Perforation of gastric and duodenal ulcer

According to I. I. Neimark (1988), perforation of an ulcer is observed in 3% of patients with peptic ulcer of the stomach and 12 duodenal ulcer. According to other data - in 6-20% of patients. According to studies, the predominance of perforation frequency, depending on the location of the ulcer in the stomach or duodenum was not noted. F.I. Komarov (1995) indicates a high frequency of perforations of the duodenal ulcer. More often, perforated ulcers of the anterior wall of the prepiloric stomach and the bulb of the duodenum. Perforation (perforation) of the ulcer occurs more often in persons aged 19 to 45 years. In old age, perforation of the ulcer is rare, but if it occurs, it is difficult and with complications. In men, perforation of the ulcer is more common than in women.

Perforation of the ulcer usually proceeds typically, into the free abdominal cavity. Less often observed ulterior perforation of the ulcer, perforation in the retroperitoneal tissue.

[1], [2], [3], [4], [5],

Typical perforation of the ulcer (into the free abdominal cavity)

In the clinical picture of the typical perforation of the ulcer (in the free peritoneum cavity) three periods are distinguished: pain shock, imaginary (false) well-being and peritonitis.

The period of pain shock has the following clinical symptoms:

• suddenly there is an extremely strong, severe, "dagger" pain in the abdomen. This pain occurs when the ulcer is being tested and the contents of the stomach or duodenum enter the abdominal cavity. In the first hours the pain is localized in the upper abdomen, but then spreads over the right (more often) or left flank of the abdomen. In the future, the pain becomes diffuse throughout the abdomen. When tapping on the stomach, turning in the bed, coughing, the pain sharply increases;
• at the time of the onset of pain and as the clinical picture of the perforation continues to develop, the patient assumes a forced position - on the back or on the side with the legs brought to the abdomen;
• there is a most important symptom - the "arched" (pronounced) tension of the anterior abdominal wall, first in the upper half of the abdomen, in the future the tension becomes widespread. The stomach is somewhat retracted, does not participate in breathing. According to the figurative expression of G. Mondor, "the tension of the muscles of the anterior abdominal wall is an over-sign of all abdominal catastrophes. The tension of the abdominal muscles is reflex and is associated with irritation of the peritoneum ";
• is characterized by the Shchetkin-Blumberg symptom, which is verified as follows. Fingers of the right hand, gently and flatly shallow should be pressed on the front abdominal wall, wait 3-5 seconds, and then quickly take away the hand. This method causes a slight concussion of the peritoneum, and in the presence of peritonitis with rapid withdrawal of the hand, pain sharply increases. The symptom of Schetkina-Blumberg is extremely characteristic for acute inflammation of the peritoneum. It should be noted that with a pronounced exertion of the anterior abdominal wall, this symptom is not necessary to check. However, this symptom acquires great diagnostic value in the event that the cardinal sign of a perforated ulcer is that the tension of the abdominal muscles is absent or very weakly expressed. This happens in old people and people with severe obesity and excessive fat deposition in the abdomen;
• with percussion of the upper abdomen revealed Jeber's symptom - tympanitis over the liver region. This is due to the accumulation of gas (released from the stomach) under the right dome of the diaphragm, which is confirmed by X-rays and radiography of the abdominal cavity;
• can be determined by a positive frenicus-symptom - a pronounced pain when pressing between the legs m. Sternocleidomastoideus (usually right) due to irritation of the diaphragmatic nerve;
• the patient's face is pale with an ash-cyanotic hue, sweat on his forehead; hands and feet are cold;
• about 20% of patients have a single vomiting. It should be emphasized that vomiting is a little characteristic of a perforated ulcer;
• the pulse is rare, the bradycardia is reflexive;
• breathing is superficial, intermittent, rapid.

The period of imaginary (false) well-being develops in a few hours from the moment of perforation. It is characterized by the following symptoms:

• abdominal pain decreases (due to paralysis of nerve endings) and may even disappear, which is perceived by the patient as a significant improvement in the condition;
• there is a state of euphoria of varying degrees of severity;
• there are objective indications of trouble in the abdominal cavity - the tension of the anterior abdominal wall (in some patients, this sign may be reduced); a positive symptom of Shchetkin-Blumberg; decrease or disappearance of hepatic dullness; paresis of the intestine develops, which is manifested by flatulence and the disappearance of intestinal peristaltic sounds in the abdomen);
• tongue and lips are dry;
• Bradycardia is replaced by tachycardia, palpation of the pulse determines its poor filling, often arrhythmias;
• blood pressure is reduced, heart sounds are deaf.

The period of imaginary well-being lasts about 8-12 hours and is replaced by peritonitis.

Peritonitis is the third stage of a typical perforation of the stomach or duodenal ulcer into the free abdominal cavity. Peritonitis is severe and characterized by the following symptoms:

• thirst; possible vomiting;
• the patient is inhibited, in the terminal stage of peritonitis, loss of consciousness is possible;
• skin moist, sticky, earthy; body temperature is high;
• facial features sharpen, eyes sunken ("face of Hippocrates");
• the tongue is very dry, rough (like a "brush"), lips dry, cracked;
• The abdomen still remains sharply tense at palpation; in the sloping places of the abdomen, blunting of percussion sound is determined; develops paresis of the intestine, which is manifested by bloating and abrupt weakening, and then by the disappearance of peristaltic sounds during auscultation of the abdomen; Painful sensations with far-reaching peritonitis can significantly weaken;
• pulse frequent, weak filling, can be threadlike, arrhythmic, arterial pressure is significantly reduced, in the terminal stage of peritonitis, the development of collapse is possible;
• breathing shallow, frequent;
• diuresis is significantly reduced, up to anuria.

Perforation of the posterior wall of the lower part of the duodenum

This type of perforation is very rare. The duodenal contents do not fall into the free abdominal cavity, but into the retroperitoneal tissue. Clinically, this option is manifested by sudden and very sharp pains in the epigastric region, radiating into the back. In the future, the intensity of pain is weakened. During the first two days, retroperitoneal phlegmon is formed, the main signs of which are fever with tremendous chills, a painful swelling to the right of the spine at the level of the X-XII thoracic vertebra. When palpation in the area of this swelling, crepitation is determined, and for X-ray examination - gas (the most important diagnostic feature).

Covered perforation of the ulcer

Covered is called a perforation, in which the perforated hole after flowing into the abdominal cavity of some of the gastric contents is covered most often with the omentum or the wall of another organ (liver, gut). Covered perforation of the stomach ulcer occurs in 2-15% of all perforations. Covering the perforated hole is only possible if the following conditions are present:

• small diameter of the perforating hole;
• slight filling of the stomach at the time of perforation;
• the proximity of the perforating aperture to the liver, epiploon, intestine, gall bladder.

In the clinical picture of occluded perforation, three phases are distinguished: perforation of ulcer, remission of clinical symptoms, phase of complications.

The first phase - perforation of the ulcer - begins suddenly, with intense ("dagger") pain in the epigastrium, which can also be accompanied by collapse. The muscle tension of the anterior abdominal wall develops, but it usually has a local character (in the epigastrium or in the upper half of the abdomen).

Then the second phase develops - remission of clinical symptoms. The perforating aperture is covered, the acute phenomena of the first phase subsides, the pain and tension of the muscles of the anterior abdominal wall decreases. However, many patients in this phase may have pain syndrome, although its intensity is significantly weakened. Characteristic is the absence of free gas in the abdominal cavity.

In the third phase complications develop - limited abscesses of the abdominal cavity, and sometimes - diffuse peritonitis.

In some cases, the covered perforation is not diagnosed, but is taken for the usual exacerbation of peptic ulcer.

In the perforation of ulcers between small glands, the clinical symptomatology develops slowly, the pains are quite intense, a clinic of the emerging small abscesses abscess appears - local pain is again amplified, a limited inflammatory infiltrate is palpated (in the projection of the covered perforation). The infiltrate is detected by ultrasound examination of the abdominal cavity.

[6], [7], [8], [9]

Laboratory and instrumental data

1. The general analysis of blood: leukocytosis is typical, the leukocyte formula is shifted, the number of stab wedges is increased, the neutrophils are toxic (especially in the development of peritonitis), the increase in ESR.
2. General analysis of urine: small amounts of protein may appear.
3. Biochemical blood test: increase in blood levels of bilirubin and alanine aminotransferase (especially if the perforated opening is covered by the liver), an increase in the level of y-globulins, beta-globulins is possible.
4. With the development of peritonitis and oligoanuria, an increase in the urea blood content is possible.
5. ECG - diffuse (dystrophic) changes in the myocardium are detected in the form of a decrease in the amplitude of the T wave in the thoracic and standard leads, it is possible to shift the ST interval down the line, extrasystolic arrhythmia.
6. Survey fluoroscopy or radiography of the abdominal cavity reveals the presence of gas in the form of a sickle on the right under the diaphragm.
7. Ultrasound of the abdominal cavity organs reveals an inflammatory infiltrate in the abdominal region with a perforated cover or in the retroperitoneal area with perforation into this zone.