Complications of gastric and duodenal ulcers

Complications of gastric ulcer and duodenal ulcer are the responsibility of surgeons, therefore all patients with complications of gastric ulcer should be hospitalized in surgical hospitals.

Perforated ulcer, as a complication of peptic ulcer disease, develops in 7-8% of patients. Perforation occurs suddenly, usually after a large meal, sometimes with alcohol. It is characterized by sudden sharp ("dagger"), diffuse abdominal pain, often causing pain shock, sharp tension of the anterior abdominal wall ("board-like" abdomen), pronounced Shchetkin-Blumberg symptom, dry tongue, tachycardia. Hippocratic face develops quickly. Percussion of the abdomen reveals high tympanitis in the epigastrium, disappearance of liver dullness, dullness of percussion sound in the flanks of the abdomen. Auscultation of the abdomen - peristalsis is absent, the following symptoms are revealed: Gustena - listening to heart sounds to the level of the navel; Koenigsberg - listening to harsh bronchial breathing in the upper abdomen. When examining the rectum, there is sharp pain in the posterior Douglas space (Kulenkampf's symptom). Peritonitis develops 8-10 hours after perforation.

In typical cases, diagnosing complications of peptic ulcer disease is not difficult. FGDS and fluoroscopy of the stomach are contraindicated. To confirm the diagnosis, a survey fluoroscopy of the abdomen is performed, and a crescent-shaped strip of gas is detected in the right hypochondrium.

The complexity of diagnostics arises in case of covered perforations and atypical ulcer perforations, especially in case of late admission of the patient. In case of covered perforations, when the opening is closed by a soldering omentum, a two-phase process is typical:

1. acute period of perforation with typical clinical manifestations of perforation;
2. the period of extinction of the process after covering the perforation, which develops 30-90 minutes after the perforation and is accompanied by some improvement in the patient's condition, a decrease in abdominal pain, and the disappearance of the "board-like" tension of the abdomen. But at the same time, intoxication continues to increase, palpation symptoms of tension and irritation of the peritoneum persist. Usually, the cover is not reliable and the leakage of gastric contents continues, albeit in small portions, with the development of peritonitis, subdiaphragmatic or interintestinal abscess, which give a vivid clinical picture. In this case, the leading role in the diagnosis of complications of peptic ulcer disease is played by the anamnesis (the presence of signs of the disease, the characteristic two-phase nature of the process) and dynamic observation of the patient. Laparoscopy is indicated to confirm the diagnosis; if it is not possible to perform it, it is better to perform laparotomy than to allow the formation of peritonitis or abscesses in the abdominal cavity.

Atypical perforations, when the perforation opens into the omentum, and then through the foramen sinus the gastric contents spread throughout the abdominal cavity or when the duodenum is perforated the contents spill into the retroperitoneal space, are rare and do not give a typical picture, they are detected during the formation of peritonitis or during laparoscopy.

Bleeding as a complication of peptic ulcer disease is observed in 15-20% of patients and is the leading cause of mortality from this disease. Quite often it is combined with other complications, especially with perforation and penetration.

Ulcer penetration is the growth of an ulcer into adjacent organs with which it is intimately connected by scar tissue: the liver, pancreas, lesser omentum, intestines, gall bladder, etc. There are 3 degrees of penetration:

• I - formation of callus ulcer and periprocess;
• II - ulcer growth throughout the entire thickness of the stomach wall or duodenum and the formation of adhesions with adjacent organs;
• III - ulcer growth into adjacent parenchymal organs with the formation of a niche in them or into hollow organs with the development of internal fistulas.

The clinical picture of complications of ulcer disease changes significantly, the seasonality of pain and the daily cyclicity of its occurrence disappear, there is no dependence on food intake, the pain becomes constant, the clinical picture of inflammation of the organ into which the ulcer penetrates joins, achylia often forms. The diagnosis is confirmed by FGDS and X-ray examination of the stomach.

Cicatricial pyloric stenosis develops gradually as a result of cicatricial deformation of the pylorus and disruption of the motor-evacuation function of the stomach. Picture of complications of peptic ulcer: pains acquire a dull character, become constant, intensify in the evening and disappear after vomiting, accompanied by a feeling of distension in the epigastrium, a sensation of food passing through the pylorus; belching of rotten, nausea and progressively increasing vomiting of food eaten the day before, and subsequently immediately after eating, appear. Patients progressively lose weight and become weaker.

There are 3 degrees of stenosis:

• I - compensation - the patient's condition does not noticeably suffer, there is no weight loss, during X-ray examination of the stomach, evacuation is not changed or is slightly reduced;
• II - subcompensation - the general condition worsens, fatigue, weakness, weight loss due to frequent vomiting appear, evacuation of barium suspension from the stomach is delayed for up to 6-12 hours;
• III – decompensation – weakness, severe weight loss, dehydration and water-electrolyte imbalance, hypochloremia, evacuation of barium from the stomach is delayed by more than 12 hours.

The same picture is observed with a stenosing ulcer of the pyloric part of the stomach (usually either giant or callous), in which the motor-evacuation function is reduced due to pylorospasm. In this case, all the typical symptoms of the disease are preserved.

Malignancy - is observed mainly when the pathological process is localized in the stomach; duodenal ulcers become malignant extremely rarely. With malignancy, pain decreases, becomes constant, the connection between heartburn and food intake is lost, appetite worsens, and weight loss is typical for patients.

Most often, callous ulcers and long-term scarring ulcers become malignant. For timely detection of complications of ulcer disease during FGDS, it is necessary to take a biopsy from three points of the ulcer - from the edges, walls and bottom.

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