. If the diagnosis ca be narrowed down to either the stomach, duodenum, or gal] bladder, the incision should be along the edge of the recto muscle, which may be supplemented by one at a right angle t it, across its upper portion ; if more room is demanded, it of great importance that the operative field should be sufficient] exposed to permit a rapid survey of the supposed site of perfon tion.

If food or material has escaped, the surgeon's action is rer dered more certain, and a rapid, thorough inspection after wiping away any escaping fluid will accurately disclose the region of perforation. If nothing is visible in this region, the examination of the posterior gastric wall can be accomplished by either tearing through the gastrocolic omentum, or by turning up the omentum and large bowel and the lesser omental cavity through the mesen tery as in posterior gastro-enterostomy. From the lower end of the wound, which is large enough to admit the hand, the appen diceal region can, if necessary, be easily explored. When the perforation is found it should be closed by a double or triple row of sutures. No attempt should be made to excise the ulcer before suturing, as this takes time ; and in the collected cases of opera tions it is shown that results are not any better where this pro cedure has been resorted to. The closure of the perforation, however, leaves much of the trouble still unfinished. The proper and systematic cleansing of the peritoneum is then of the utmost importance. If the extravasation is limited, careful wiping out of the affected portion of the peritoneal cavity with gauze will in most cases suffice better than the large, warm irrigations of sterile salt solution, which are more suitable in extensive or gen eral peritonitis. The systematic cleansing of the peritoneal cavity will be of the utmost importance, and too great care cannot be given to this procedure. • If there is any question in the mind of the surgeon as to his ability to close the perforation, a small packing of iodoform gauze may be left in around the sutures and allowed to remain forty-eight hours; but this is rarely necessary if careful and sys tematic suturing with two or three rows of carefully introduced sutures has been resorted to. It is needless to say that the mor tality in this condition is very great, the percentage of recoveries being exceedingly small. In perforating gastric ulcer, according to the paper published by Weir, the mortality was 78 per cent., the patients dying invariably of shock or peritonitis.

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