Obstruction pyloric

Pathogenesis. Obstruction of the pyloric stomach, or stenoses privratnika, is one of the complications of peptic ulcer disease and occurs as a result of ulcer cicatrization, located in the pyloric Department of the stomach or in the initial part of the duodenum. If scarring occurs a considerable deformation of the body and narrowing his oral - channel, which entails stenosis exit from the stomach, or that the degree of obstruction.
Pathological anatomy. Not only in the place cicatrizing or healed ulcers but for several centimeters in oral or aboral towards the wall of the pyloric canal stomach and the initial part of the duodenum is on the circumference rublevochange to 1.0-1.5 cm on the cut. Atrophic mucosa, scar replaced elements of its scattered islets among sklerozirovanie connective tissue, growing among atrophic muscle fibers. On serosa have plastic scar layers. Pyloro-duodenal Department entirely or partially implanted scars to a small gland, liver, gall bladder, sometimes to the channel, often to the head of the pancreas, and sometimes can be free from the seam. The length of narrowing often takes a few inches, giving the affected Department appearance of scar cylinder with negligible clearance up to 2-3 mm Sometimes scars capture only 1,0-1,5 cm wall and give the stenosis of the nature of a circle. The plot of the pyloric stomach, and the adjacent part of the duodenum (deprived of scars) are extended, and the area stenosis has the form of interception, waist, disfiguring the affected Department like the "hourglass". Due to obstacles to push food through narrowed the exit from the stomach muscles in the wall first hypertrophies, and then begins to develop its a stretch, but with even saved muscular tone; still later there is a loss contractility of muscles of the stomach wall, she overly stretched, and the stomach turns into a atonic bag.
Classification. You should distinguish between clinical stage 3 stenosis exit from the stomach or obstruction of his pyloric: 1) stage periodic delays and occasional vomiting, 2) the stage of constant food remains in the stomach with a weakened but still partly preserved muscle tone and 3) the stage of insolvency of the stomach wall with permanent stasis, atony and hyperextension of the stomach with the sound of lapping.
Clinical symptoms, course and diagnosis. In stage I of the periodic delays and occasional vomiting mainly preserved the classic clinical picture of peptic ulcer. The General condition of patients varies little, and meals are not violated. Pain worry less, and some are inclined to explain this by the result of the treatment. The more is only a feeling of fullness in the epigastrium, and more frequently than in uncomplicated form of peptic ulcer disease, there are occasional vomiting increasing portions of gastric contents with a strong sour taste. Vomiting brings relief to the patient, but not for long; after 1-3 days painful feeling of fullness in the epigastric region appears again. When sounding out of it pumped increased the number (200-300 ml - 500) with a slightly sour odor content with reasonable admixture recently adopted almost unchanged food masses. Sometimes when probing the stomach may be empty when shortly before had been vomiting. Treatment systematic washing stomach brings obvious subjective improvement, but on the state of the case no effect. Stenosis does not disappear, progress and termination washes its clinical manifestations resume to a greater extent. Stenotic disease exit from the stomach is progressing with different speed and passes in the second stage - the stage of constant food residue hypertrophy of the stomach wall, with partially preserved even tone her muscles.
This stage II is characterized by the feeling of heaviness and overflow in the epigastric region, which are sometimes combined with pains, frequent otricali large number of air regurgitation sour, bitter, unpleasant taste gastric contents. Now occasionally, and almost every day or several times a day is very rich (more than 500 ml) vomiting. It appears or immediately after a meal or after 1 -2 hours, following mounting pain under the spoon, and a feeling of fullness. In vomitus contains just adopted, and food items eaten the day before, but still no signs of putrefaction fermentation. Wound in the stomach after vomiting probe can pump out more new significant portion of the residual content, sour, bitter, or with a bad smell. Fasting in the stomach is a large number of gastric contents. After vomiting or pumping comes relief, but not for long. In this stage, is the progressive loss of weight of the patient. Stenotic disease with different speed turns in III clinical stage of the disease.


In the third stage - the stage of insolvency of the muscles of the stomach wall, characterized by permanent stasis, atony and hyperextension of the stomach, there is a rapid dehydration and extreme depletion of the patient from whom you receive the dry language, General lethargy, etnicheskiy voice, characteristic earthy colour lost turgor of the skin. Pain in epigastria disturbed patients have little, malaise, apathy and lethargy suppress other symptoms of the disease. Meanwhile, their Stomach is constantly filled and stretched, its walls atonic and not able to push even liquid content through the pyloric canal and the ring, narrowed to the extreme limits (sometimes barely passes only a match or pugovicy probe). In the epigastric region through the thinning of the veil and the abdominal wall often appear contours stretched stomach, visible with the naked eye. Even light strokes on the abdominal wall in the area of the stomach cause clearly audible in the distance the sound of lapping. The feeling of bloating in the stomach and discomfort in heart cause patients often to resort to artificial vomiting fingers, without waiting for the appearance of independent vomiting, which may not be in a few days. When it erupts huge number stench of decomposing the contents of the stomach with a days decayed food remnants. Unfortunately, vomiting brings relief only for a few hours. Are similar and mass obtained from the stomach when it is sounding. Unlike cancer admixture of blood is usually not the case. Used with the medical purpose systematic stomach effect not give.
It is for this stage is characteristic deschisa the degree of dehydration. Error diagnosis in favour of stomach cancer often. Sometimes surgeons even unreasonably refuse operations, thinking that there is an advanced stomach cancer, as with x-ray studies to exclude it can be difficult. At the same time, even with the sharp degree of depletion operation can save the life of the patient.
If the first two stages of stenosis of the exit from the stomach can be characterized as offset in some degree periods, the third stage is the period of decompensation. Develop severe metabolic disorders (hypoproteinemia, gipohloremia, azotemia), which lead to the development of so-called gastro (chloroprene) gastric tetanii with seizure data of brushes, symptoms Huasteca and trusso, delirious seizures. Appear long persistent constipation, under which enema not give effect; sharp oliguria.
There is a thickening of the blood: the hematocrit is 1 : 3-4, in the blood decreases the amount of chlorides (below 400 mg % at norm 500 mg %); the same happens in the urine (chlorides is 2,0-3,0 instead of 10 - 15,0 OK); grows azotemia, oliguria.
X-ray diagnosis of this complication of peptic ulcer disease is not always easy and precise (see appropriate Chapter).
Prevention. The only way to prevent the development of stenosis of the output section of the stomach as a complication of peptic ulcer disease is timely surgical treatment in cases when conservative therapy of ulcer is unsuccessful.
Treatment. The only method of treatment of patients with occlusion of the exit from the stomach is an operation in the form of a gastrectomy. In the first two stages it is usually associated with moderate risk, and in the third stage - high smertelnoj.
Regardless of the stage before the operation it is necessary to carefully prepare patients daily emptying of the stomach probe with subsequent washing saline solutions to improve the tone of its walls. For the elimination of severe metabolic disturbances should be sufficient parenteral (intravenous and subcutaneous infusion of chlorides (2-3 litres per day physiological sodium chloride solution subcutaneously and 200-300 ml of 5% solution intravenously), and 1-2 l 5% glucose solution subcutaneously and 20-40 ml of 40% solution her intravenously, vitamins a, B, nicotinic acid, ascorbic acid, blood transfusion and high-molecular dekstrana, calcium chloride when events chloroprene tetanii and in relation to changes of the blood coagulation system introduction the vikasola, anticoagulants (including heparin), antibiotics in combined with nystatin.
It must be remembered that the operation in the third stage poorly tolerated and therefore should pay special attention to the careful preparation of the patient before operation and technique of the surgery. If the operation went well, the result is a striking success, provided that they have not appeared before surgery is irreversible malnutrition.
In all cases gastrectomy brings better results than the imposition of gastrojejunostomy, and should be considered as select, since the imposition of gastrojejunostomy besides it is not excluded that the cancerous changes in the wall of the pyloric stomach.