In a patient who is known to have had symptoms of peptic ulcer | Surgery videos & books

In a patient who is known to have had symptoms of peptic ulcer disease for many years and presents with nausea and vomiting, one should consider gastric outlet obstruction. The obstruction can be the result of an exacerbation of the ulcer and subsequent edema or it can be secondary to scar tissue formation. These patients typically describe the sensation of epigastric fullness and demonstrate visible peristalsis going from left to right. A succussion splash may be audible. The history of periodicity and pain relief by taking antacids also favors a diagnosis of previous peptic ulcer disease. Patients with an umbilical hernia will have a mass in the region of the umbilicus. Patients with acute cholecystitis usually present with the sudden onset of pain, radiating to the back, with fever and chills. Volvulus of the sigmoid colon presents with constipation and abdominal distention but vomiting is a late feature. Small bowel obstruction would be associated with a history of colicky abdominal pain, nausea, and vomiting. Additionally, patients with small bowel obstruction usually have hyperactive highpitched bowel sounds on examination. (Townsend et al., 2004, pp. 1283–1284, 1295) With persistent vomiting, the patient becomes dehydrated and hypovolemic. Loss of hydrogen ions, potassium, and chloride in the vomited gastric contents leads to alkalosis, hypokalemia, and hypochloremia. In response to the hypovolemia, adrenocortical and renal mechanisms are stimulated to conserve sodium at the expense of potassium and hydrogen ions. Excretion of potassium in the urine further aggravates the hypokalemia. The kidneys then compensate by exchanging hydrogen ions for potassium, which results in a paradoxical aciduria and self-perpetuating metabolic alkalosis.