Perforated Gastric Ulcer Research Articles

7491 Post operative Euglycemic Diabetic Ketoacidosis in Type 2 Diabetic patient - A diagnostic challenge

Abstract Disclosure: S. Azmat: None. O. Lodhi: None. H. Ashok: None. M.F. Siddiqui: None. Euglycemic Diabetic Ketoacidosis (EDKA) is a rare but potentially fatal condition that is often difficult to diagnose as underlying ketoacidosis is masked by euglycemia. The diagnosis and management of this condition requires a swift and comprehensive approach to avoid delay. We report a case of 66-year-old female with Insulin-dependent Type 2 DM who developed postoperative euglycemic diabetic ketoacidosis, highlighting the significance of maintaining a high degree of suspicion for EDKA in postoperative patients, whose surgical course may obscure the underlying diabetic ketoacidosis symptoms. Clinical Case: A 66-year-old female with past medical history of Insulin dependent Type 2 DM presented to the emergency department with severe epigastric pain. CT Abdomen revealed perforated gastric ulcer with pneumoperitoneum requiring urgent laparoscopic graham patch repair. Patient’s outpatient medications include Lantus and metformin. She had mild hyperglycemia on admission with blood glucose of 176 mg/dL (140-160mg/dL) without metabolic abnormality. Insulin administration was omitted due to pre and post operative normoglycemia. The patient was NPO followed by initiation of nasogastric tube feeds. Postoperative course was complicated by hypotension, generalized abdominal discomfort and anion gap metabolic acidosis. Graham patch failure, abdominal infection, and post-surgical complications were systematically ruled out. Patient continued to decline with worsening anion gap metabolic acidosis; pH of 7.18 (7.35-7.45), HCO3 < 10 mEq/L (21 mEq/L - 31 mEq/L), anion gap15 mmol/L (8 to 12 mmol/L), blood sugar (147-208 mg/dl). There was no lactic acidosis or renal impairment. Beta hydroxybutyrate levels were elevated at > 4.5 mmol/L. Thus diagnosis of euglycemic DKA was established and treated with insulin drip per DKA protocol and dextrose fluids. EDKA resolved within five days with clinical improvement. She was transitioned to subcutaneous basal bolus insulin. She remained euglycemic and and had good surgical outcomes.Discussion: Euglycemic DKA is rare with only 2.6% to 3.2% of DKA, presenting as euglycemic. It presents as unique diagnostic challenge due to atypical DKA presentation with blood glucose less than 250 mg/dL. The primary driver for EDKA is either a reduction in hepatic glucose production at times of fasting or the overabundance of counter-regulatory hormones resulting in excess glucosuria. Literature has reported the effects short-term fasting on developing EDKA and starvation induced ketosis secondary to extreme ketogenic diets or bariatric surgery primarily among Type 1 diabetics. Clinically patients may exhibit symptoms similar to classic DKA, however, this classic picture may be confounded in a critically ill post-surgical patient, thus delaying recognition. This emphasizes the importance of including EDKA in differentials while evaluating such patients. Presentation: 6/1/2024

313. CLINICAL EVALUATION OF PEMBROLIZUMAB PLUS CISPLATIN AND FLUOROURACIL AS INDUCTION FOR PATIENTS WITH CT4B ESOPHAGEAL SQUAMOUS CELL CARCINOMA

Abstract Background Definitive chemoradiotherapy (dCRT) is a standard treatment for patients with cT4b esophageal squamous cell cancer (ESCC). In these 3 decades, radiation technique has been improved, and chemotherapy with cisplatin, fluorouracil, and/or taxans was combined before and after dCRT. However, its CR rate remains around 25% and its 3-year survival rate also remains below 30%. Although conversion surgery has been applied to improve the survival of these patients, no study has shown significant superiority to CR after dCRT in survival to date. Chemotherapy of pembrolizumab plus cisplatin and fluorouracil was applied to patients with unresectable or recurred esophageal cancer and demonstrated significant survival benefit and good objective response. We provided this therapy as induction to improve the therapeutic result of patients with cT4b ESCC. Method From April 2022 to August 2023, 11 untreated patients with cT4b ESCC had this chemotherapy as induction, with pembrolizumab 200 mg plus chemotherapy (5-fluorouracil 800 mg/m2 on days 1-5 plus cisplatin 80 mg/m2 on day 1) once every 3 weeks. Patients with cervical lymph node metastasis were included. After 2 or 3 cycles, the therapeutic effect was evaluated according to RECIST. Adverse events were evaluated according to CTCAE. Result Average age was 70, and 3 patients had cervical lymph node metastasis. Objective response rate was 82% (CR 1, PR 8). In these 9 patients, the volume of tumors shrank by more than 60% within 11 weeks. Over Grade 3 neutropenia developed in 2 (18%), but no G-CSF was administered. Gastric ulcer perforation developed in 1 (9%). In 2 patients, the dose of cisplatin should be modified due to renal damage. One patient had prolonged renal damage and had conversion surgery after 1 cycle. Eight patients had dCRT. One of 8 terminated dCRT due to another disease. Two of 8 just finished dCRT, and one is under dCRT. Of 3 were evaluated as CR, and followed without any treatment. Local and lymphatic recurrence developed in one PR patient. To date, no specific adverse events relating to pembrolizumab developed during and after dCRT. Of the 2 had conversion surgery without any severe post-operative complications. Discussion and Conclusion In our preliminary study, chemotherapy of pembrolizumab plus cisplatin and fluorouracil showed good objective response (82%) and early tumor shrinkage (more than 60% within 11 weeks). Over grade 3 hematological adverse events developed in only 18% of patients. These results suggest this regimen could be administered to patients with cT4b ESCC as induction especially followed by dCRT. This regimen can reduce tumor volume and control lymphatic spread, and these factors seem to improve prognosis and prevent fatal complications such as fistula or stricture of patients with cT4b ESCC who have dCRT. We plan a clinical trial of this chemotherapy followed by dCRT for patients with cT4b ESCC.

Excisional biopsy of perforated gastric ulcer: mandatory or potentially harmful?

PurposeThis study aimed to evaluate the morbidity associated with excisional biopsy in patients with spontaneous gastric perforation.MethodsA retrospective, single-center, observational study was performed. All consecutive patients with spontaneous gastric perforation who underwent surgical therapy were included. Outcomes were assessed concerning the performance of excisional biopsy.ResultsA total of 135 adult patients were enrolled. Of these, 110 (81.5%) patients underwent excisional biopsy, while 17 (12.6%) did not. The remaining eight (5.9%) patients who underwent gastric resection were excluded from the analysis. Patients undergoing excisional biopsy developed significantly higher rates of postoperative complications (p = 0.007) and experienced more severe complications according to the Clavien-Dindo classification, particularly type III and above (p = 0.017). However, no significant differences were observed regarding in-hospital mortality, reoperation, suture dehiscence, or length of hospital stay.ConclusionExcisional biopsy for gastric perforation has been shown to be associated with increased morbidity. Surgical closure followed by early endoscopic biopsy may be a superior approach for gastric perforation management to rule out malignancy.

Особливості виникнення поширеного перитоніту та вплив поліморфізму гена 5,10-метилентетрагідрофолатредуктази

It is relevant in modern surgery to clarify the risk factors of widespread peritonitis and to improve the treatment and diagnostic algorithms for the management of such patients. Aim - to establish the features of the occurrence of widespread peritonitis and the influence of MTHFR gene polymorphisms on the risk of its occurrence. Materials and methods. The study included 100 patients who underwent surgical interventions for acute abdominal diseases complicated by peritonitis: acute appendicitis (48%), acute cholecystitis (32%), perforated ulcer of the stomach or duodenum (8%), tumor perforation (3%), injuries of the abdominal cavity (3%), pinched hernia (2%) and intestinal obstruction (4%). Genotypes of MTHFR gene polymorphisms rs1801131 and rs1801133 were determined by real-time polymerase chain reaction. Mathematical processing of the research results was carried out using the Statistica 10 program. Results. The risk of disseminated peritonitis was increased with perforated gastric or duodenal ulcer, tumor perforation, abdominal trauma, herniated hernia, or intestinal obstruction compared with acute appendicitis and cholecystitis. The risk of disseminated peritonitis was lower in II blood group carriers compared and was associated with temperature at hospitalization and pulse rate. Conclusions. The factors determining the risk of disseminated peritonitis in the multivariate regression model were the diagnosis, heart rate, and the rs1801131 genotype of the MTHFR gene. The research was carried out in accordance with the principles of the Helsinki Declaration. The study protocol was approved by the Local Ethics Committee of the participating institution. The informed consent of the patient was obtained for conducting the studies. No conflict of interests was declared by the authors.

Contained gastric ulcer perforation presenting with acute pancreatitis.

Contained gastric ulcer perforation presenting with acute pancreatitis.

Acquired Factor V Deficiency After Carbapenem Administration: A Case Report

Factor V (FV) deficiency is a coagulation disorder (congenital or acquired). Unlike congenital FV deficiency, mixing tests for prothrombin time and activated partial thromboplastin time are not corrected in acquired FV cases. A 79-year-old male was admitted to the intensive care unit after an emergency operation due to gastric ulcer perforation. While receiving antibiotic treatment for septic shock, the coagulation profile began to show prolongation of prothrombin time and activated partial thromboplastin time. FV deficiency (< 1%) following meropenem administration was diagnosed . The patient did not show spontaneous bleeding or bleeding tendency. With fresh frozen plasma transfusion, steroid administration, and discontinuation of meropenem, the blood coagulation profile test result was normalized 20 days after diagnosis. His follow-up FV level increased to 78.7%. Although abnormalities in coagulation profiles are common in sepsis patients, in our patient, timely recognition and hematological consultation allowed early diagnosis and proper management of FV deficiency.

NSAID-induced gastropathy in a comorbid patient in a multidisciplinary hospital

The purpose of this case report is to demonstrate the importance of outpatient management of nonsteroidal anti-inflammatory drugs (NSAIDs) in patients, especially those at risk (elderly patients, alcohol abusers, patients with a history of peptic ulcer disease, patients taking glucocorticoids or anticoagulants) to avoid life-threatening complications. The following clinical case shows the association between gastric and duodenal mucosal barrier disruption and the use of nonsteroidal anti-inflammatory drugs. Methods: a complete blood count, blood biochemistry test, ultrasound, and abdominal radiography. Results. The clinical case describes a patient with coronary heart disease, ischemic cardiomyopathy, hypertension, permanent atrial fibrillation, impaired glucose tolerance, obesity, and a long history of smoking who had been taking 1–2 tablets of Nimesulide per day for a long time without doctor’s prescription; the intake of NSAIDs was not controlled on an outpatient basis. The reason for hospitalization was sharp pain in the epigastrium; the plain abdominal radiography in the emergency room revealed free gas below both domes of the diaphragm, and ultrasound examination of the abdominal cavity showed a level of inhomogeneous free fluid detected in all sloping areas and pneumatosis intestinalis. In this regard, the patient was urgently hospitalized to the department of surgery, where surgical intervention was performed, including upper-middle laparotomy, abdominoscopy, suture repair of the perforated gastric ulcer, and sanitation and drainage of the abdominal cavity. Conclusion. This clinical case draws attention to the problem of NSAID gastropathy in clinical practice. The task of a clinician is to prevent the development of NSAID-induced gastropathy, identify patients with risk factors for NSAID gastropathy at the earliest possible time, and carry out preventive and therapeutic measures. Patient management at the outpatient stage according to the clinical recommendations could have prevented the development of gastrointestinal bleeding associated with NSAID gastropathy.

POSSIBILITIES OF TREATING PERFORMATIVE ULCERS OF THE STOMACH AND DUODENUM BY MEANS OF ENDOVIDEOSURGERY

The article presents the results of treatment of gastric and duodenal ulcer perforation and its complications in 35 children aged 12 to 18 years. Cases of videolaparoscopic removal of gastric and duodenal ulcers performed in these patientsIn 27 (77.2%) cases, it was successfully completed, and in 3 (8.6%) cases, conversion occurred. Traditional "open" surgical interventions were performed in 5 (14.2%) patients. The information content of ultrasound and X-ray methods of preoperative diagnosis was evaluated. In particular, the specific course of the disease and the results of diagnosis and treatment of the clinical manifestations of the studied disease were analyzed. A comparative analysis of videolaparoscopic and "open" surgical interventions for perforated ulcers of the stomach and duodenum was conducted.

Primary hyperparathyroidism and concurrent severe hypergastrinemia in a dog

AbstractA 7‐year‐old, neutered, male beagle dog was presented for the investigation of hyporexia, vomiting and polyuria‐polydipsia. Ionised hypercalcaemia secondary to primary hyperparathyroidism was diagnosed. The dog developed a perforated gastric ulcer associated with marked hypergastrinemia. The dog died of cardiopulmonary arrest 6 days after admission. Gastrinoma can be associated with Zollinger–Ellison syndrome, characterised by the presence of peptic ulcers and hypergastrinemia. Concurrent primary hyperparathyroidism and gastrinoma is a typical presentation of multiple endocrine neoplasia type 1 syndrome, a human syndrome that causes the development of several tumours in endocrine glands; but has never been described in dogs. Hypergastrinemia secondary to hypercalcaemia, and unrelated to gastrinoma, has also been described in humans, but not in dogs. This case reports the atypical co‐occurrence of primary hyperparathyroidism and severe hypergastrinemia, which could be a consequence of hypercalcaemia, or be secondary to a concurrent disease such as an undetected gastrinoma.

Laparoscopic repair for perforated ulcer

To improve the immediate postoperative results in patients with perforated ulcers. The study enrolled 25 patients with perforated peptic ulcer (diameter of perforation <8 mm). Mean age of patients was 39 years (range 24-56), perforation size - 5.92 mm (range 3-8). Mean surgery time was 59.8 min (range 50-85). There were no intraoperative and postoperative complications. All patients were discharged. The proposed method of repair for perforated gastric ulcers is simple, effective, safe and may be recommended for clinical practice.

Algorithm for surgical treatment of gastroduodenal ulcer with multiple combined complications

Surgical management of gastroduodenal ulcers (GDU) and multiple combined complications (MCC) remains a relevant, complex and unresolved issue. There are currently no well‑defined algorithms, strategies, or surgical procedures for the treatment of gastroduodenal ulcers accompanied by a variety of complications. Objective — to improve the results of surgical treatment and reduce the mortality of patients with GDU and MCC by implementing a surgical treatment algorithm. Materials and methods. The results of surgical treatment of patients with complicated GDU for the period 2000—2022 are presented. A total of 395 (100.0%) patients with GDU accompanied by MCC (a combination of two or more complications) were operated on. There were 52 (13.16%) patients with gastric ulcer perforation and 301 (76.2%) patients with duodenal perforation. A combination of two complications was noted in 299 (75.69%) patients, three — in 88 (22.28%) patients, and four — in 8 (2.03%) patients. Results. A total of 352 (89.11%) operative interventions were performed in an emergency, 43 (10.88%) were performed in the early delayed period (EDP). The implementation of a new algorithm of surgical treatment in the main group and the use of modern measures of endoscopic hemostasis made it possible to increase the rate of operated patients in EDP by 2.6 times, and reduce the mortality rate from 10.14% to 6.45%. The highest rate of mortality is associated with gastric resection in patients with GDU and MCC — 3 (42.87%) out of 7 patients. The lowest mortality rate was among patients who underwent one of the types of organ‑saving surgery — 7 (2.86%) patients out of 245 operated on in this group. Conclusions. The implementation of the algorithm for providing surgical care to patients with GDU accompanied by MCC made it possible to reduce intraoperative mortality from 10.14% to 6.45%. The use of modern means of endoscopic hemostasis made it possible to stabilise, adequately prepare, and operate patients in EDP, which is confirmed by the increase of this indicator in the main group by 2.6 times. The highest mortality rate was in patients who underwent gastric resection and was 42.87%.

Хірургічні аспекти лікування перфоративних гастродуоденальних виразок із поєднаними ускладненнями пенетрацією, стенозом та гострою кровотечею

The problem of surgical treatment of perforation of gastroduodenal ulcers (GDU) remains relevant and difficult, despite the introduction of new schemes of anti-ulcer and eradication therapy. Algorithms of surgical approaches and tactics of surgical treatment of patients with perforated GDU in combination with other complications in various combinations have not been developed. Purpose - to improve the results of surgical treatment of GDU with associated complications. Materials and methods. The results of surgical treatment of patients with complicated GDU for the period from 2000 to 2022 are presented. In total, 353 (100%) patients with perforated GDU in combination with other complications (a combination of two or more complications) were operated on. There were 52 (14.7%) patients with gastric ulcer perforation, and 301 (85.3%) patients with duodenal perforation. There were 267 (75.6%) patients with a combination of two complications; with a combination of three complications in 78 (22.1%) patients; four - 8 (2.3%) patients. The combination of perforation with gastrointestinal bleeding was observed in 138 (39.1%) patients. Results. The vast majority of patients (267 (75.6%)) had a combination of two complications. The number of patients with a combination of three complications was 78 (22.1%). The number of patients with a combination of all complications was insignificant - 8 (2.3%) people. The implementation of the developed algorithm made it possible to reduce the number of postoperative complications and mortality from 12% to 6.5%. The highest rate of complications and mortality was observed among patients with a combination of multiple (three and four) complications who underwent gastric resection - 3 (33.3%) patients, and the lowest mortality rate was observed among patients who underwent organ-preserving operations - 6 (2.8%) patients. Conclusions. In patients with perforated GDU in combination with bleeding, the use of endoscopic hemostasis made it possible to stabilize the patient and better prepare him for surgical intervention, and reduce the number of postoperative complications and mortality rates by almost 2 times. The use of resection techniques was extremely limited and had the highest rate of complications and mortality. Implementation of the developed algorithm made it possible to optimize surgical tactics when combining perforation with other complications of GDU. The research was carried out in accordance with the principles of the Declaration of Helsinki. The research protocol was approved by the Local Ethics Committee of the institution mentioned in the work. Informed consent of the patients was obtained for the research. No conflict of interests was declared by the authors.

Assessment of the condition severity and prediction of postoperative complications in elderly and senile patients with perforated gastric and duodenal ulcer

Aim. To assess the condition severity and predict postoperative complications and mortality in elderly and senile patients with perforated gastric and duodenal ulcer using the P-POSSUM score. Materials and methods. To conduct a scientific study, 80 (100.0 %) cases of treatment for patients aged 60 to 89 years with a diagnosis of gastric or duodenal ulcer perforation were analyzed. At the stage of hospitalization, the general condition was assessed using the variables of the P-POSSUM score. All patients underwent emergency surgery. Results. The obtained sum of points was compared with postoperative complications and mortality. We defined the discrimination point as &gt;43 points for postoperative complications and &gt;48 points for mortality. Based on the result, the patients were divided into group A with a sum of points up to 43 inclusive – 39 patients (48.8 %), and with a greater number of points – 41 patients (51.2 %) – group B. Evaluation of the detected complications in the postoperative period and comparison with the sum of points significantly confirmed an increase in their frequency in group B (sum of points &gt;43) as compared to group A (sum of points ≤43) – p = 0.0018, U = 474.0. To compare the mortality rate, all the patients were divided into group C – 48 (60.0 %) patients with a sum of points ≤48, and group D – 32 patients (40.0 %) with a sum of points ≥49. In the group of patients with a total score &gt;48 (group D), the mortality rate was significantly increased compared to group C with a score ≤48, p = 0.0002, U = 384.0. Conclusions. Our study has led to the following conclusions: the P-POSSUM score use in elderly and senile patients with perforated gastric and duodenal ulcers significantly confirms the increase in the frequency of postoperative complications, in group A – 6 (15.4 %) patients, while in group B – 23 (56.1 %), p = 0.0018, U = 474.0 and increased mortality, in group C – 6.3 %, in group D – 56.3 %, p = 0.0002, U = 384.0; the P-POSSUM score provides reliable prediction an increase in the risk of postoperative complications and mortality. This, in turn, makes it possible to predict and change treatment approaches and improve the quality of emergency surgical care for elderly and senile patients.

МИНИИНВАЗИВНЫЕ ТЕХНОЛОГИИ В ЛЕЧЕНИИ ОСЛОЖНЕНИЙ ОСТРОГО ПАНКРЕАТИТА

Abstract. Introduction. Hollow organ perforations accompanying pancreatic necrosis are a severe complication. In this case, surgical intervention is limited to a degree due to the extensive process in the upper abdomen and the patient’s functional condition. Aim. To share our experience in the minimally invasive repair of gastric perforation in a case series of severely infected pancreatic necroses and retroperitoneal phlegmons. Materials and Methods. We analyzed a case series in our clinic over 5 years, including the necrotizing forms of acute pancreatitis with complications, such as acute perforations of hollow organs. This paper describes the minimally invasive surgeries we performed to treat perforations in upper abdominal. Results and Discussion. In 3 of 4 cases in our clinic, acute perforations of the upper gastrointestinal tract developed along with necrotizing pancreatitis were successfully released using the minimally invasive approach. Conclusions. Hollow organ perforation is one of the most severe complications of infected pancreatic necrosis resulting from the aggressive effects of pancreatic secretion. In this case, the tactical approach depends on the nature and localization of perforation, the course of pancreatic necrosis, and the patient’s functional condition. For perforation of acute gastric ulcers, it is technically possible to use a minimally invasive approach using endoscopic clips, which has been successfully demonstrated in our clinic. We hope that our experience will allow avoiding extended operations in this category of patients.

METHODS FOR CLOSING PERFORATIONS OF GASTRIC AND DUODENAL ULCERS

This literature-based review analyzes different methods of closure of perforated gastric and duodenal ulcers. In addition, there have been determined the indications for the use of each method, the technique of performing, the advantages and disadvantages, as well as the prospects for use and their feasibility at the current level of abdominal surgery development.

Refractory gastrocutaneous fistula treated by two-stage surgery: a case report

BackgroundGastrocutaneous fistulas are a rare complication of enterocutaneous fistulas and can be caused by intestinal injury, infection, and anastomotic leakage. They are typically treated conservatively or endoscopically; however, for large or difficult-to-treat gastrocutaneous fistulas, surgical intervention is required. Herein, we present a case of a huge gastrocutaneous fistula that was successfully treated with a two-stage surgery performed using open abdomen management.Case presentationA 61-year-old man with a perforated gastric ulcer underwent omental filling as an emergency surgery. Post-operative leakage led the development of a 10-cm gastrocutaneous fistula. He was transferred to our hospital for the treatment of gastrocutaneous fistula. Furthermore, nutritional therapy was administered for dehydration, electrolyte abnormalities, metabolic acidosis, and acute kidney injury due to the high-output nature of the fistula. Moreover, owing to the intraperitoneal severe adhesion and poor nutritional status, two-stage surgery was planned. In the first stage, extensive dissection of the adhesions, distal gastrectomy reconstruction with Roux-en-Y anastomosis, and jejunostomy were performed. Furthermore, open abdomen management was conducted to check for the presence of unexpected complications due to extensive dissection of the adhesion and anastomotic leakage. Subsequently, in the second stage of the surgery, abdominal closure was performed on the 9th day after gastrectomy.ConclusionOpen abdomen management may be effective for huge gastrocutaneous fistulas with extensive adhesions that require surgical intervention.

S4134 Severe Anemia as Initial Presentation of Hepatic Abscess Secondary to Subclinical Gastric Ulcer Perforation

S4134 Severe Anemia as Initial Presentation of Hepatic Abscess Secondary to Subclinical Gastric Ulcer Perforation

Overview of Peptic Ulcer along with its Conventional and Improvement Therapies: A Study of Glycopyrrolate and Management of Peptic Ulcer

Peptic ulcer disease remains a prevalent gastrointestinal disorder globally, posing significant challenges in its management. This comprehensive review provides an overview of peptic ulcer pathology, conventional treatment modalities, and recent advancements in therapeutic approaches. Traditional treatments, among them histamine receptor antagonists, proton pump inhibitors, and antibiotic regimens, have shown efficacy in ulcer healing and symptom alleviation. However, emerging evidence suggests limitations such as drug resistance and adverse effects. In light of these challenges, this article delves into the potential of Glycopyrrolate, a muscarinic receptor antagonist, as a novel therapeutic agent for peptic ulcer management. However, still there may be aggravation of peptic ulcer leading to severe conditions like perforated gastric ulcer, and gastric bleeding where surgery is only beneficial.

Severe anaemia secondary to a perforated gastric ulcer in a male alpaca

BackgroundAnaemia is a common condition in alpacas and attributable to a variety of causes. Severe anaemia with a packed cell volume (PCV) less than 10% is frequently diagnosed, usually due to blood loss resulting from haemonchosis. Many South American camelids (SACs) also suffer from gastric ulcers, which are often associated with anaemia in other species. However, in alpacas and llamas, gastric ulcers usually do not lead to anaemia due to blood loss according to the current literature. There are no detailed clinical and laboratory data on this condition in the scientific literature so far.Case presentationWe report on the case of a nine-year-old male alpaca that was presented to the clinic with suspected forestomach acidosis. The animal showed clinical signs of colic, hypothermia, tachypnea, tachycardia, pale mucous membranes, and died shortly after admission to the clinic. Laboratory diagnosis revealed a markedly decreased haematocrit (0.13 l/l), leucopaenia with band neutrophils, azotaemia, hypocalcaemia, hyperphosphataemia and vitamin D deficiency. Post-mortem examination revealed multiple ulcers in the first and third compartment with perforation of one ulcer in the first compartment, resulting in intraluminal blood loss and purulent peritonitis.ConclusionsTo the authors’ knowledge, this is the first detailed description of clinical and laboratory data of severe anaemia due to a perforated gastric ulcer in a SAC. Although the current literature suggests that severe blood loss due to gastric ulcers does not occur in SACs, this condition should be considered as a possible differential diagnosis in anaemic animals. Clinical indicators can be colic and pale mucous membranes.

755 Management of Perforated Peptic Ulcer in Laparoscopic Era

Abstract Aim We want to share our initial experience in treating Perforated Peptic ulcer by mini-invasive techniques. Method Retrospectively, data was collected by looking at surgical files for patients who were admitted with perforated peptic Ulcers under an experienced consultant surgeon between 2016 and 2021 at Benghazi Medical Centre in Libya. Only patients were managed laparoscopically were included and were managed by the same surgeon. Results In the period of 2016 until 2021, 18 patients with perforated peptic ulcers were treated laparoscopically in our hospital.All were men except three women, age ranged from 23 years to 56 years. Laparoscopy was attempted in all patients , none of the cases were converted to open , 14 patients of perforations were located in the first part of duodenum (80%) and 4 were pre-pyloric , simple closure with omental patch were enough to close the perforation, copious peritoneal lavage with normal saline access to all abdominal compartments is very easy and never can be reached in open surgery. Mean operative time was 90min (60-120 min). the hospital stay ranged from 3 to 7 days. with no morbidity, leak , and no mortality within 30 days. Conclusions We shared our experience for management of perforated Peptic ulcer at Benghazi Medical Centre, by managing 18 patients with perforated viscus Laparoscopically. Laparoscopy is safe and permits successful primary suture closure of perforated duodenal and gastric ulcer and provides excellent access to different regions of the abdomen for better lavage. Furthermore, it confers benefits on patients in the form of reduced postoperative pain, and early recovery.