Diagnosing a Perforated Ulcer

Discussions
1
The mechanics of breathing are greatly compromised in each of the cases in the following manners: infant respiratory distress syndrome leads air sacs to collapse when air is expired and increases the energy needed to breathe; emphysema leads to air sacs becoming damaged and enlarged, which makes it difficult to breathe; and pulmonary fibrosis leads to air sacs becoming scarred, which makes it difficult to breathe.
The physiology that plays a vital role in the development of these diseases consists of the following: infant respiratory distress syndrome stems from a lack of surfactant in the lungs; premature birth is often one reason for this lack.[footnoteRef:2] The physiology of the development of emphysema can include the presence of chronic bronchitis which can lead to it; smoking, or exposure to harmful chemicals and irritants over time. For pulmonary fibrosis, the physiology includes exposure to silica dust, asbestos, coal dust, and long term exposure to toxins. [2: Jasani, Bonny, Nandkishor Kabra, and Ruchi Nanavati. "Surfactant replacement therapy beyond respiratory distress syndrome in neonates." Indian pediatrics 53, no. 3 (2016): 229-234.]
The factors that are most important for them to know as they treat patients are to understand the patient’s quality of life and to include the patient in the care process. Quality of care is meaningless if it does not include a conversation about quality of life when it comes to treating the patient. This conversation can help each form the other.
2
I would tell the father that fluid management is what helps to improve the burn patient’s chances of survival. Burned skin sets of a chain reaction in the body: a necrotic zone develops and toxins can spread creating a shock to the system; unless the body is stabilized with fluids, the patient’s status can quickly become critical.[footnoteRef:3] [3: Haberal, M., Abali, A. E. S., & Karakayali, H. (2010). Fluid management in major burn injuries. Indian journal of plastic surgery: official publication of the Association of Plastic Surgeons of India, 43(Suppl), S29.]
Fluids are monitored by looking at blood pressure, heart rate and urine output, electrolytes, potassium and sodium levels, and to make sure the right balance is achieved.
As a clinician, the aspects of the boy’s condition that I would be most concerned about would be his breathing and his fluid levels. If these can be stabilized, the boy has a fighting chance.
3
The boy should be made aware of the possibility of infection that could occur from being cut by a rusty nail. He made need a tetanus shot, as Clostridium tetani thrive in oxygen deprived settings, like a rusty nail.[footnoteRef:4] It is important to let the boy know that he needs to check his records to see when the last time he had a tetanus shot was. If he hasn’t had one, it would be a good idea to get one just in case. However, the boy should not be frightened so badly that he is fearful for his life and does not want to leave the hospital. [4: Cutter, Richard D. "Auditory nerve involvement after tetanus antitoxin: first reported case." Journal of the American Medical Association 106, no. 12 (1936): 1006-1007.]
The boy’s response shows that he is aware of what can happen if an infection is untreated. To avoid frightening the child or causing him to think he might lose his are from infection, I would respond by assuring him that gangrene is only caused when a wound is untreated. The child may need a tetanus shot to ensure that no bacterial infection will cause him harm from the cut—but other than that, the wound has been cleaned and dressed and is now taken care of. Tetanus does not live on every rusty nail—it is just a place where it can be found, so in order to be safer rather than sorry the child might be encouraged to look into getting a tetanus shot, and the matter should be discussed with his parents as well, as they may have a better idea on when the child last had the shot if ever.
4
Possible explanations for Frank’s condition are: 1) Frank is likely severely constipated, a side effect of taking Lasix. His hypoactive bowel sounds, distended abdomen, epigastric pain and low calcium. 2) Acute pancreatitis may be something to consider as well. Frank should be put on fluids so that his body is properly hydrated, and treatment of his epigastric pain should be commenced. 3) Perforated ulcer could also be something that is causing the pain.[footnoteRef:5] [5: Sgroi, Michael D., and Brian R. Smith. "Severe Epigastric Abdominal Pain." In Surgery, pp. 493-499. Springer, New York, NY, 2015.]
Endoscopy is recommended to examine for ulcer perforation. A CT scan can be given to help detect perforation of the ulcer. Erect CXR has also been recommended in order to better detect perforation.[footnoteRef:6] If found to be the case, conservative treatment can be given to help the ulcer to seal itself; however, surgery may also be required in order to address the issue. [6: Di Saverio, Salomone, Marco Bassi, Nazareno Smerieri, Michele Masetti, Francesco Ferrara, Carlo Fabbri, Luca Ansaloni et al. "Diagnosis and treatment of perforated or bleeding peptic ulcers: 2013 WSES position paper." World Journal of Emergency Surgery 9, no. 1 (2014): 45.]
Treatment modalities for Frank would include medications to ease the ulcer’s impact, as well as antibacterial medications in case an infection is what is causing the ulcer. If no ulcer is found, Frank may need fluids and treatment to ease constipation, or treatment may involve removal of the pancreas, depending upon what diagnosis is made following a complete inspection of Frank upon arrival at the ICU.
Bibliography
Cutter, Richard D. “Auditory nerve involvement after tetanus antitoxin: first reported
case.” Journal of the American Medical Association 106, no. 12 (1936): 1006-1007.
Di Saverio, Salomone, Marco Bassi, Nazareno Smerieri, Michele Masetti, Francesco
Ferrara, Carlo Fabbri, Luca Ansaloni et al. “Diagnosis and treatment of perforated or bleeding peptic ulcers: 2013 WSES position paper.” World Journal of Emergency Surgery 9, no. 1 (2014): 45.
Haberal, M., Abali, A. E. S., & Karakayali, H. “Fluid management in major burn
injuries.” Indian Journal of Plastic Surgery: official publication of the Association of Plastic Surgeons of India, 43(Suppl) (2010): S29.
Jasani, Bonny, Nandkishor Kabra, and Ruchi Nanavati. “Surfactant replacement therapy
beyond respiratory distress syndrome in neonates.” Indian Pediatrics 53, no. 3 (2016): 229-234.
Sgroi, Michael D., and Brian R. Smith. “Severe Epigastric Abdominal Pain.” In Surgery,
pp. 493-499. Springer, New York, NY, 2015.