Perforation of the stomach or duodenal ulcers

Among the acute diseases of the abdominal cavity perforation, ulcers stomach and duodenal ulcer is about 1.5%. The frequency of this complication in ulcer patients but to the statistical data of various authors ranges from 5 to 15%. According to M. G. Schreiber (1961), it is more likely to occur at a young age is between 20 and 40 years (67,6%) and in men occurs 7 to 8 times more often than women. Known cases of perforated ulcers in children under 10 years old, and the old men older than 80 years. As well as exacerbation of ulcer disease, an increase in the number of perforations in spring and autumn.
Related perforation points are: alcohol, overflow stomach food, excessive physical stress, trauma, and negative emotions.
Pathogenesis. Perforation occurs when reducing power tissue edges and bottom of the ulcer, which is developing at various violations of permeability of blood vessels (sclerosis, thrombosis, obliteration). This leads to necrosis of this section and perforation. This explanation is indirectly proved by the fact that if the perforation is bleeding in the area of the defect in the wall of the stomach or duodenum, and the combination of perforation, bleeding is rare (1%). In some cases, acute and sudden perforation occurs without prior indication as "bombshell", and then, I suppose, it is based on acute neuro-degenerative factor. In most cases, perforation is preceded by a period of painful exacerbation of ulcers, and then, probably, in the basis of the collapse of the walls of the bottom of the ulcer is the strengthening of pathological changes in the walls of small arteries, coronary thrombosis and periarterial neuritis.
A ruptured stomach ulcer or duodenal ulcer occurs in 3 variants: 1) the perforation in the free abdominal cavity - 87%, 2) covered perforation - 19% and 3) the perforation in the retroperitoneal fat and thick lesser omentum - 14%.
Perforation in the free abdominal cavity entails rapid development of spread purulent peritonitis. Exudate is distributed on the right lateral channel of the peritoneum and causes the development of the first Puritanism, and then peritonitis, primarily under the liver, in the right iliac region and in the pelvis. Therefore, often there diagnostic errors in assumptions about appendicitis, oophoritis, etc. you can also aspiration of the exudate and left subphrenic space with menicus-symptom, painful breathing problems left and pain in the left shoulder girdle.
Perforation in the retroperitoneal space causes the development of retroperitoneal abscess, phlegmon, true subphrenic retroperitoneal abscess, parkolni phlegmon, sepsis. The picture of such complications is characterized more obserations than peritoneal, phenomena.
Pathological anatomy. Perforation occurs in deep fresh and old, often Kalesnik, ulcers. Undoubted role localization ulcers. Most often exposed perforating ulcer on the front wall of the stomach and duodenum. Favorite places of localization of perforation be the front surface of the initial part of the duodenum, gatekeeper, place of transition gatekeeper in the duodenum, several less - angle area of the lesser curvature below a. gastricae sin., then just above a. gastricae sin.; much less perforation occurs in the plague subcatalog Department of the lesser curvature of the stomach.
Deep ulcers back wall of the stomach or duodenal ulcers most often end up a kind of perforation: they gradually penetrate (penetrates) in one of the adjacent neighbouring structures - small gland, pancreas, liver, cross the colon or her mesentery. Due to this there was no free or covered with perforation and not developed peritonitis.
The size of free holes range from 1 to 5 mm in diameter. The border of his thickened, calloused, infiltrated, brittle and break. This is especially important when the operation; if done through these edge seams thread joints erupt, and the aperture becomes larger.
Covered perforation first is accompanied by acute phenomena of peritoneal irritation in epigastria, then soon phenomena peritonitis become more limited, more often in the area a little to the right and above the navel, and then subside. Fever and toxicity in the blood remain. Later, because of the cicatricoadhesive changes around bodies subhepatic space and resorption of the exudate picture subsides. Another possible outcome is covered with perforation: suppuration of infiltration and sudden his breakthrough with the appearance as if secondary, diffuse purulent peritonitis or education nadrezanno-subphrenic and Leopoldville abscesses finally saw - and thrombophlebitis, intrahepatic abscesses, septicemia. The outcome will largely depend on the reactivity of the organism of the patient and timely surgical intervention.
The clinical picture of perforation usually develops badly, but in 20% of cases is it subacute occurs when 2-3-4 days, patients may exacerbation of pain in epigastria, but still no signs of peritoneal irritation. Then, all of a sudden, there comes the moment acute local pain with a common reaction. After this picture acute perforation blossoms in full. Sometimes, especially in the old or very weakened and depleted patients, the whole picture of perforation proceeds more slowly, masked, erased.
In preparation to perforation period (it can be called prodromal) have heightened pain, low grade fever, constipation, nausea, unreasonable vomiting, possible and chills. For a typical picture of acute perforation in the free abdominal cavity characteristic 3 main symptom: 1) sharp, "dagger" pain in the epigastric region (95%); 2) doskoobraznye muscle tension, mainly direct, in epigastria (92%), and 3) a history of gastroduodenal ulcer disease (80%).
However, in 20% of patients perforation is the first manifestation of peptic ulcer. It often refers or to the very young, or, conversely, to people of very old age.
Pain when perforation very strong and can bring a patient to a state of pronounced collapse; cold, clammy sweat on his forehead, suffering face, with a wandering eye, sallow complexion of the face, cold extremities (even acrocyanosis), shallow breathing, thirst and dry tongue. The first pulse slowed down or even harsh ("vagusnye" pulse), but a couple of hours appears tachycardia. Blood pressure goes down already in the first hours and further reduced even more. Vomiting when incurred acute perforation is relatively rare, and thus, if a patient with suspected perforation she continues, there is a significant probability speaks against having perforation and in favor of some other acute abdominal diseases.
An objective study of the abdomen reveals rescisao the PAL-paternal and percussion pain in epigastria; positive symptom Shchetkina - Blomberg, at first, too, localized mainly in epigastria, but after a few hours spreading to the navel and below it, mainly to the right, and even around the abdomen.
The above doskoobraznye muscle tension in EPI - and esogastrice gradually decreases, but peritoneal phenomena are saved together with increasing flatulence.
In the first hours can be observed, the passage of stool and gas, but then flatulence is growing and there is a delay chairs, gas and even urine. The patient tries to maintain peace and lies on his back or right side with their legs bent and reduced to the abdomen thighs.
Only in some cases, as an exception, it can be tossed about in bed and take a quaint posture (for example, the knee-elbow, and so on).
For percussion, thorax and abdomen noted the disappearance of hepatic stupidity and replacing it before - and nudecanada tympanites. At the same time marked the move symptom Shchetkina - Blomberg in the right iliac region and the presence in it of dullness due to accumulation of pouring out from the stomach fluid running down the right lateral channel. This symptom De-quervain's very typical for the perforation of gastric ulcer or duodenal ulcer.
Quite often, but not always the radiation of pain in the left, right or both shoulder girdle according to the principle of prunicus-symptom. The same can be said about skin giperestesia in areas Zakharyin - Ged (D10-L1) on the right. A rectal examination may detect pain in the pelvic deepening of the peritoneum.


The course and prognosis. For several hours the clinical picture of acute ulcer perforation in the free abdominal cavity is clearly changing. If during the first 5-6 hours was observed severe pain and severe General reflex hemodynamic disorders, called by many the "shocked"by the intensity of the pain subsides. There comes some compensation initial hemodynamic disorders, reduced (but not eliminated entirely) of the muscles of the abdominal wall. The disease is entering a period of "imaginary improvement", which lasts 3-5 hours, and then steadily evolving and growing phenomenon of peritonitis. Only a very debilitated patients or persons in old age in the period of "imaginary improvement" may take some time for a longer time, even more than one day and widespread peritonitis will be accompanied by very sluggish manifestations. However in process of progressing of peritonitis General condition of all patients change dramatically for the worse; occurs disproportionately temperature tachycardia, arrhythmia, falls filling pulse and blood pressure. Again, more sharply, sharpened facial features, skin acquire earthy colour, language becomes dry and rough, becomes uncontrollable vomiting masses of coffee colour, revealed paralytic sharp bloating, and in the sloping abdomen with percussion is determined by shifting dullness.
The clinical course of perforation depends not only on its type (a perforation in the free abdominal cavity, covered with perforation, perforation in the retroperitoneal fat), but in a greater degree and from age of the patient, reactivity of his body and aggravating diseases. This is especially true covered and retroperitoneal perforations. Perforation in the free abdominal cavity under any conditions (without urgent surgery) completed within 70-80 hours from the moment of their occurrence death due to diffuse purulent peritonitis.
The clinical picture is covered with perforation is not so typical. Acute onset can relatively quickly lose its urgency and be followed by a period not "imaginary"and, perhaps, full of calm that later gradually instead of progressing of peritonitis develops or obstructive infiltration, or subphrenic abscess.
The outcome in suppuration will require time of opening of abscess, although described and spontaneous outbursts him in the gut or through the abdominal wall, in particular through the navel out.
If the plague punches arise in the retroperitoneal space, the clinical picture is much more common, and more resembles the development of acute paranemia, parkolni phlegmon with rapidly increasing septic condition of the patient.
In all variants of perforation recognition extremely valuable help gives routine clinical analysis of peripheral blood. It quickly and dramatically increases leukocytosis: 20 000 - 30 000 are quite frequent numbers, and, what is especially important, even in a depressed increase in the number of cells in their formula increases rapidly sharp toxic shift. Changes in the urine little characteristic; in the period of peritonitis it appears protein, possible microhematuria.
Diagnosis perforating ulcer is confirmed by x-ray examination, where due to the receipt of gas from the stomach below the diaphragm between it and the liver occurs enlightened sickle bar. The discovery of gas is typical for covered with perforation, and in cases of perforation in the retroperitoneal space beneath the diaphragm it does not happen, but described the discovery of retropreparation with kontoritooli one or both kidneys or identification pneumomediastinum. In these cases, sometimes in the lower back or neck may appear when very careful palpation feeling gas creditarii. The usual perforation free pneumoperitoneum is approximately 75%.
Treatment of patients who have perforation of gastric ulcer or duodenal ulcer, should only be operative and immediate. Emergency laparotomy is the only successful event, along with which to place all the stimulating hemodynamics and protective forces of the body therapy, including blood transfusion. The best method of anesthesia is for this operation intratracheal air anaesthesia with the giving of oxygen and the use of muscle relaxants, antihistamines, and gangliosidoses drugs. The main operation is resection of the stomach, and stitching the ulcer perforation is used only in patients of advanced age or in the presence of other diseases, or when the Statute of limitations perforation exceeded 8-10 hours and already have diffuse peritonitis. From resection reasonable to refrain, if for some reason turned out to be unsuitable conditions in the given medical institution or when the experience of the surgeon is insufficient for the production of the stomach resection in urgent circumstances. Stitching of perforation sores typically requires repeated in subsequent operations to unesenye ulcers and getting rid of the patient from the threat of its zlokacestvennoe. Resection, performed within up to 8 hours from the beginning of perforation (i.e. outside of peritonitis) patients, does not burdened additionally, well tolerated, and direct smertelnoj thereafter does not exceed 2%.