Perforation of gastric and 12-peritoneal ulcer

According to I. I. Neimark (1988), ulcer perforation is observed in 3% of patients with gastric ulcer and duodenal ulcer. According to other data - in 6-20% of patients. According to research, there is no prevalence of perforation frequency depending on the ulcer localization in the stomach or duodenum. F. I. Komarov (1995) indicates a higher frequency of duodenal ulcer perforations. Ulcers of the anterior wall of the prepyloric part of the stomach and the duodenal bulb perforate more often. Perforation (breakthrough) of the ulcer most often occurs in people aged 19 to 45 years. In old age, ulcer perforation is rare, but if it occurs, it is severe and with complications. Ulcer perforation is observed more often in men than in women.

Perforation of the ulcer most often occurs typically, into the free abdominal cavity. Less often, covered ulcer perforation, perforation into the retroperitoneal tissue is observed.

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Typical ulcer perforation (into the free abdominal cavity)

In the clinical picture of a typical ulcer perforation (into the free peritoneal cavity), three periods are distinguished: pain shock, apparent (false) well-being and peritonitis.

The period of pain shock has the following clinical symptoms:

• an extremely strong, severe, "dagger-like" pain in the abdomen suddenly appears. This pain occurs when the ulcer ruptures 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 to the right (more often) or left flank of the abdomen. Later, the pain becomes diffuse throughout the abdomen. When tapping the abdomen, turning in bed, coughing, the pain increases sharply;
• at the moment of pain occurrence and as the clinical picture of perforation develops further, the patient takes a forced position - on the back or on the side with the legs drawn up to the stomach;
• the most important symptom appears - "board-like" (sharply expressed) tension of the anterior abdominal wall, initially in the upper half of the abdomen, later the tension becomes widespread. The abdomen is somewhat drawn in, does not participate in breathing. According to the figurative expression of G. Mondor, "tension of the muscles of the anterior abdominal wall is a super-sign of all abdominal catastrophes. Tension of the abdominal muscles is reflex and is associated with irritation of the peritoneum";
• characteristic symptom of Shchetkin-Blumberg, which is checked as follows. With the fingers of the right hand, carefully and shallowly press on the anterior abdominal wall, wait 3-5 seconds, and then quickly remove the hand. This technique causes a slight concussion of the peritoneum, and in the presence of peritonitis, when the hand is quickly removed, the pain increases sharply. The symptom of Shchetkin-Blumberg is extremely characteristic of acute inflammation of the peritoneum. It should be noted that with pronounced tension of the anterior abdominal wall, it is not necessary to check this symptom. However, this symptom acquires great diagnostic significance in the case when the cardinal sign of a perforated ulcer - tension of the abdominal muscles is absent or very weakly expressed. This happens in old people and people with pronounced obesity and excessive fat deposition in the abdomen;
• percussion of the upper abdomen reveals Jobert's symptom - tympanitis over the liver area. This is due to the accumulation of gas (exited from the stomach) under the right dome of the diaphragm, which is confirmed by fluoroscopy and radiography of the abdominal cavity;
• A positive phrenicus symptom may be determined - severe pain when pressing between the legs of the m. sternocleidomastoideus (usually on the right) due to irritation of the phrenic nerve;
• the patient's face is pale with an ashen-cyanotic tint, sweat on the forehead; hands and feet are cold;
• Approximately 20% of patients experience a single episode of vomiting. It should be emphasized that vomiting is an uncommon symptom of a perforated ulcer;
• the pulse is rare, bradycardia is reflex;
• breathing is shallow, intermittent, rapid.

The period of apparent (false) well-being develops several hours after 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;
• a state of euphoria of varying degrees of severity appears;
• objective signs of trouble in the abdominal cavity persist - tension of the anterior abdominal wall (in some patients, this sign may decrease); positive Shchetkin-Blumberg symptom; decrease or disappearance of liver dullness; intestinal paresis develops, which is manifested by flatulence and the disappearance of intestinal peristaltic noises in the abdomen);
• tongue and lips are dry;
• bradycardia is replaced by tachycardia, when palpating the pulse, its poor filling is determined, often arrhythmia;
• blood pressure decreases, heart sounds are muffled.

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

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

• thirst; vomiting is possible;
• the patient is inhibited, in the terminal stage of peritonitis loss of consciousness is possible;
• the skin is moist, sticky, earthy in color; body temperature is high;
• facial features become sharper, eyes are sunken (“Hippocratic face”);
• the tongue is very dry, rough (like a “brush”), the lips are dry and cracked;
• the abdomen remains sharply tense upon palpation; dullness of percussion sound is determined in sloping areas of the abdomen; intestinal paresis develops, which is manifested by abdominal distension and a sharp weakening, and then disappearance of peristaltic noises upon auscultation of the abdomen; pain in advanced peritonitis can significantly weaken;
• the pulse is frequent, weak, may be threadlike, arrhythmic, blood pressure is significantly reduced, in the terminal stage of peritonitis, collapse may develop;
• breathing is shallow and frequent;
• diuresis decreases significantly, even to the point of anuria.

Perforation of the posterior wall of the lower duodenum

This type of perforation is very rare. Duodenal contents enter the retroperitoneal tissue rather than the free abdominal cavity. Clinically, this variant is manifested by sudden and very sharp pains in the epigastric region, radiating to the back. Later, the intensity of the pain weakens. During the first two days, retroperitoneal phlegmon is formed, the main signs of which are fever with stunning chills, painful swelling to the right of the spine at the level of the X-XII thoracic vertebrae. Upon palpation, crepitation is determined in the area of this swelling, and gas (the most important diagnostic sign) is determined by X-ray examination.

Covered ulcer perforation

Covered is a perforation in which the perforation opening after the leakage of a certain amount of gastric contents into the abdominal cavity is covered most often by the omentum or the wall of another organ (liver, intestine). Covered perforation of a gastric ulcer occurs in 2-15% of all perforations. Covering the perforation opening is possible only under the following conditions:

• small diameter of the perforation hole;
• slight filling of the stomach at the time of perforation;
• proximity of the perforation opening to the liver, omentum, intestines, gallbladder.

In the clinical picture of a covered perforation, three phases are distinguished: ulcer perforation, attenuation of clinical symptoms, and the phase of complications.

The first phase - ulcer perforation - begins suddenly, with intense ("dagger") pain in the epigastrium, which may also be accompanied by collapse. Tension of the muscles of the anterior abdominal wall develops, but it is usually local in nature (in the epigastrium or in the upper half of the abdomen).

Then the second phase develops - the clinical symptoms subside. The perforation is covered, the acute symptoms of the first phase subside, the pain and tension of the muscles of the anterior abdominal wall decrease. However, many patients may still experience pain in this phase, although its intensity significantly weakens. The absence of free gas in the abdominal cavity is characteristic.

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

In some cases, covered perforation is not diagnosed, but is taken for a normal exacerbation of peptic ulcer disease.

When the ulcer between the layers of the lesser omentum is perforated, clinical symptoms develop slowly, the pain is quite intense, and clinical signs of a developing abscess of the lesser omentum appear - local pain increases again, a limited inflammatory infiltrate is palpated (in the projection of the covered perforation). The infiltrate is detected by ultrasound examination of the abdominal cavity.

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Laboratory and instrumental data

1. Complete blood count: characteristic leukocytosis, left shift in the leukocyte formula, increased number of band neutrophils, toxic granularity of neutrophils (especially with the development of peritonitis), increased ESR.
2. General urine analysis: small amounts of protein may appear.
3. Biochemical blood test: increased levels of bilirubin and alanine aminotransferase in the blood (especially if the perforation is covered by the liver), possibly increased levels of gamma globulins and beta globulins.
4. With the development of peritonitis and oliguria, the level of urea in the blood may increase.
5. ECG - reveals diffuse (dystrophic) changes in the myocardium in the form of a decrease in the amplitude of the T wave in the chest and standard leads, a possible shift of the ST interval downwards from the line, extrasystolic arrhythmia.
6. Plain fluoroscopy or abdominal radiography reveals the presence of gas in the form of a crescent on the right side below the diaphragm.
7. Ultrasound of the abdominal organs reveals an inflammatory infiltrate in the abdominal region with a covered perforation or in the retroperitoneal region with a perforation in this area.