Perforated gastric and duodenal ulcers - one of the most severe diseases of the abdominal cavity. Perforation is a serious complication of gastric ulcer and duodenal ulcer is common, taking second place after acute appendicitis.
As with other acute diseases of the abdominal cavity, with perforated ulcer, early negotiability, timely diagnosis and surgery are a prerequisite for a favorable outcome.
Despite all the achievements of the last decades in the treatment of peptic ulcer, the frequency of perforated ulcers reaches 10%. They account for up to a quarter of all complications of peptic ulcer and symptomatic ulcers. More often it is observed in men. Moreover, a formidable state can end not only with an operation, but also with a fatal outcome.
Why does perforated gastric ulcer develop, and what is it? Perforated ulcer is not an independent disease, but a complication of a stomach ulcer. Perforation is essentially the emergence of a through hole in the wall of the stomach and the outflow of stomach contents into the patient’s abdominal cavity and its part.
This phenomenon is very dangerous in itself, a sufficiently large number of deaths occur in cases where the diagnosis of the disease was carried out too late, or in the case when the patient ignored the simple rules of treatment and recovery after surgery.
Certain factors contribute to the perforation of the organ wall:
- lack of treatment of acute ulcers;
- gross violations of the diet;
- severe overeating;
- frequent stressful situations, constant mental and mental stress;
- heavy exercise and increased pressure inside the abdominal cavity;
- long-term use of glucocorticosteroids and salicylic acid preparations.
As you can see, the causes of the development of this disease can be easily prevented if you carefully consider your health.
Symptoms of perforated gastric ulcers
In the case of a perforated ulcer, the severity of the symptoms directly depends on the clinical form of the perforation. She may be:
- typical, when the contents of the stomach immediately flows into the abdominal cavity (up to 80 - 95%);
- atypical (covered perforation), if the hole formed is covered by an omentum or other nearby organ (about 5–9%).
The classic picture of signs of perforated ulcer is observed when perforation in the free abdominal cavity, occurring in 90% of cases. It distinguishes 3 periods:
- primary "abdominal shock" (chemical inflammation);
- latent period (bacterial);
- diffuse purulent peritonitis.
The harbingers of perforation can be:
- increased pain in the patient;
- "causeless" vomiting;
- dry mouth.
Then there is a sudden change in the picture of the disease. The patient appears:
- intense burning pain, which is usually compared with a dagger strike;
- faster, then lower heart rate;
- drop in blood pressure with loss of consciousness and sometimes even with the development of a shock.
Stage of pain shock
During this period, the patient feels an acute pain in the abdomen. Patients compare it with a dagger strike: it is a sharp, strong and sharp pain. At this time, vomiting may occur, the patient is difficult to get up, his skin is pale and cold sweat may come out.
Breathing is rapid and shallow, with a deep breath pain occurs, blood pressure is lowered, but the pulse remains within the normal range: 73-80 beats per minute. When perforated duodenal ulcer abdominal muscles are strained, so the feeling is difficult.
The duration of the second period, as a rule, is 6-12 hours. Symptoms include the following:
- face acquires normal color;
- pulse, pressure and temperature return to normal;
- shallow breathing, dryness and scarceness of the tongue are absent;
- pain subsides (with the flow of the contents of the stomach along the right side canal, the pain remains, but becomes less intense and becomes localized).
As a rule, during this period, patients are sure that the disease has receded, and reluctantly give themselves to be examined, hesitate before agreeing to surgery.
The transition of the disease to the stage of diffuse peritonitis occurs by the end of the first day. Painful sensations return in an even more pronounced form, becoming unbearable. The patient suffers from nausea, vomiting. Sometimes joins hiccups. Body temperature rises to 38 degrees C.
The stomach becomes bloated, while listening to intestinal noises with a stethoscope, very faint noises are noted, but sometimes you can only hear silence.
The diagnosis of perforated gastric ulcer is based on a detailed questioning of the patient and inspection. Since in some cases, the patient gets to the doctor in the second period of the disease, when the symptoms are not expressed, it is possible to make a mistake.
Therefore, when any suspicion of perforation is necessary to conduct a comprehensive survey:
- X-ray diagnostics. With its help, you can determine the air in the abdominal cavity (in 80% of cases). At the same time, it is necessary to differentiate it from the signs of the airy intestine by its characteristic features ("subphrenic hemilunus").
- Endoscopy. It is used in case of negative results of X-ray examinations, but in case of suspicion of perforation. Allows you to determine the presence of peptic ulcer disease, the localization of the outbreak. The study is carried out using air inflation, which helps to determine the true clinical picture.
- Diagnostic laparoscopy is the most sensitive method for detecting perforated gastric ulcers, gas and effusion in the free abdominal cavity.
In the clinical analysis of blood there will be all signs of inflammation (increased ESR, the level of stab leukocytes), and when bleeding the level of hemoglobin decreases.
Perforated gastric ulcer: surgery
Treatment of perforated gastric ulcer is only surgical, and the operation must be carried out as early as possible, because in the third period of the disease it may already be meaningless.
The overall choice of operational benefit depends on:
- The time elapsed from the onset of the disease.
- Properties of the ulcer (origin, localization).
- The severity of the phenomena of peritonitis and its prevalence.
- The age of the patient and the presence of severe comorbidities.
- The technical capabilities of the hospital and the skills of the medical team.
The operation for perforated gastric ulcer in most cases is carried out by means of a classical laparotomy (dissection of the anterior abdominal wall). This is determined by the need for a thorough revision of the abdominal organs. Sometimes it is possible to perform suturing of small perforations, using the method of laparoscopy (through a puncture of the abdominal wall).
After the operation for perforated ulcer, the diet is based on a limited intake of salt, fluid, and simple carbohydrates (sugar, chocolate, pastries, etc.). On the second day after surgery, they give mineral water, weak tea and fruit jelly with a small amount of sugar.
10 days after the operation, potatoes are started to be given to the patient in the form of mashed potatoes, as well as boiled pumpkin and carrots. All food should be soft, not spicy, not salty, not greasy. Bread is allowed to add to the menu only after a month.
The basic principles of diet:
- The daily number of meals up to 6 times in small portions.
- All accepted products must be pure or semi-liquid.
- Cooking should be steamed or boiled.
- Salt should be taken in limited quantities.
- You should also limit the intake of simple carbohydrates (sugar, chocolate, pastries) and liquids.
In general, after surgery for a perforated ulcer, you must follow a special diet for 3 to 6 months.
The absence of surgical treatment leads to death in the coming week after perforation, in almost all cases. During surgical treatment, the average postoperative mortality is 5-8% of the various complications associated with the general severity of the condition, age and comorbidities of the patient.
According to statistics, the earlier the operation was performed, the lower the risk of death. For example, when conducting an operation in the first 6 hours, the risk is up to 4%, after 12 hours - 20%, after 24 hours - 40% and higher.