Specified dangerous condition is called a perforated ulcer requires urgent surgical intervention. Reasons serve chronic and acute stomach ulcers.
Most prone to perforation of ulcers situated on the anterior wall of the stomach in pyloric and predeliriosnom departments.
Peptic ulcer has many unpleasant and dangerous consequences. One of these is the perforation of the ulcer of the wall of said body. As a result of stomach contents flowing into the abdominal cavity, which can lead to the development of peritonitis (inflammation of peritoneum), threatening human life.
The perforation of the body wall is facilitated by certain factors:
- the lack of treatment of acute ulcers;
- gross violations of diet;
- strong overeating;
- frequent stress, constant mental and mental stress;
- heavy exercise and increasing of the pressure inside the abdominal cavity;
- long-term use of corticosteroids and drugs of salicylic acid.
Signs of a perforated gastric pathology
Symptoms of perforated ulcers, and their severity depends on clinical form of perforation.
It can be:
- typical (into the free cavity of the peritoneum; including covered);
- atypical (in the space behind the peritoneum, between the sheets, in megspace region).
The classical picture of signs of perforated ulcer occurs when perforation into the free abdominal cavity, occurring in 90% of cases.
There are 3 periods:
- primary “abdominal shock” (chemical inflammation);
- the latent period (bacterial);
- diffuse purulent peritonitis.
Every period has its own special symptoms. The initial phase of shock, ongoing 6-10 hours, is characterized by the sudden occurrence of sharp “stabbing” pain in the epigastric region, often radiating along the course of the phrenic nerve to the area of the right shoulder, scapula and outer part of the neck.
Externally, the sick person looks pale, haggard, with sunken eyes. A characteristic feature – the forced fixed position of the body, lying on his side, given to the stomach feet. Respiration is shallow and rapid, his forehead a cold sweat. “Maskoobraznoe” tension of the abdominal muscles which is not involved in the act of inhalation and exhalation.
The phase of bacterial peritonitis is also called the period of imaginary well-being. Marked reduction in the symptoms of the disease, the cessation of pain. The face is a normal color, pulse and breathing are normalized. When the feeling remains soreness in the epigastric region and signs of muscular tension of the abdomen.
After 12-24 hours from the moment of perforation, the unfolding picture of peritonitis. Symptoms resumed with renewed vigor, the patient’s condition deteriorates. The pain sharply intensified, there is repeated vomiting, nausea, hiccup. The breathing is frequent and shallow, the pulse quickens, the body temperature increases, the stomach is inflated.
Methods of treatment of ulcers
Perforated gastric ulcer of any shape and localization is an absolute indication for urgent surgical intervention. So when people came to the hospital with the specified diagnosis, I ask, do the operation, no other answer except Yes, can not be. And the sooner it is done, the better the prediction and lower the likelihood of complications.
Treatment without surgery is performed in extreme cases when the person is strongly against surgery. It is the constant aspiration of the contents of the stomach through the probe on the background of intravenous administration of electrolyte solutions and antibiotics. The effectiveness of this method possible in the early stages of the disease, when the contents of the stomach did not have time to leak into the abdominal cavity. But often these activities only consume your precious time and have no effect. For this reason, in the end, the person gives the consent for the surgery, but it so happens that it is too late.
Treatment in the prehospital setting for suspected perforated gastric ulcer includes intravenous infusion of saline solutions, medications, constricts blood vessels, oxygen. Narcotic pain relievers can not enter, because they “lubricate” the true picture of the disease. For this reason, can be misdiagnosed in a hospital. Before the operation with a probe is carried out gastric lavage to remove the contents.
If surgical treatment methods are used:
- suturing of the perforation;
- removal of part of the stomach (resection);
- excision of the ulcer with vagotomy (cut vagus nerve).
Typically, surgical access to the organ is performed by laparotomy. If you have the necessary equipment it is possible to conduct operations endoskopiceski, under the control of the videoscope, a few holes in the abdominal wall, without the wide cut. If the detected diffuse peritonitis and intra-abdominal inflammatory process, are transferred to laparotomy.
The choice of surgical method is carried out in accordance with the patient’s condition, age, type of ulcer, presence of comorbidities, time from the beginning of the perforated process. Any selected method aims to cure the patient and save his life.
Closure of the perforation is applied if it is more than 6-12 hours from the onset of its formation, young people with recent gastric ulcer, in the elderly, in General condition of a person.
Removal of part of the stomach (resection) is performed when:
- long-standing ulcer that cannot be cured with medication;
- is detected during the operation, chronic ulcers, which cannot be repaired;
- suspected malignancy of the ulcer;
- the perforation of multiple ulcers.
Treatment after surgery includes:
- receiving anti-ulcer drugs (Kvamatel, Zantac; Maalox, Almagel);
- use of antibacterial drugs (Ampiox);
- the reception of blockers of the proton pump (Omez);
- intravenous introduction of solutions to improve microcirculation and wound healing (Trental, Actovegin, Reopoligljukin, Solkoseril).
After completing any of the selected methods of produce sanitation and provision of outflow occurring inflammatory fluid from the peritoneal cavity (drainage). Sometimes I put two probes: to jejunum for feeding, into the stomach for decompression.
In the postoperative period it is recommended that early activation of the patient, conducting breathing exercises and physical therapy. Help to restore the health of fresh air, rest, elimination of physical loads and psycho-emotional stress, nutrition required by the rules of the diet.
With the help of modern methods of laser therapy removes the formed after surgery scars. Such activities can be carried out only in the complete healing of surgical wounds in the absence of any complications, after the control gastroscopy.
The particular diet after surgery
Often the patient’s relatives, the question arises, what is the food shown after removal of a perforated ulcer. On the first day only drink water from a spoon in a small amount, the next day you have 200-250 ml of liquid food (porridge). On the third day, the food volume is 500 ml, then it increases up to 1 L.
After 7 days the patient is transferred to a basic diet, the same treatment table used in the aggravation of gastric ulcer. It is a dietary table No. 1A on Pevsner. After a week, go on a diet number 1B, and then, after 10-12 days, on table # 1, which you need to adhere to 8-12 months.
When meals according to the diet №1A the food consumed in boiled, grated, steamed, maximum liquefied form. Excludes all vegetables, bakery, dairy and confectionery products, raw fruits, spices, snacks, sodas, coffee.
When switching to a diet number 1B added steam cutlets, fish in aspic, baked apples or grated raw. Treatment table 1 is not as strict as No. 1A. It allows the use of non-rigid meat and fish slices, wheat bread from flour, boiled and pureed vegetables, mildly acidic yogurt, cottage cheese, yogurt. Cooking methods remain the same – boiled, broiled, steamed, hard food clean.
Complications of the disease and prognosis
The sooner accurate diagnosis perforated gastric ulcer, the higher the probability to get rid of this debilitating condition. With proper early diagnosis (within the first 12 hours) and carrying out the necessary surgical treatment the prognosis is favorable.
Complications after surgery develop infrequently and can be represented by:
- bronchopneumonia;
- purulent process (abscess under the diaphragm, between loops of bowel in subhepatic space);
- violation of the exit of food from the stomach;
- intestinal obstruction;
- bleeding (stomach or abdomen).
Each of these conditions with any degree of severity of symptoms requires careful treatment and, if necessary, repeat the operation.
Prevention of pneumonia contributes to lavage the trachea and bronchi, removal of the fluid from the pleural cavity, early activation of the patient and breathing exercises. In case of violation of passage of food through the stomach out of him, remove all content through the probe. At the same time struggling with slowing of the bowel, giving plenty of fluids and intravenously injecting proteins and electrolytes.
While maintaining the gastric obstruction is carried out gastroscopy for the detection of causes of disorders of the stomach, possible mechanical obstacle arising in the course of the operation or its complications, and the decision of a question on necessity of repeated surgical intervention.
Poor outcome usually occurs as a result of late treatment of a person for medical help when the symptoms are the apparent manifestation. Deaths occur due to diffuse peritonitis, postoperative pneumonia and concomitant severe diseases. In recent years, the mortality rate among people with a diagnosis of perforated ulcer in the surgical treatment significantly decreased to 5.7 %.
Long-term complications of the operation depends on its type and the correct choice of the method. Re-perforation of gastric wall occur in less than 2% of operated people.
