Among the complications peptic ulcer Perforated ulcers of the stomach and duodenum are quite common. When the stomach and duodenum are perforated, the ulcer breaks through and gastrointestinal contents leak into the free abdominal cavity (perforation).

Perforated ulcers of the stomach and duodenum may be covered. The resulting hole in the wall of the stomach and intestines in these cases is temporarily closed with pieces of food or surrounding organs (omentum, liver, gallbladder). In such cases, the flow of contents into the abdominal cavity temporarily stops (covered perforation).

Most often, perforated ulcers occur in men aged 30 to 55 years. More often they occur during exacerbation of peptic ulcer disease, especially in the spring. Errors in diet and alcohol consumption also play a role in perforation.

During perforated gastroduodenal ulcers, three periods are distinguished: 1) period of shock; 2) a period of imaginary prosperity; 3) period of peritonitis.

The nature and severity of clinical manifestations and changes in abdominal cavity depend on the amount of gastrointestinal contents spilled into the abdominal cavity and the time since the perforation. It has been established that the more gastrointestinal contents enter the abdominal cavity and the faster it spreads in the abdominal cavity, the brighter the clinical manifestations of the disease and the more severe the patient’s condition.

Clinical picture. Perforated ulcer characterized sudden appearance sharp dagger pains, which are initially expressed in upper section abdomen, and then become widespread. The pain radiates to the supraclavicular region and intensifies with changes in body position, and nausea appears. There is usually no vomiting. Sharp pain is accompanied by pale skin and cold sweat. The patient's position is forced. The abdomen is retracted and tense, sharply painful on palpation and percussion. Liver dullness disappears. In the first hour from the onset of the disease, a rare pulse is observed and a decrease in blood pressure is possible. The tongue quickly becomes dry and coated.

With development purulent peritonitis within more than 12 hours after perforation of the ulcer, the patient’s condition worsens: vomiting, bluish coloration of the mucous membranes appears, body temperature decreases, and facial features become sharper. The abdomen becomes swollen, tense, less painful, the pulse is frequent, poor filling, and arterial pressure decreases.

Great difficulties on prehospital stage represents the diagnosis of a covered perforated ulcer. In these cases, it is necessary to take into account the ulcer history, characteristic Clinical signs perforated ulcer and subsequent improvement of the condition with subsidence of pain. Despite this, patients continue to have tachycardia, and palpation of the abdomen reveals tension abdominal wall and symptoms of peritoneal irritation, which are usually localized in the right hypochondrium and right iliac region.

Urgent Care. All patients with suspected perforated gastric ulcer and duodenum are subject to urgent hospitalization in a surgical hospital. Transportation is carried out on a stretcher with the patient lying down. It is strictly forbidden to enter narcotic drugs and give the sick something to drink. In severe cases, cardiovascular drugs (cordiamine, caffeine) should be administered subcutaneously and oxygen inhaled.

During long-term transportation, it is necessary to insert a probe into the stomach, pump out the contents and leave the probe for subsequent aspiration of the contents. An ice pack is placed on the abdominal area. Transfusion therapy is carried out using hemodez, rheopolyglucin and 5-10% glucose solution with a total volume of up to 1000-1500 ml; penicillin is administered intramuscularly (1,000,000-2,000,000 units).

Ambulance health care, ed. B. D. Komarova, 1985

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Perforation of the wall of the stomach and duodenum

Perforation (perforation) - the formation of a hole in the wall of the stomach or duodenum in the projection of a pre-existing ulcerative defect and the entry of gastrointestinal contents into the abdominal cavity. It is a complication of gastric and duodenal ulcers in 80% of cases. It occurs more often when the ulcer is localized on the anterior wall of the pylorus or duodenum. In 25% of patients there may be a clinical debut of peptic ulcer disease. Perforation is often preceded by increased pain and mild tension in the muscles of the abdominal wall.

Factors risk:age 20-40 years, male gender (10 times more often).

Factors provoking perforation: drinking alcohol; binge eating; psycho-emotional, mental and physical stress, cranial or burn injury, drug intoxication, acute respiratory infections, exacerbation of chronic diseases.

There are perforations

· into the abdominal cavity;

· covered perforation (penetration) - penetration of the ulcer up to serous membrane and beyond it into organs adjacent to the stomach or duodenum (liver, pancreas, intestines, gastrohepatic ligament). Penetration is characterized by a long history, constant pain radiating to the back and hypochondrium; ineffectiveness of treatment. Penetrating ulcers often bleed.

During the course of the disease they secrete

· initial period (6-7 hours from the onset of the disease);

· period of imaginary well-being (8-12 hours from the onset of the disease);

· peritonitis (13-16 hours from the moment of perforation).

Initial clinic: suddenly intense “dagger” pain appears in the abdomen. With perforation of the stomach wall, pain is localized in the epigastrium and umbilical region. With perforation of the wall of the duodenum, pain is observed in the right hypochondrium, and then descends to the right iliac region. The pain radiates to right shoulder blade, right shoulder, right collarboneand can spread throughout the abdomen. Vomiting, fever, and slow pulse are observed.

A phrenicus symptom may be detected - pain when pressing between the legs of the sternocleidomastoid muscle.

Patients take a forced position: on their back or side, their knees are bent, pulled up to their stomach, and remain motionless, as movements increase the pain.

Second period clinic: health and condition improve, pain decreases

Peritonitis clinic: pained facial expression; skin covered in cold sweat; hypotension, abdomen tense, board-shaped; absence of hepatic dullness; positive symptoms peritoneal irritation.With percussionAbdominal pain increases even with a weak blow. Atauscultationabdomen, bowel sounds are weakened or absent.

Sometimes an atypical (painless) course of perforation is observed.

Complications: 1. shock, collapse, 2. with a covered perforation - abdominal abscess.

In blood test the number of leukocytes is increased.

Differential diagnosis Pis born with myocardial infarction, lower lobe right-sided pneumonia, and other diseases of the abdominal cavity, which are designated by the term “acute abdomen.”

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Notes.

NSAIDs and drugs do not reduce pain in peritonitis (with the exception of tramadol and xefocam). Antiacid agents and myotropic antispasmodics (no-spa, drotaverine, duspatalin) are not effective.

Hemodynamics, respiratory rate and temperature are monitored at the prehospital stage every 15-30 minutes.

Hospitalization V surgical hospital on a stretcher (gurney) in order to ensure maximum rest, somewhat reducing the intensity of abdominal pain.

Gastric ulcer occurs when destructive changes occur in the mucous membrane of the organ, when its protective function decreases. This leads to an increase in the pathological focus and, without treatment, completely destroys the gastric wall. When, under the influence of a physical, bacterial or chemical irritant, a lumen appears in the wall of the stomach, a perforated ulcer develops, which can be fatal.

Causes of perforated ulcers and risk factors

Perforation of a stomach or duodenal ulcer is a chronic disease that occurs as a result of complications chronic disease these organs. The following points may be a provoking factor:

1. Filling the stomach with an increased volume of food.
2. Exacerbation of a chronic ulcer.
3. Drinking alcohol, fatty or spicy foods.
4. Increased stomach acidity.

All these causes of perforated gastric ulcer are valid in the presence of peptic ulcer, the causative agent of which is the bacterium Helicobacter pylori. Although 50% of the world's population is infected with this microorganism, not everyone gets sick. Any disorder activates the pathogenic influence of bacteria protective functions our body. Risk factors for peptic ulcer disease include:

• sleep quality disturbance;
• long-term stress;
• decreased immunity;
• uncontrolled use of NSAIDs;
• smoking;
• alcohol consumption;
• violation of nutritional quality;
• the presence of gastritis or other gastrointestinal pathologies;
• heredity.

Symptoms and signs of the disease

Treatment of perforated gastric ulcer (IBC code 10) depends on the stage inflammatory process. The disease is provoked by the entry of stomach contents into the abdominal region. Then the first period of development of a perforated ulcer begins - chemical peritonitis. It lasts from 3 to 6 hours, accompanied by acute pain in the right hypochondrium or periumbilical segment, later covering the entire abdominal area. The patient's sweating increases, the skin turns pale, blood pressure decreases, breathing becomes rapid, sometimes vomiting and gastrointestinal bleeding occur.

If untreated, it appears after 6 hours bacterial peritonitis when the sharp pain disappears. During this phase, the temperature rises, the pulse quickens, and the body becomes more intoxicated. The patient begins to experience relief and becomes uncritical of his condition. If no assistance is provided during this period, the patient moves on to the most severe stage of a perforated ulcer.

Period acute intoxication begins after 12 hours from the onset of the disease and is characterized by constant vomiting, which quickly leads the body to dehydration. Characteristic symptoms perforated ulcer stage 3: the skin becomes dry, elevated temperature the body drops to 36 degrees, blood pressure drops below normal, the process of urination stops, and the patient’s reaction to external stimuli slows down. It is no longer possible to save the life of a patient who has reached this phase.

Classification of perforated ulcers

Perforated ulcer of the duodenum and stomach is classified according to the clinical course of the disease, according to the localization of the focus (stomach or 12 duodenum) and according to pathological and anatomical characteristics. The disease occurs in two forms: typical, when the contents of the stomach enter the abdominal region and atypical, when the contents enter the omental bursa or flow into the retroperitoneal tissue.

Diagnosis begins with a thorough survey of the patient’s complaints, studying the medical history, physical and laboratory research, the use of X-ray and endoscopic method. A perforated (perforated) ulcer is characterized by a painful attack, so the first thing the doctor resorts to is an examination using palpation on the left side and an x-ray. Using the main X-ray method The presence of a through defect, air in the abdominal cavity under the diaphragm and airiness of the intestine, characteristic of a perforated ulcer, are determined.

Additional research methods to clarify the diagnosis:

1. Endoscopy. It is carried out if there is a suspicion of a perforated ulcer, and X-ray examination gave a negative result.
2. Electrocardiogram. It is done to assess cardiac activity, the presence of scars on the heart, and determine rhythm disturbances. Using an ECG, myocardial infarction is excluded.
3. Ultrasound. The presence of gases in the intestines is confirmed, the source of damage to the walls of the stomach and the size of the circumference of the perforated hole are identified.
4. Blood test (general). Shows availability high content leukocytes.
5. Laparoscopy. Helps quantify and qualitative analysis accumulation of effusion in the abdominal cavity.

Treatment of perforated gastric and duodenal ulcers

Perforated ulcers are treated only by surgical intervention. Preoperative preparation for gastric resection consists of restoring blood pressure and removal of gastric contents. Specialists take into account the onset of the attack in time, the size and location of the ulcer, the patient’s age, the presence of other pathologies, and then determine the surgical technique.

Surgical intervention for a perforated ulcer is of two types: suturing, in which the organ is preserved during the operation, and resection - radical excision of the ulcer, which leads to the loss of a large part of the stomach, and after that the patient receives disability. Suturing is indicated for widespread peritonitis, and the technique consists of excision of the edge of the ulcer and subsequent suturing of part of the stomach. Resection is done in the presence of large chronic ulcers, suspected cancer, or purulent peritonitis.

Emergency care for sudden acute pain

If there is any suspicion of an attack of a perforated ulcer, the patient should be provided with first aid, which consists of urgently transporting him to the hospital. Only a qualified doctor can make an accurate history of the disease, and the sooner this happens, the better. Do not think that emergency care for a perforated gastric ulcer is a narcotic analgesics, since these drugs will only alleviate the symptoms, which will disorient the doctor and interfere with proper organization nursing process.

Diet after surgery for perforated ulcer

Nutrition during the recovery period after excision of a perforated ulcer plays a very important role. important role. The diet is aimed at restoring peristaltic and secretory functions, so the diet should be complete and balanced. It should consist of daily carbohydrates (420 g), fats (100 g), proteins (100 g). You can eat no more than 12 g of salt per day, and drink at least 1.5 liters of water per day. The calorie content of the daily menu should not exceed 3000 kcal.

Meals after surgery should be divided into 5-6 times a day and in small portions. The break between meals should not be longer than 4 hours. As for prohibited foods, you should not include baked goods, coarse bread and any freshly baked products in your diet. We'll have to give up mushrooms and meat broths, fatty meat, fried foods, smoked meats, canned food and fermented milk products.

Prohibited foods after surgery for perforated ulcers: hard-boiled eggs, corn, beans, millet, pearl barley, cabbage, radishes, spinach, cucumbers, mushrooms, seasonings, spicy snacks, kvass, coffee, carbonated water, alcohol.

What you can eat: sample menu for the day

Despite numerous prohibitions, the menu after removal of a perforated ulcer can be very diverse. Right after surgical intervention for 1-2 days they give only water and weak tea. Gradually add pureed soups, cereals, and vegetable purees.

If on the 10th day after surgery there is no nausea, no pain, belching and other unpleasant signs, then it is allowed to use unprocessed food. Approximate menu one day after rehabilitation:

• Breakfast - soft-boiled egg, low-sour cottage cheese, sandwich with butter, cocoa.
• Lunch - pumpkin baked with honey.
• Snack - crackers, yogurt.
• Lunch - vegetable soup, chicken fillet steamed.
• Afternoon snack - boiled rice, steam cutlet, milk and berry jelly.
• Dinner - baked fish, carrot puree.

Possible complications of the disease and prognosis

The most important consequence of a perforated ulcer is peritonitis. The stomach contents that have leaked out accumulate in the abdominal cavity, causing the formation of pus. If the operation is not performed on time, the person will live for 2-3 days. Absence surgical treatment perforated ulcer – 100% death in all cases. Postoperative mortality is 5-8% depending on the occurrence of complications, age and the presence of concomitant pathologies of the patient.

A huge number of people suffer from various kinds violations in activities digestive tract. And quite often doctors have to deal with advanced diseases stomach and intestines, which the patient ignored year after year and tried to drown out the unpleasant symptoms with self-medication. However, we must remember that many of these ailments can cause complications that pose a serious threat to life. One of the classic examples of such complications is perforation of a stomach ulcer, the symptoms of which we will now consider, and we will also talk about what emergency care the patient needs during its development, and also answer the question of how this disease is treated.

Symptoms of perforation of a stomach ulcer

Ulcer perforation occurs in three periods: sharp pains, imaginary well-being, and then diffuse peritonitis. The first stage lasts from three to six hours. In this case, the patient at the time of perforation of the ulcer feels extremely strong sharp pain, which is often described as dagger-like. This symptom can lead to the development of shock.

Initially, the pain is localized in the upper abdomen or right hypochondrium, over time it spreads to right area abdomen, and even later - covers the entire abdomen.

The pain may shift to the area of ​​the right or left shoulder blade, which usually indicates irritation of the endings of the phrenic nerve. Before the ulcer perforates, the patient may experience vomiting.

In the first hours of the development of the disease, patients look characteristic: their face becomes pale, they look frightened and are covered in cold sweat. Victims may be forced to lie on their back or right side, pressing their hips against a sharply tense abdomen. Every movement leads to increased pain. In this case, the body temperature remains normal or decreases.

At the second stage of development of the disease, the patient’s condition noticeably improves, and the symptoms begin to decline. However, do not rejoice; analysis of clinical data shows the active development of peritonitis. The patient experiences an increased heart rate, his body temperature rises, intestinal paresis occurs, and the number of leukocytes also increases.

After about twelve hours, a period of peritonitis develops. In this case, the patient experiences moderate abdominal pain and is also bothered by repeated vomiting. Body temperature decreases or increases to 38-40C. Dehydration and intoxication lead to sharpening of facial features, eyes look dull, skin becomes dry, and the mucous membranes of the mouth become very dry.

Perforation of a stomach ulcer - emergency care

At the slightest suspicion of the development of perforation of a gastric ulcer, the patient should be immediately taken to the hospital for urgent surgical intervention. In this case, under no circumstances should the patient be administered analgesics, including narcotics, as they can significantly complicate diagnosis. Oral intake of liquids, medications, etc. is also prohibited.

Before transporting to the hospital, doctors usually insert a tube into the patient, with which the entire contents of the stomach are sucked out. Next, the patient is placed on a board and stretcher so that his head is slightly elevated and his limbs are moderately bent. This allows you to slightly relax the muscles of the anterior abdominal wall and slightly reduce the intensity. painful sensations.

To correct symptoms toxic shock usually administered cardiac or respiratory analeptics, for example, strophanthin or cordiamine. Drip infusion is also practiced saline solutions in a volume of four hundred to eight hundred milliliters.

How is perforation of a stomach ulcer corrected, what treatment will help?

The only one possible method treatment of perforation of a gastric ulcer is immediate surgical intervention. The method of operation is selected depending on the patient’s condition, the stage of peritonitis, the duration of the peptic ulcer, and also based on the availability of conditions for the operation. Surgeons can perform suturing of the ulcer, excision of the ulcer with pyloroplasty in combination with vagotomy, and gastrectomy can also be performed.

Most often, the ulcer is sutured, but it is worth considering that such treatment does not help cure the disease. In most cases, the disease recurs.

Excision ulcerative lesion with vagotomy and pyloroplasty - this is a much more complex surgical intervention that can only be performed with a highly qualified surgeon. This therapy helps to achieve a permanent cure in approximately 90% of cases.

Economical gastrectomy can be carried out if perforation of a chronic ulcer does not cause the development of peritonitis and operational risks.

After surgery, doctors carry out particularly thorough sanitation, and in some cases, drainage of the abdominal cavity. In this case, several probes can be installed - one is inserted into jejunum and provides nutrition, and the second is placed in the stomach for decompression.

At the postoperative stage, surgeons most often advise active management of patients. In other words, the patient needs to start moving as early as possible, perform breathing, and also therapeutic exercises, and a little later - eat well. This approach helps prevent the development of complications and significantly accelerates regenerative processes.

If you suspect the development of perforation of a gastric ulcer, you should immediately call ambulance or transport the patient to a medical facility on your own.

Ekaterina, www.site

P.S. The text uses some forms characteristic of oral speech.

Intestinal perforation (perforation) - this is the formation of a through hole in its wall with the release of contents into the abdominal cavity. The pathology develops against the background of intestinal disease or as a result of abdominal trauma. Intestinal perforation causes and without surgical intervention leads to the death of the patient.

Intestinal perforation - acute condition, the patient usually calls exact time onset of symptoms. The clinical picture of the disease includes two successive stages: primary shock (the first 6 hours after perforation) and peritonitis.

Primary stage shock

Changes in the body according to the mechanism of development resemble shock. Intestinal contents spill into the abdominal cavity, irritating and damaging the peritoneum.

Stage of peritonitis

The sensitivity of the nerve endings of the peritoneum is impaired, the bacterial flora of the intestinal contents leads to purulent inflammation in the abdominal cavity.

The clinic depends on the location and size of the defect. The higher and larger it is, the more pronounced the symptoms. Perforation of the duodenum is the most acute and severe.

It happens that a small hole in the intestinal wall is covered by a lobe of the liver or a strand of omentum. The contents of the intestines stop flowing into the abdominal cavity, and pathological process limited. The patient's well-being improves. Subsequently, an abscess forms at this site.

Causes

Diagnostics

Patients with suspected intestinal perforation should be immediately taken to a surgical hospital.

History taking and examination

The doctor makes a diagnosis based on the following clinical data:

Laboratory methods

• General blood analysis – with peritonitis, the number of neutrophilic leukocytes and ESR increases.
• General urine analysis – high relative density, traces of acetone.
• Blood biochemistry – electrolyte disturbances, increase in acute phase parameters.

Instrumental methods

Treatment

In case of intestinal perforation with peritonitis, it is indicated emergency surgery, the only contraindication to it is the patient’s state of agony. The earlier surgery is performed, the better results treatment and prognosis.

With limited perforation, satisfactory condition A patient with a formed infiltrate up to 4 cm in size is treated conservatively.

Surgery

The operation is performed under general anesthesia. At the preparation stage, the stomach is emptied using a tube. After a laparotomy (an incision in the abdomen), an opening in the intestine is found. The scope of intervention depends on the location of the lesion, the time from the onset of the disease, the patient’s condition, and the doctor’s qualifications.

Operation methods

Important stage surgical treatment for perforation - washing the abdominal cavity from intestinal contents. Drains are placed to drain exudate from the peritoneal cavity.

Recovery period

IN postoperative period control diuresis and drainage discharge. If the patient’s condition is satisfactory, early activation is recommended to prevent complications. After recovering from anesthesia, patients are advised to freely extend and bend their arms and breathe deeply; a day later - get up and do breathing exercises.

Nutrition and fluid:

• on the second day after surgery, you are allowed to drink (no more than half a glass per day);
• by day 4, increase the volume of liquid to 4-5 glasses per day: jelly, tea, broth, compotes, vegetable decoctions;
• on day 5 add pureed liquid porridge, cottage cheese, slimy soups;
• after a week, pureed rabbit, turkey, and veal are introduced into the diet.

Further diet is prescribed depending on the underlying disease and the extent of the operation performed.

With a smooth flow recovery period The sutures are removed after 8-10 days. Duration inpatient treatment is 14-15 days.

Drug therapy

Drug therapy is carried out with the aim of preoperative preparation, stabilization of the patient’s condition, to prevent complications in the postoperative period.

Complications, possible outcomes

After surgery for intestinal perforation, complications are possible:

• Pneumonia – inflammation of the lungs due to decreased ventilation due to low motor activity patient.
• – purulent complications associated with insufficient sanitation of the abdominal cavity, resistance of the bacterial flora to antibiotics, and decreased immunity.
• Impaired motility of the digestive tract - gastrostasis, intestinal paresis, manifested by vomiting and lack of stool.
• Failure of sutures - associated with infectious process, suppuration.

Treatment results depend on the duration of the disease, the size of the perforation, the patient’s age, the presence concomitant pathology. Postoperative mortality for intestinal perforation ranges from 1.3 to 19.4%, and with the development of purulent peritonitis reaches 30%. Causes of death: postoperative complications and decompensation of chronic diseases.

If you consult a doctor within the first 6 hours after intestinal perforation, the prognosis is favorable. In the future, patients should be monitored by a gastroenterologist.