Perforated ulcer - Causes, symptoms and treatment. MF.

Perforation, or perforation, stomach ulcers - this is nothing but a formidable complication of peptic ulcer of the stomach and duodenum. Its origin is due to the fact that with the prolonged existence of ulcers on the mucous membrane under the influence of aggressive gastric juice, there is a "erosion" of submucosal structures and the muscular wall of the organ with the formation of a through defect. Through the defect, acidic gastric contents enter the free abdominal cavity, causing irritation and infection of the peritoneum, that is, peritonitis.

Perforation of the wall of the hollow organ can occur with ulcers on the mucosa of the esophagus, small and large intestine, but most often the perforation occurs in the outlet stomach in the pylorus and in the early part of the duodenum, therefore this term is most often mentioned in connection with the ulcerstomach.

About 10% of all cases of stomach ulcers are complicated by perforation. At the same time, perforation occurs in 30% of other complications - bleeding, penetration and malignancy of the ulcer. In women, perforation is less common than in men.

Causes of the disease

The main cause of the perforated ulcer is the effect of hydrochloric acid produced in the stomach on the existing ulcerative defect with the gradual destruction of all layers of the gastric wall. The following factors can contribute to its development:

- food intake in very large quantities, stretching the stomach wall, and eating foods that irritate the mucous membrane( sharp, fried, fatty foods, alcohol, carbonated and fizzy drinks),
- a strong physicalstress, conducive to a sharp increase in pressure in the stomach,
- smoking, frequent stress,
- persistent inflammation in the area of ​​the ulcer, for example, when the patient does not take drugs to treat peptic ulcer,
- save(
- increased acidity of the stomach,
- taking medications that reduce the protective function of the mucosa - non-steroidal anti-inflammatory drugs( aspirin, diclofenac, nimesulide, etc.), glucocorticoid hormones( prednisolone,hydrocortisone), etc. Such drugs for patients with peptic ulcer should be prescribed strictly according to indications and under the cover of omeprazole, which reduces the production of hydrochloric acidsAnd thus, reduces the acidity of the stomach.

Symptoms of a perforating ulcer

In the clinical picture of a perforated ulcer, it is possible to distinguish specific symptoms that make up the Mondor triad - pain, plaque and ulcerative anamnesis.

Pain in the abdomen is acute, sudden, resembling a knife or dagger, localized first in one place in the upper abdomen, near the umbilical area or under the ribs on the right. Before the appearance of "dagger" pain in most patients for several days before this, there is an exacerbation of peptic ulcer, increased night or hungry pain, heartburn.

The dolorous abdomen is characterized by a strong tension of the abdominal muscles due to the ingestion of gastric contents to the peritoneum, which is richly endowed with receptors-a thin serous membrane lining the internal organs. The belly does not participate in the act of breathing, and the patient takes a forced posture that can ease the pain a little - lying on his side, bringing his knees to his stomach.
The presence of an ulcer in the patient's history of a patient with acute abdominal pain should always alert the doctor to the perforation of the wall of the stomach.

In the first hours of the disease the most pronounced clinical picture develops, called of the primary shock .The patient is pale, blood pressure is lowered, abdominal pains reach their maximum.

After 4-6 hours later, the pain syndrome becomes less intense, the tension of the abdominal muscles decreases. This apparent relief of the condition is associated with the fact that receptors on the peritoneum become intact to stimuli, and the nervous system begins to produce neurotransmitters that facilitate the tolerability of pain stimuli. However, in this second stage of a perforated ulcer, or during a period of imaginary well-being, lasting up to 12 hours from the onset of the disease, infection of the abdominal cavity rapidly develops and peritonitis appears - the third stage of the process.

The acute period during the perforated ulcer takes no more than 4 days, as after this irreversible changes in the abdominal cavity develop, terminal period and death occur.

Diagnosis of perforating ulcers

The clinical picture of a perforated ulcer is specific and in most cases does not cause difficulties in diagnosing. The diagnosis is based on these complaints, medical history and examination of the patient. On examination, sharp soreness in the abdomen, tension of the abdominal muscles and peritoneal symptoms( symptoms of irritation of the peritoneum) are revealed.

If the suspected ulcer is suspected, the following examination methods are performed:

- general blood and urine tests to detect signs of inflammation in the blood, to diagnose renal dysfunction in the terminal stage,
- biochemical blood test, clotting time, prothrombin time to detect abnormalitiesliver and kidney function, evaluation of the blood coagulation system before surgery,
- blood group determination, blood test for HIV, syphilis, hepatitis as part of emergency trainingto surgery,
- abdominal radiography to confirm the diagnosis, in which a characteristic symptom is the presence of gas released from the stomach in the free abdominal cavity,
- in case of inadequate examination, a history of the ulcerative anamnesis and radiographic data, an emergency gastroscopy is prescribed,
-if there is a suspicion of covering the aperture from the side of the abdominal cavity with a gland site, diagnostic laparoscopy or laparotomy may be performed-an introduction into the abdominal cavity through small incisions of the omentumdoskopicheskogo equipment or dissection of the abdominal wall, respectively.

Treatment of perforating ulcer

The main method of treatment of perforated ulcer is surgical. Two types of operations are used: suturing the end-to-end defect with preservation of the stomach, and excision of the ulcer within the healthy tissues with resection( removal of the part) of the stomach.

Suture of a perforated ulcer refers to palliative( accessory) methods of treatment. It is used in young patients without prolonged ulcer history, in old age, with a severe general condition of the patient, and also in the presence of diffuse peritonitis, if the duration from the beginning of perforation is more than 12 hours. The operation is performed under general endotracheal anesthesia. Laparotomy is performed in the upper abdominal wall along the middle line. After the discovery of a defect on the stomach wall, two rows of seams are applied, and the gland site is hemmed to this place. More recently, such operations are performed by laparoscopic access.

Laparoscopic suturing of the perforated gastric ulcer

Gastric resection is indicated in cases where the patient has a long-term gastric ulcer that is not amenable to drug therapy, and if a callous ulcer is found during surgery that can not be sutured due to severe scarringher day. In addition, resection is indicated for suspected malignancy( ulceration) of the ulcer or perforation of two or more ulcers at the same time. The operation is also performed under general anesthesia, with the same access, but only the volume of the operation is to remove two thirds of the stomach in the area of ​​the ulcer.

Due to the fact that surgery on the perforation of the stomach wall is carried out urgently, doctors in most cases have little data characterizing acidity, evacuation function and other indicators of the stomach. Therefore, every responsible decision by the doctor is taken during the operation.

In the postoperative period, anti-ulcer therapy with antimicrobial agents( clarithromycin, amoxicillin or metronidazole), as well as proton pump inhibitors( omeprazole), is necessary to reduce the acid-forming function of the stomach.

Lifestyle

After surgery for a perforated ulcer, the patient must take good care of his health. For this it is necessary to have more rest, walk more often outdoors, exclude physical and psychoemotional loads.

A special place during the post-operation period is diet. In the first two days after surgery, the patient is only allowed to drink water in small quantities, since a strict diet is required. Two days later, mashed low-fat soups, liquid porridges on the water, jellied and unsweetened tea are offered. After ten days in the diet, you can enter lean meat, stewed vegetables, cereals. In the first months after the operation, chocolate, sweet drinks, buns, buns are excluded from the ration. Bread is allowed to be consumed only one month after the operation.

For the rest of his life, the patient must stop smoking, drinking alcohol, carbonated drinks, fatty, spicy, salty, smoked products to prevent recurrences of peptic ulcer.

Complications after operation

Complications are rare. These include suppuration of the wound after surgery and the development of abscesses( ulcers) under the diaphragm, in the subhepatic space, between the loops of the intestine. It is also possible the development of gastric bleeding, bleeding into the free abdominal cavity and obstruction of the intestine. The risk of complications increases in elderly patients and in persons with immunodeficiency.

Forecast

Prognosis for a timely operation is favorable - repeated perforations of the stomach wall are less than in 2% of patients, and a lethal outcome - in 2 - 8% of cases.

If more than 12 hours have passed since the beginning of perforation, the forecast is unfavorable, since the mortality rate reaches 20-40%.

Doctor therapist Sazykina O.Yu.