Perforated ulcer
The content of the article:
- Causes and risk factors
- Forms of the disease
- Disease stages
- Perforated ulcer symptoms
- Diagnostics
- Perforated ulcer treatment
- Possible complications and consequences
- Forecast
- Prevention
A perforated ulcer is a serious complication of gastric ulcer or duodenal ulcer, when a through hole forms at the site of the ulcer through which the contents enter the abdominal cavity and leads to the development of peritonitis. Most often, perforation occurs in the initial parts of the duodenum and in the distal part of the stomach. In addition to perforated ulcers of the stomach and duodenum, similar complications occur when ulcers are localized in the esophagus, small and large intestines, but this happens extremely rarely.
A perforated ulcer is complicated by about 15% of all cases of peptic ulcer disease. People of any age and gender suffer from peptic ulcer disease and its complications, but men 20-40 years old are more susceptible to it.
A perforated ulcer is the formation of a through defect in the wall of the stomach or duodenum
Causes and risk factors
The main immediate cause of perforation is chronic peptic ulcer disease in neglect, not receiving proper treatment. Peptic ulcer is referred to as polyetiologic diseases, that is, arising under the influence of several reasons at once. A necessary condition for its development is infection with Helicobacter pylori, and contributing factors include:
- hereditary predisposition;
- diseases of the gastrointestinal tract (gastritis, pancreatitis, etc.);
- systematic eating disorders (irregular, unbalanced diet, food abuse that irritates the mucous membrane of the digestive tract);
- decreased immunity;
- alcohol abuse;
- smoking;
- excessive physical and psycho-emotional stress for a long time;
- long-term exposure to a number of medications (for example, glucocorticosteroids, nonsteroidal anti-inflammatory drugs, etc.).
Less commonly, a perforated ulcer occurs as a complication of severe acute conditions - chemical burns of the digestive tract, poisoning with poisonous substances, stroke, heart attack, etc.
Forms of the disease
Depending on the etiology:
- perforation of acute ulcers;
- perforation of a chronic ulcer;
- perforation of a malignant tumor in a hollow organ;
- perforation in case of violation of local blood circulation;
- perforation with parasitic invasions.
Depending on the localization, perforated ulcers are distinguished:
- esophagus;
- stomach;
- duodenum;
- small intestine;
- large intestine;
- combined.
Perforated gastric ulcer, in turn, is subdivided into perforation of the lesser or greater curvature of the stomach, the anterior or posterior wall of the stomach, in the body of the stomach or in the cardiac, prepyloric, pyloric, antrum. A perforated duodenal ulcer can be bulbar or postbulbar.
According to the clinical picture:
- typical - perforation into the abdominal cavity;
- atypical (covered, that is, the perforation is covered by some organ) - perforation occurs in the greater or lesser omentum, omental bursa, retroperitoneal tissue, inter-adhesion cavity.
Ulcer perforation may be accompanied by bleeding into the gastrointestinal tract or into the peritoneal cavity.
Disease stages
In the clinical picture of the disease, the following stages are distinguished:
- Chemical peritonitis (abdominal shock, primary shock).
- Bacterial peritonitis (serous-fibrous peritonitis and systemic reaction, a period of imaginary well-being).
- Spilled purulent peritonitis (severe abdominal sepsis).
Perforated ulcer symptoms
A perforated ulcer manifests itself as a sudden, sharp and severe, so-called dagger pain in the epigastrium. The pain radiates to the left abdomen, supraclavicular region, scapula and left shoulder. For a perforated duodenal ulcer, pain is localized in the right hypochondrium, then spreading to the entire abdomen. With perforation of a stomach ulcer, peritonitis develops faster, since gastric juice acts as an additional aggressive factor of the contents poured into the abdominal cavity. Intense pain forces the patient to take a forced position - lying on his side with tucked legs (fetal position). Pallor of the skin, cold sweat, a decrease in blood pressure, rapid shallow breathing (tachypnea) are noted, and facial features are sharpened. The muscles of the anterior abdominal wall are tense (this symptom is usually absent in personsin a state of alcoholic intoxication, in debilitated patients and in obese patients), gentle palpation aggravates pain. The abdomen does not participate in the breathing process. Free gas is found in the abdominal cavity, which is determined by tapping (percussion) of the lower edge of the costal arches.
A perforated ulcer manifests itself as acute and severe pain in the epigastrium.
The process passes into the stage of bacterial peritonitis after about 6 hours from the onset of a painful attack. The intensity of the symptoms of a perforated ulcer during this period decreases, but signs of intoxication are increasing. The pressure decreases even more, tachycardia is noted, and the body temperature may rise. The signs of the presence of free gas in the abdomen become more pronounced.
If no medical care is provided, about 12 hours after the perforation of the ulcer, the stage of severe abdominal sepsis begins. At the same time, the general condition deteriorates sharply, signs of intoxication become pronounced. The patient has severe vomiting, leading to dehydration of the body, dry skin, an increase in body temperature at first to febrile values, then its decrease, low blood pressure, an increase in tachycardia, an increase in the abdomen, oligo- or anuria. The patient becomes lethargic, apathetic, limited contact is available, later a coma sets in.
When an ulcer perforates into the head of the pancreas, severe intestinal bleeding and vomiting of blood are noted. Atypical perforation of the ulcer into the thickness of the greater or lesser omentum is accompanied by moderate pain in the abdomen without clear localization, while muscle tension is not as pronounced as in a typical form of pathology.
Diagnostics
Diagnosis of a perforated ulcer is based on data obtained during an objective examination, collection of complaints and anamnesis, as well as as a result of instrumental and laboratory examination, which includes:
- X-ray (the presence of free gas in the abdominal cavity is determined);
- ultrasound examination of the abdominal cavity;
- electrocardiography;
- general and biochemical blood test;
- diagnostic laparoscopy.
Ultrasound of the stomach - one of the methods for diagnosing a perforated ulcer
Differential diagnosis with perforation of a stomach tumor, abdominal myocardial infarction, gastric phlegmon, acute pancreatitis, acute appendicitis, acute mesenteric circulation disorder, ruptured aneurysm of the abdominal aorta, pleurisy, etc. Subsequently, the clinical picture of the disease is smoothed out, since the signs of peritonitis become predominant.
Perforated ulcer treatment
With a perforated ulcer, emergency surgery is indicated. Conservative treatment of perforated ulcers is ineffective and fraught with the development of numerous complications, up to and including death. Conservative therapy is carried out when it is impossible to immediately carry out the operation and consists in freeing the intestines from the contents, antibacterial therapy, infusion therapy (maintaining vital body functions and preventing further infection).
With a perforated ulcer, emergency surgery is indicated
During the preoperative preparation of the patient, the stomach contents are evacuated, the urinary bladder catheterized, and the blood pressure normalized. The tactics of surgical treatment depends on the localization of the perforated ulcer, the form and stage of the disease. According to the indications, the following methods of surgical intervention are used:
- open or laparoscopic suturing of perforation;
- resection of the stomach;
- vagotomy with excision of a perforated ulcer and pyloroplasty;
- pyloroantrumectomy with stem vagotomy;
- suturing of perforation in combination with selective proximal vagotomy.
Possible complications and consequences
In case of untimely seeking medical help, severe purulent complications of a perforated ulcer, including generalized sepsis, may develop. Such conditions are life threatening.
Postoperative complications of perforated ulcers can be:
- bronchopneumonia;
- peritonitis;
- incompetence of the sutures with repeated release of intestinal contents into the peritoneal cavity;
- gastrointestinal bleeding;
- violation of the evacuation function of the stomach.
Patients with immunodeficiency and elderly people are more at risk of developing postoperative complications of perforated ulcers.
Forecast
A perforated ulcer is a life-threatening condition, in about 8% of cases it ends in death, even with timely diagnosis and timely surgical treatment. At the same time, relapses are noted in less than 2% of cases. When performing a surgical intervention 12 hours after the onset of the disease and later, postoperative mortality increases to 20–40%. Treatment of a perforated ulcer at the stage of diffuse peritonitis is often belated and has no positive effect.
Prevention
In order to prevent the formation of perforated ulcers, timely diagnosis and treatment of gastric ulcer and duodenal ulcer are shown. A measure of nonspecific prophylaxis is maintaining the body's defenses at the proper level through rational nutrition, rejection of bad habits, compliance with an optimal sleep and rest regimen, etc.
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Anna Aksenova Medical journalist About the author
Education: 2004-2007 "First Kiev Medical College" specialty "Laboratory Diagnostics".
The information is generalized and provided for informational purposes only. At the first sign of illness, see your doctor. Self-medication is hazardous to health!
