Perforated gastric and duodenal ulcer is an acute surgical pathological condition. Peptic ulcer and duodenal ulcer occurs chronically and is characterized by spring and autumn exacerbations. The most frequent exacerbations of chronic disease occur in the autumn and spring periods. Untreated duodenal ulcer can perforate, and the contents of the intestine is poured into the abdominal cavity.
Treatment of perforation of duodenal ulcer requires surgical intervention. After surgery, a strict diet and restorative conservative treatment are mandatory.
Causes of pathology
The factors provoking the development of this ailment are so numerous that sometimes, after the perforation began, and it was successfully stopped, it is not possible to find out exactly which prerequisite caused the pathology. Such cases are most often observed in young patients.
The main prerequisite for a perforated duodenal ulcer is the helicobacter bacterium. It is also commonly believed that it can be caused by the following factors:
- Contact with a foreign object on the duodenal or gastric mucosa and causing mechanical damage.
- Disorders in the diet - nutrition in the acute phase of the development of duodenal ulcer and stomach smoked, spicy, fatty or fried foods.
- Development of concomitant pathologies of the gastrointestinal tract, which have an indirect effect on the condition of peptic ulcer.
- Chemical poisoning or burn them to the mucous membrane of the digestive organs.
- Abdominal trauma.
- Infectious infection of the digestive tract.
- Alcohol abuse in the presence of a history of chronic ulcerative pathology.
- Excessive use of certain drugs, usually non-steroidal anti-inflammatory drugs.
- Inadequate treatment or lack thereof in acute or chronic form of peptic ulcer.
- The presence of diseases such as diabetes, cancer, AIDS or autoimmune diseases.
In the rarest cases, physical overstrain of the abdominal cavity can provoke the development of a duodenal ulcer. It usually occurs when lifting excessive weights.
Symptoms of perforated duodenal ulcer in medical practice can be divided into several stages of development. They are distinguished depending on the clinical forms of perforation, the reasons that provoked ulcer perforation and localization. According to the clinical course stand out:
- The flow of intestinal contents into the free abdominal cavity (typical).
- Atypical can perforate in the retroperitoneal tissue, small or large omentum, omental bag or cavity, isolated by adhesions.
- Penetration - a destructive process spreads into the thickness of a neighboring organ (pancreas or liver).
- The leakage of intestinal contents is combined with heavy bleeding into the gastrointestinal tract.
There are 3 clinical phases of the development of pathology. Each has individual, characteristic only for her symptoms:
- The initial stage (the first 6 hours) is characterized by the appearance in the epigastric region of acute, penetrating pain that occurs with each movement. Unrestrained vomiting may occur. The whole body is covered with cold, sticky sweat, and the skin becomes pale. On palpation, the abdominal region is characterized by increased rigidity. The patient's position on the side with the knees led to the stomach is somewhat easier.
- In the second phase, a few hours after the onset of an acute attack, temporary relief occurs. The condition of the person becomes more or less stable, the nature of the pain is dull, the spasm of the muscles of the peritoneum passes. But at the same time, the temperature starts to rise, strong flatulence begins, and the patient is thirsty. The appearance of these signs indicates that the intestine broke, and from it flowed into the abdominal cavity of the mass, triggering the onset of the inflammatory process. On palpation, the highest pain is detected in the right hypochondrium.
- The final stage of the pathology of the duodenum 12 sets in a day. At this time, the human condition is deteriorating. Dehydration begins, the temperature rises significantly, the pressure drops. The patient’s pulse and respiration become speeded up and he is incessant vomiting.
Once these symptoms appear, surgery may be useless and everything will be fatal.
In order to prevent death, it is necessary to know the initial symptoms of the pathology. This will make it possible to promptly prompt and significantly increase the chances of life.
Symptoms that indicate the development of pathology
The signs that may indicate that perforation started in the ulcer are not specific enough. It is rather difficult to identify the beginning of the pathological process without a differential diagnosis, excluding renal colic, heart attack and acute appendicitis. In general, the duodenal ulcer symptoms are so pronounced that they simply can not be overlooked:
- The temperature rises to 40–41 degrees and fever begins.
- Acute pains of the arching or cutting character in the abdomen, often radiating to the lower back or limbs.
- The indomitable vomiting of bloody masses, which absolutely does not give a person relief.
- Diarrhea with blood.
- Hallucinations, loss of consciousness.
- Reflexively caused by a man of forced posture, when he lies on his side with knees pressed to his chest and his hands on them. The face of the patient at this time is distorted by an agonizing grimace.
- Cases of uncontrolled urination are noted.
These symptoms, as already mentioned, may indicate not only the perforation of duodenal ulcers, but also other dangerous pathologies. Only urgent differential diagnosis will be able to determine the disease, therefore, when such symptoms appear, an urgent need to call a doctor.
Differential Pathology Detection
Due to the fact that the perforated ulcer of the intestine in its clinical manifestations is similar to a number of ailments of other organs located in the upper part of the abdominal cavity, first of all, it must be differentiated from them. Of great importance in making a diagnosis is the presence of duodenal ulcer in history and the characteristic symptoms, which include acute cutting pain in the epigastrium, patient-specific posture, tense, hard abdomen.
If possible, an urgent X-ray is done, which shows that there is an accumulation of free gas in the abdominal cavity.
If the case is controversial, the patient is allowed to drink a glass of soda. If a person has an ulcer in the duodenum, air will escape through a hole in the intestine. A repeat radiograph will show this well. Differentiate this pathology with the following diseases:
- Phlegmon of the stomach.
- A rupture of the abdominal aorta in the retroperitoneal region.
- Acute appendicitis.
- Heart attack.
- Disturbance of the mesenteric circulation.
This is only part of the pathologies that have symptoms similar to an ulcer into the abdominal cavity. If the differential diagnosis confirms that the exit of fecal masses from the intestines became the cause of the negative signs, urgent treatment is required.
Basically it is performed surgically, but there are cases when, according to the individual testimony of the patient, surgery is not possible. A conservative method of therapy is used here, but it is used so rarely that it is most likely considered an exception from medical practice.
When diagnosing a breakthrough in the gastroduodenal region of the ulcer, emergency surgery is required. If the patient refuses it, he is doomed to death. It is possible to use the conservative Taylor method, but the survival rate here is very low and there are numerous complications. Such treatment consists in the following:
- A transnasal probe is introduced with the help of which the duodenum is released from the contents and is constantly drained for several days.
- On the stomach of the patient lies an ice pack.
- Massive infusion therapy is performed to detoxify and normalize the acid-base balance.
- Injections are given during the week with strong antibiotics.
If the clinical picture remains the same, before removing the probe, a contrast agent is injected through it and the X-rays are performed again.
Preparatory measures are to remove the contents of the duodenum and normalize blood pressure. Access is via the upper third of the midline of the abdomen. After the preliminary examination has been carried out and the diagnosis has been confirmed, that is, foreign masses have been found in the abdominal cavity, and the pathological fluid has been removed, the surgeon is determined with the site of perforation. The choice of operational activities depends on this. There are 2 types of surgeries for the elimination of an ulcer and its consequences:
- Organ-preserving, which consists in suturing perforation.
- Radical - excision with vagotomy or pyloroplasty of perforated ulcer.
The overall choice of surgery depends on how much time has passed since the beginning of the breakthrough, the location and origin of the defect, the prevalence and severity of peritonitis that the perforated ulcer caused, the physical condition, age and presence of concomitant diseases in the patient, and the technical capabilities of the hospital.
Breakthrough duodenal ulcers, as already mentioned, a very terrible and transient disease. It takes less than a day to go to the stage when even surgery may not help. That is why it is necessary to urgently call a doctor at the very first signs, since the lethal outcome of this pathology is directly related to late appeal for medical help.
What is perforation?
This pathology is a consequence of a complication of a peptic ulcer, which can occur for various reasons, but they can all lead to the formation of a through hole in the hollow organ. It can be either the stomach or any part of the intestine.
As a result of the formation of perforation, the entire contents of the stomach or intestine, along with the contents and enzymes, enter the abdominal cavity and begin to corrode it. Infectious agents do not remain indifferent, and in response to such an event, an inflammatory process develops, which is called peritonitis.
This is a serious situation that requires immediate medical intervention. Most often, this complication occurs in a strong half of humanity, with the peak of occurrence occurring in the spring and autumn period.
Causes of perforation in the stomach
There are several reasons that can lead to a perforated ulcer, among which the main place is occupied:
- Frequent inflammatory processes in the stomach.
- Exercise, which leads to an increase in intra-abdominal pressure.
- Large amounts of food.
- Careless attitude to diet.
- Stressful situations.
- Aspirin use or glucocorticoid therapy.
The presence of inflammation in the mucous membrane can lead to the fact that perforated ulcer, its symptoms can visit the patient. It is imperative to regularly undergo examination and follow the recommendations of the doctor.
Causes of duodenal ulcer
Most often, the causes of ulcers of this organ are rooted in stomach problems. If you do not take any measures to eliminate the inflammatory process in it, then it will necessarily spread to the duodenum.
Causes may also be:
- Gallbladder disease, chronic appendicitis.
- Infection caused by the bacteria Helicobacter pylori.
It must be borne in mind that perforated duodenal ulcer occurs more often than the stomach.
Symptoms of a perforated ulcer
When a patient has a disease that is exacerbated, it is always manifested by pain, vomiting, it all happens most often after eating. At the moment of perforation formation, the perforated ulcer has symptoms in the form of sharp “dagger” pain that cannot be tolerated. The patient tries to pull his legs to his chest to reduce it.
At this point, there is also an increase in signs of intoxication of the body as a result of the ingress of all that is in the stomach, into the abdominal cavity. The skin becomes pale, cold sweat appears, blood pressure decreases and the heart begins to beat more often.
There are several stages in the development of this pathology:
- Shock stage. It is characterized by unbearable sharp pains that can be given to the right side of the back. Because of this, it is difficult to breathe, the muscles become very hard and tense.
- Imaginary improvement. At this time, and this is approximately several hours after the onset of all pain, the condition improves slightly, perforated ulcer reduces its symptoms. Weakness appears, the pressure remains low, the muscles relax a little, and it becomes easier to breathe. Body temperature usually rises during this period, flatulence occurs, patients familiar with this condition should no longer confuse it with poisoning or flu. It is impossible to do without ambulance during this period.
- After 12 hours, the symptoms of peritonitis appear: dryness in the mouth, abdominal pain. It should be noted that the signs of peritonitis are always the same, regardless of the reason that provoked it. It is possible to suspect that this happened against the background of a perforation of a stomach ulcer or intestine only on the basis of the diagnosis.
Peritonitis can be caused by appendicitis, pancreatitis, but in any case, if such a pathology is suspected, urgent hospitalization is necessary. A dangerous situation is when the developing ulcer practically showed no signs. The patient may leave the symptoms of perforation without attention, and just try to relieve the pain with home remedies and painkillers, and this is life threatening.
Gut ulcer symptoms
If perforation of the duodenum is observed, the symptoms may be as follows:
- Acute pain in the left hypochondrium, which can extend to the neck and collarbone.
- Vomiting, most often it happens only once.
- It becomes a "disc-like belly."
- A cold sweat and blue tint of the mucous membranes appears.
Just as with perforation of the stomach, perforated duodenal ulcer, the symptoms of which we are considering, leads to the fact that at the second stage of development, signs of the contents of the intestine in the abdominal cavity immediately begin to appear. Tachycardia, fever, severe pain are prominent witnesses of peritonitis. In this condition, urgent help of surgeons is needed.
Since the perforated ulcer of the stomach and duodenum symptoms are pronounced in the first stage, and patients, as a rule, come to a medical institution for the second, the correct diagnosis is based on the history of the disease. In addition, additional research is required:
- X-ray, which shows the presence of free gas, if there is a perforation.
- Ultrasound detects the onset of inflammation in the abdominal cavity and the presence of fluid.
- FGDs are sometimes used to identify the exact localization of pathology, but there is a risk of gas entering the abdominal cavity, so special care must be taken.
- If the case is severe, and the perforated duodenal ulcer symptoms are blurred, then laparoscopy is done.
- A blood test will also show elevated ESR, high levels of stab leukocytes and a decrease in hemoglobin levels.
Only after confirmation of the assumptions about the presence of perforation will be performed surgical intervention.
First aid for perforated ulcer
The formation of perforations in the stomach or intestines is very dangerous for a person’s life, which is why it is necessary to call an ambulance at the first suspicion of such a condition. In the process of transporting the patient in a serious condition injected drugs to maintain blood pressure, make inhalation with oxygen, give pain medication.
It is inappropriate to use narcotic analgesics during this period, as they disturb the patient’s consciousness and lubricate the clinical manifestations, which makes it difficult to make a correct diagnosis.
Perforated ulcer treatment
The perforated intestinal ulcer has almost the same symptoms as perforation of the stomach, they are also united by the fact that only surgeons can cope with this condition. Surgical intervention is necessary as early as possible, because at a later stage it may be meaningless.
If the situation requires, then all manipulations are carried out in the intensive care unit. Before the operation, a probe and a catheter are inserted into the bladder, and the surgery itself is performed under general anesthesia.
The surgeon makes an incision and examines the cavity of the stomach or intestine, detects perforation, and then decides how to eliminate it. There are several options for this:
- You can take a hole.
- In some cases, part of the stomach is removed along with perforation.
- Excision of the ulcer and vagotomy.
Most of the time, surgeons know from their experience that suturing is not a 100% guarantee of complete recovery, often relapses occur. Therefore, this method of dealing with perforation is resorted to in situations with severe peritonitis or in the presence of pathology in young people who have stress caused this condition.
In most other cases, it is more effective to exclude an ulcer or resection of the stomach.
Both before excision or suturing, and after the operation, a complete reorganization of the cavity is carried out and several drains are installed.
We reviewed the topic: "Perforated ulcer symptoms and treatment." First aid in this situation is very important, but most often its meaning lies in the speedy hospitalization of the patient.
Complications after surgery and future prognosis
Among all the complications of the postoperative process are the following:
- Development of an abscess in the abdominal cavity.
- If the stitches are made poorly, it is fraught with repeated perforation and the formation of peritonitis and sepsis.
- It is very rarely possible violation of the promotion of food through the esophagus into the stomach due to a narrowing of the input sphincter.
If a perforated ulcer is detected in time, the symptoms are eliminated and all necessary measures are taken to eliminate the pathology, then the prognosis is often favorable. If you follow all the recommendations of the doctor and diet, you can lead a normal life.
Folk treatment of ulcers
If the disease has gone too far, and perforation has formed, then therapy with folk methods will not have any effect. But after the surgery, along with the standard course of treatment, it is possible to apply the recommendations of traditional healers.
Here are some recipes that will help reduce the acidity of gastric juice to prevent the development of relapse:
- Mix the juice of two lemons with 0.5 liters of honey and the same volume of olive oil. Finished medicine to use 1 tbsp. l before meals 3 times a day for a month.
- Grind 250 grams of aloe leaves in a meat grinder, add 250 grams of honey and heat the mixture to 50 degrees, then add half a liter of red wine. All this insist in a dark place for 7 days, and then you can take a tablespoon 3 times a day for an hour before meals. The duration of this treatment is 3 weeks.
It must be remembered that traditional medicine can be effective in the initial stages of the development of an ulcer, and when perforation occurs, there is no longer any sense in it.
How to prevent recurrence of perforation
In order to prevent the recurrence of perforated ulcers, it is necessary to regularly conduct anti-relapse therapy, which includes:
- Compliance with the diet. As a preventive measure, patients are encouraged to follow diet No. 1, especially during periods of possible exacerbation of the disease.
- Reception of necessary medicines. Your doctor will definitely give advice on this.
- Physiotherapy. They give excellent results in combination with proper nutrition and medication.
- Periodic spa treatment.
Diseases of the gastrointestinal tract can bring a lot of trouble to its owner. If you do not adhere to strict restrictions in eating, abuse bad habits, and are exposed to frequent stresses, then you may not be surprised that the ulcer again declares itself with its unpleasant symptoms. Take care of yourself and your health, it can not be bought for any money.
Types and signs of perforation
Perforation of duodenal ulcer can occur in several ways.:
- Perforation is typical. In this case, a hole is formed in the abdominal cavity. In people with this form of development of the pathological process, a painful shock is observed, after which imaginary relief occurs and peritonitis develops.
- Perforation in the lower part of the duodenum (behind). After the wound has formed, the contents of the organ begin to penetrate into the retroperitoneal space. It is possible to identify this type of perforation by the following signs: a sharp pain syndrome, which is located in the spoon (can radiate to the back area). The acute purulent process develops in the fiber of the peritoneum (retroperitoneal). A person has chills, fever develops. Painful swelling in the region of 10-12 vertebra (breast) can be detected. When listening, a specialist can reveal a crepitus (a special crunch). Gas formation increases.
- Covered perforation. During perforation, the contents of the organ (duodenal) is thrown into the peritoneum. The process takes place as follows: a through wound is formed, which is accompanied by a sharp pain syndrome, the site of localization of which is the epigastric zone or the upper abdomen. There comes a period of temporary relief, after which complications begin: a purulent inflammatory process develops in the tissues of the peritoneum, peritonitis (diffuse). This type of perforation is rather slow, so people have all the chances to get timely surgical or medical assistance.
If people have noticed signs of perforation of duodenal ulcer, they need to urgently contact the medical institution for adequate help. Experts at the reception carefully examine patients, conduct a survey, collect anamnesis, palpate the abdominal cavity.
After that, they prescribe a complex of laboratory and hardware studies, the results of which will help confirm or refute the primary diagnosis.:
- Blood test, feces, urine.
- Radiography (using a contrast agent) peritoneum.
- Ultrasound of the digestive tract.
How is the perforation
Perforated duodenal ulcer occurs as a result of ineffective conservative therapy or with unsuccessful formation of scar healing. As a result, instead of healing, a through hole is formed in the duodenum.
Most often, young men under the age of 40 years are prone to perforation of the duodenum, the duration of peptic ulcer disease is more than 3 years.
The contents of the duodenum penetrate through the perforated opening into the abdominal cavity, causing inflammation of the peritoneum. The perforated hole is surrounded by fibrinous deposits. In some cases, perforation is accompanied by bleeding from a duodenal ulcer.
The most frequent localization is the area of the duodenal bulb.
In 10% of cases, perforation in the retroperitoneal region or subhepatic space occurs. Such atypical perforation is called covered. Later on, a hepatic or retroperitoneal abscess is formed in this place.
Acute perforated duodenal ulcer is characterized by the appearance of acute pain. Patients usually describe sensations as excruciating cutting pains.
- The clinical picture of the first stage is accompanied by the development of shock: the patient's skin turns sharply pale, it is covered with cold sweat, blood pressure decreases.
- On palpation, a sharp tension of the muscles of the abdominal wall is detected.
- The patient complains of pain, difficulty breathing.
Peritonitis during the perforation of duodenal ulcers develops slower compared with perforation of gastric ulcers. Vomiting is not characteristic of this period, however, sometimes the condition may manifest itself before pain.
Characterized by the forced position of the patient - lying on the right side with legs pressed to the stomach. Less often, the patient lies on his back.
For the second stage of perforation, some subjective relief is characteristic.
- The intensity of the pain decreases, it becomes much easier for the patient to breathe.
- The complexion becomes normal.
- Muscular defans of the anterior wall of the abdominal cavity are reduced.
In the described period of the disease, patients feel relief and believe that they will soon recover. For this reason, patients often refuse surgical treatment.
The duration of the period reaches 6 hours. There is a distribution of the contents of the duodenum in the abdominal cavity and the development of the inflammatory process.
Before the onset of the third stage, 12 hours pass, the patient’s condition again deteriorates significantly. Repeated vomiting appears. The skin becomes dry and gets a grayish tint. Body temperature rises sharply. Gradually increasing intoxication. The patient's breathing becomes frequent and shallow, the heart rate increases.
Palpation is determined by the pain of the abdominal wall in all areas. The tongue dries out, covered with a whitish bloom. A clinical picture of diffuse peritonitis develops with characteristic signs of peritoneal irritation, allowing to verify the diagnosis.
About 5% of cases of duodenal ulcer perforation occur according to an atypical scenario. This is due to the unusual localization of the ulcer - on the back wall of the duodenum.
Clinical manifestations are also atypical. The pain is moderate, localization is difficult to determine. A localized abscess forms, and a perforated hole is found at the opening.
Covered perforation is such a perforation of a duodenal ulcer, when, after a short-term expiration of the intestinal contents, the hole is covered with an omentum or wall of the adjacent organ. This may be the intestines, liver.
Covered ulcer is found in 15% of all cases of perforation. For the formation of this form of perforation, you must have the following conditions:
- The perforated opening in the duodenum must be small.
- During perforation, the gastrointestinal tract should be a little full.
- The perforation hole should be localized close to the intestinal loops, omentum or liver.
In the clinic covered perforation there are three stages.
The first phase of ulcer perforation begins rapidly, accompanied by a sharp pain that resembles a dagger strike, the development of a sharp collapse is possible. Localized muscular defamation develops along with perforation. The pain spreads to the upper part of the epigastric region.
Relapse of clinical symptoms
The perforation hole in the duodenum is covered, acute clinical phenomena gradually decrease, the tension of the muscles of the anterior abdominal wall also decreases. Free gas in the abdominal cavity is not marked. Pain in the abdominal cavity remains, the intensity becomes much less.
Phase of complications
In the last stage, perforated duodenal ulcer is complicated by purulent processes. Localized abscesses are most often found. The picture of diffuse peritonitis is extremely rare.
Often the pattern of covered perforation resembles the usual exacerbation of a peptic ulcer, which is the cause of diagnostic errors.
Principles of treatment
With such an acute disease as perforated gastric ulcer, treatment should be operational. Conservative treatment is used exclusively in extreme cases.
At the prehospital stage, in case of suspected perforation of duodenal ulcer, the primary task is to hospitalize the patient in a surgical hospital.
If the patient is in an extremely serious condition, infusion therapy is urgently prescribed, oxygen inhalations are given. Analgesics, especially narcotic, should not be given to the patient - they can smear the picture of the disease and disorient the doctors.
For the treatment of perforation of duodenal ulcer is carried out laparotomy. The operation is performed under general anesthesia. A longitudinal section of the muscles of the abdominal wall. When dissecting the sheets of peritoneum, a small amount of air can escape from the cavity with a characteristic sound. In the abdominal cavity is found a certain amount of greenish turbid fluid. The exudate is removed from the cavity using an electric suction.
On the wall of the duodenum can be detected infiltrated white area with a diameter of 3 centimeters. In the center of the infiltrate can be found small, with a diameter of up to 0.5 cm, a rounded hole with smooth edges. If the adhesive process is expressed in the abdominal cavity, the search for the place of perforation is greatly complicated. If it is not possible to conduct a visual assessment of the operative field, the surgeon will perform a digital evaluation of the duodenum and detect the location of the perforation.
The method of surgical intervention is chosen by the surgeon, depending on the location and size of the perforation, the age and general condition of the patient. The presence and severity of peritonitis, the presence of associated diseases are taken into account. In most cases we are talking about the removal of perforated ulcers.
Indications for suturing perforated ulcers are diffuse peritonitis, a greater degree of risk during the operation, the presence of a stressful ulcer in a young man without a long ulcer history.
In young people, closure of the ulcer and postoperative treatment lead to the fact that the ulcer heals well and no longer recurs. The prognosis is favorable, the frequency of relapses is minimal. In elderly patients, ulcers are often prone to malignancy, it is desirable to have a resection of the stomach.
The duodenal ulcer is sutured with a single stitch in the transverse direction, without capturing the mucous membrane.This method of suturing will prevent intestinal stenosis. If the duodenal tissue is friable and erupts when suturing, adjacent epiploons or ligaments are used.
In the postoperative period, the patient is individually selected a special gentle nutrition. Diet after surgery for duodenal ulcer should be strict and gentle.
Power should be fractional. In order to avoid excessive load it is necessary to take food every 3 hours in small portions. The diet after a duodenal ulcer includes boiled or baked dishes.
Each diet product must be crushed with a blender. Salt in food should be the minimum amount. Diet after perforated duodenal ulcer should contain such products that will not irritate the stomach and intestines.
Too hot or cold foods, alcohol, carbonated drinks, rich broths, coarse vegetable fiber are contraindicated.
- pains - sharp, sudden, intense, sharp, excruciating,
- state of shock - pallor of the skin, cold sweat, a sharp decrease in pressure,
- muscle tension of the abdomen,
- pain breathing.
The development of the clinical picture in the perforation of the duodenal ulcer rapidly, develops in 3 hours. Vomiting is possible before acute pain. It becomes easier for the patient on the right side in the prone position with his knees tucked.
- a sharp deterioration in well-being,
- severe vomiting
- dry skin
- fever, fever,
- aggravation of intoxication,
- shallow breathing
- heart palpitations
- soreness of the entire abdomen,
- dry tongue, tight bloom.
The condition characterizes the development of diffuse peritonitis.
Ulcer perforation occurs when treatment failure. For example, due to the formation of an insolvent scar, the ulcer does not heal, but is gradually perforated with the formation of a through wound. Through the holes formed, the contents of the duodenum 12 enter the peritoneum. In response, the cavity sheets begin to inflame, protecting themselves from the infection and the extrudate. Around the wound on the intestine is formed fibrin.
10% of all through ulcerative wounds bleed. It occurs more frequently on the anterior onion wall of the intestine.
Less often, hidden perforation occurs. There is a breakthrough of an ulcer in a limited space, for example, in the ligaments, organs, subhepatic space, the fossa of the peritoneum on the right. An abscess subsequently develops.
The wound opens into the freed abdominal cavity. Along with the standard manifestations characteristic of the three stages of inflammation (pain shock, imaginary lull, peritonitis), this type of perforation can be identified in other ways. Symptoms:
- Strong tension of the abdominal wall, which is pronounced. Due to muscle spasm, the abdomen does not take part in the respiratory process.
- Shchetkin-Blumberg syndrome. Palpation with pressing on the anterior part of the abdominal wall and abrupt retraction of the arm after 5 seconds, sharp pain increases.
- Severe abdominal distention over the hepatic region.
- Soreness between the legs of the sternocleidomastoid muscle in the supraclavicular region.
- Soils of the skin, cold limbs.
- Rare pulse, intermittent breathing.
With a false well-being, the pain decreases, euphoria appears with preservation of peritoneal discomfort. Paralytic intestinal obstruction develops, accompanied by flatulence and decreased peristalsis. Dry lips and tongue. The duration of the period is 12 hours.
Severe thirst is one of the signs of inflammation in the abdominal cavity.
The third stage of inflammation of the peritoneum is particularly difficult. Manifest themselves:
- strong thirst
- loss of consciousness,
- moisture, stickiness, earthy shade of the skin,
- sharpening facial features, sunken eyes,
- decrease in the volume of urine, up to the cessation of urination,
Perforation of the intestine from the bottom, behind
Duodenal contents infect retroperitoneal tissue. The main symptom is unexpected, sharp pains under the spoon, with recoil in the back. Over time, the pain subsides. An acute inflammatory purulent process develops in the retroperitoneal fiber of the abdominal tissue. The period is characterized by the development of fever with chills. A 10–12th thoracic vertebra results in a swelling that hurts when it is palpated. When listening to her area you can hear the characteristic crunch - crepe. X-ray shows increased gas formation in this place.
Symptoms of the disease
If the duodenum is covered with ulcers with pronounced perforation, the following symptoms may be observed:
- painful sensations of a sharp character in the left hypochondrium region,
- vomiting, which most often has a single character,
- excessive sweating (cold sweat),
- there is a cyanotic shade of the skin and mucous membranes.
As with the perforation of ulcers in the stomach, such a pathology in the duodenum 12 provokes the appearance of signs indicating the penetration of the intestinal contents into the abdominal cavity. These symptoms are:
- increased body temperature
- strong pain in the abdomen.
Any of these symptoms may be a sign of peritonitis. This phenomenon in most cases leads to death. Therefore, with such symptoms, the patient needs urgent help from specialists.
Most often, exacerbation of duodenal ulcers (symptoms become more pronounced, the patient's condition worsens) occurs after eating. If the intestine is covered with perforated ulcers, the main symptom is severe cutting pain that cannot be tolerated. In this case, the patient tends to press the knees to the chest, which allows to slightly reduce the pain syndrome.
At this time, there is also an increase in the symptoms of poisoning caused by the penetration of the intestinal contents into the peritoneal cavity. At the same time, the patient's skin becomes pale, cold sweat starts to stand out, blood pressure drops dramatically, and the pulse quickens.
The process of progression of this disease is divided into the following stages:
- The shock stage is characterized by severe pain of the acute type, which can be given slightly to the lumbar region. As a result, it becomes difficult for the patient to breathe, the muscles become very tense.
- The stage of imaginary improvement implies a slight improvement in the patient’s condition. Pain decreases, muscle tension subsides, and breathing becomes easier. At the same time, there is a weakness in the body, an increased gas formation, bloating appears. Often there is an increase in body temperature. During this period of development of the disease, the patient urgently needs medical help.
- After 12 hours, the patient has all the signs of peritonitis. Observed severe pain in the abdomen and drying of the mucous membranes of the mouth. It should be remembered that the symptoms of peritonitis are always the same, no matter what factors provoked its development. To establish the exact cause of this phenomenon is possible only after appropriate examination.
Regardless of the causes of peritonitis, the patient needs urgent hospitalization. The most dangerous is an ulcer, which does not show pronounced symptoms, since a person may feel sick by writing off other diseases, trying to relieve pain with analgesics, which is a great danger to life.
Endoscopy is the most popular and effective way to diagnose ulcerative diseases of any nature. This procedure is considered not very pleasant for the patient, however, it is with its help that doctors can establish the most accurate diagnosis and determine the severity of the disease by examining all the processes occurring in the digestive organs.
Modern equipment that is used for endoscopic examination, is equipped with all the necessary devices to help take a sample of the contents of an organ and a tissue sample. This will reveal the presence of pathogenic bacteria in the body, provoking an inflammatory process. In addition, this method helps to explore the gastric juice and determine the level of its acidity.
Sometimes direct testing for the detection of the Helicobacter pylori bacterium can be used. For this, an analysis of vomit, blood, feces, or other material taken during a biopsy is carried out.
A significant role in the diagnosis of x-ray examination plays, which greatly simplifies the diagnosis. Another important method that is used for any pathological processes in the abdominal area is palpation. The probing of certain areas allows you to determine the preliminary diagnosis, which is further confirmed or refuted by instrumental methods of research.
Treatment of the disease
If a person has been diagnosed with perforated duodenal ulcer, urgent surgical intervention is necessary. In the presence of any contraindications to surgical treatment, assistance with perforated gastric and duodenal ulcers consists in the combination of drug therapy and diet. This method of treatment is often ineffective and in many cases leads to death.
A conservative method of treatment involves the following procedures:
- the introduction of transnasal probe with the aim of parenteral nutrition,
- applying cold compresses to the stomach,
- powerful infusion therapy used to normalize acid-base balance
- elimination of toxins from the body
- the course of antibiotics (lasts at least 1 week),
- regular X-ray examination in order to monitor the condition of the ulcer.
Together with drug treatment prescribed a certain diet. In this case, the power sets by the attending physician.
If the patient is in a very serious condition, infusion therapy is required, consisting of oxygen inhalations. In no case should pain-relieving drugs be given to the patient, especially of narcotic origin, as this may blur the clinical picture and mislead the doctors.
For the treatment of this disease is used laparotomy. This operation is performed under general anesthesia. The method of therapy used in surgical intervention is determined directly by the surgeon. This takes into account the size of the lesion, the age and sex of the patient, the general condition of his body. Most often, suturing of perforated ulcers.
The indications for the implementation of this method of treatment are a diffuse form of peritonitis, a high risk of complications during surgery, the presence of a stress type of ulcer.
At a young age, suturing of the ulcer and treatment in the postoperative period leads to full recovery. Damage overgrowth, relapses occur extremely rarely. The forecast is quite favorable. In elderly people, peptic ulcers tend to be malignant (degenerate into malignant tumors), so it is desirable in this case to perform a resection of the stomach.
In the postoperative period, the patient is prescribed a strict diet. In order for the body to fully recover, you must comply with all prescriptions of the attending physician. Dietary nutrition must adhere to at least 4 months. The diet can gradually become more complex.
Observing a diet, you must adhere to the following rules:
- Meals should include at least 5 meals per day. The portions should be small.
- All foods included in the diet should be liquid or have the appearance of mashed potatoes.
- Cooking is better steamed or boiled.
- Be sure to reduce the amount of salt consumed to a minimum.
- Simple carbohydrates (chocolate and other sweets) should be completely excluded from the diet.
2 days after the operation, mineral water without gases, weak tea and fruit jelly can be included in the diet.
After 3 days, the diet allows for decoction of rosehip berries, pureed soups or porridge. In addition, you can eat boiled eggs, mashed cottage cheese and vegetable soups, mashed potatoes.
On the tenth day after the surgery, the meal consists of boiled vegetables, steamed patties, lean meat and fish in boiled form. You can include cheesecakes and cottage cheese casseroles in the diet. Cottage cheese and other fresh milk products are allowed to be consumed in small quantities.
After 1 month, flour products, such as dryers and crackers, are allowed in the diet. After 2 months you can eat fresh sour cream and dairy products (kefir, yogurt).
As the diet gets better, it becomes less rigid, however, all canned, smoked products and dishes with lots of spices are prohibited.
Consequences and possible complications
In the absence of timely treatment or violation of medical prescriptions, the following complications of a peptic ulcer may develop:
- Stenosis is a narrowing of the intestinal pylorus (the area between the stomach and duodenum). This complicates the process of movement of food through the digestive tract, which provokes its accumulation in the cavity of the stomach. As a result, the person is tormented by constant nausea and vomiting. The main symptoms of this phenomenon are loss of appetite, feeling of heaviness in the stomach (especially in the upper part), bloating and heartburn. As the pathological process progresses, the patient begins to lose weight, the amount of vitamins and macronutrients in the body decreases. The problem can be solved only with the help of surgery. Conservative treatment brings the desired effect only in very rare cases.
- Bleeding is the most common and dangerous complication of perforation of duodenal ulcer, the symptoms of which most often manifest themselves in the advanced form of the disease at a young age. The main signs are blood inclusions in the fecal masses. As a result, not only significant blood loss occurs, but also pathogenic microorganisms enter the bloodstream.
- Malignancy is the degeneration of diseased cells into malignant neoplasms. The main symptom of this complication is a strong pain in the abdomen, which appear regardless of the meal. In most cases, this pathological process develops in elderly patients, but it is rather difficult to identify it. Most often, in the treatment of a disease, complex therapy is applied, which includes surgery and the use of drugs.
- Penetration is one of the most dangerous forms of complications of a peptic ulcer. The main danger is that the lesion can affect not only the stomach or duodenum, but also other internal organs. To eliminate the pathological process of this nature requires urgent surgical intervention.
It should be remembered that even after successful treatment of the disease a serious complication can develop. Therefore, it is very important in the postoperative period to comply with all the requirements of a doctor (diet, proper nutrition, taking certain medications). This will help to completely restore the body and prevent recurrences.
Duodenal content is thrown into the peritoneum, but this area is hidden by the omentum, liver or intestines. You can identify the following features:
- the small size of the wound,
- low filling of the organ at the time of perforation,
- proximity of a through wound to a liver, an epiploon, intestines, a gall bladder.
The process proceeds in three stages:
- Perforation. The phase is characterized by sharp pains in the epigastrium or above the abdomen. Possible collapse.
- Lull Pain decreases, tension is relieved from muscles, there is no free gas in the peritoneum.
- Complications - local purulent inflammation of the tissues of the peritoneum, less often - diffuse peritonitis.
This type of perforation develops slowly.
It is used when there is no surgical resolution of the problem. Taylor's method is to designate:
- the introduction of transnasal probe for parenteral nutrition,
- applying cold to the belly
- powerful infusion therapy to stabilize the acid-base balance,
- detoxification measures
- combined antibiotic therapy course of a week or longer,
- periodic x-ray monitoring of the development of perforation of the duodenal.
Along with medication prescribed a strict diet.
The preoperative phase includes:
- release of the duodenal region from the contents,
- stabilization of blood pressure, if hypovolemia is detected,
- strict diet.
The incision line is located in the upper third of the peritoneum. The location of the through wound is determined by the location of the food mass in the peritoneum, according to which the surgical technique is selected. When perforation into the retroperitoneal fiber, the degree of its penetration with bile and blood is observed for the selection of tactics. There are two large groups:
- organ preserving - with the closure of a through wound,
- radical - with resection of the organ with removal of the ulcer, pyloroplasty, vagotomy.
The choice of technology depends on several factors:
- time of the disease,
- characteristics, etiology, localization of the ulcer,
- symptoms and prevalence of peritonitis,
- age category of the patient, the presence of background diseases.
- Suture closure of perforated ulcerative wounds. It is prescribed when: diffuse peritonitis develops, the duration of inflammation exceeds 6 hours, the presence of background diseases, advanced age, the absence of gastritis and chronic ulcers. The essence of the operation: the edges of the ulcer are excised with suturing by a double-row suture of the muscular and serous membrane along the axis and transversely. The method allows to preserve the shape and diameter of the body. Perhaps a laparoscopic intervention.
- Resection of the stomach. It is prescribed when: ulcers are chronic, large, rough, there is suspicion of malignancy or a tumor with perforation is diagnosed, decompensated stenosis is observed, the age group up to 65 years, the absence of acute background diseases, the development of peritonitis lasting less than 12 hours. complete removal of the organ with defects is assumed.
- Piloroantrumectomy with bilateral total vagotomy. It is prescribed when: insufficiency of the gastroduodenal anastomosis is diagnosed with the pulp dilation of the mouth of the appendix, and ulcers of the duodenum with the distal part of the stomach open simultaneously. The essence of the operation: removal of the defect with plastic imitation of pulp and cutting a large branch of the vagus nerve.
- Proximal selective vagotomy with wound closure. It is used if: the duration of the inflammation process is less than 6 hours, the patient is young, there are no cicatricial changes.