Complications of gastric and duodenal ulcers

Complications of gastric ulcer and duodenal ulcer refer to the competence of surgeons, so all patients with complications of peptic ulcer disease must be hospitalized in surgical hospitals.

A perforated ulcer as a complication of peptic ulcer develops in 7-8% of patients. The perforation occurs suddenly, usually after a heavy meal, sometimes with alcohol. It is characterized by sudden sharp ("dagger") pains, poured pains in the abdomen, often causing pain shock, abrupt tension of the anterior abdominal wall ("dace-shaped" abdomen), pronounced symptom of Shchetkin-Blumberg, dry tongue, tachycardia. Quickly develops the face of Hippocrates. When percussion of the abdomen is determined by high tympanitis in epigastrium, the disappearance of hepatic dullness, dullness of percussion sound in the flanks of the abdomen. With auscultation of the abdomen - there is no peristalsis, symptoms: Gusten - listening to heart tones to the level of the navel; Koenigsberg - listening to hard bronchial breathing in the upper abdomen. In the study of the rectum, sharp soreness in the posterior Douglas space (Kulenkampf symptom). Peritonitis develops 8-10 hours after perforation.

In typical cases, the diagnosis of complications of peptic ulcer does not cause difficulties. FGS and fluoroscopy of the stomach is contraindicated. To confirm the diagnosis, an overview radiograph of the abdomen is performed, with a crescent strip of gas in the right hypochondrium.

The complexity of diagnosis occurs with closed perforations and atypical perforations of ulcers, especially with late admission of the patient. When the perforations are covered, when the opening is closed by a soldering gland, the two-phase process is characteristic:

1. acute period of perforation with a typical perforation clinic;
2. the period of extinction of the process after covering the perforation, which develops in 30-90 minutes after perforation and is accompanied by some improvement in the patient's condition, a reduction in pain in the abdomen, and the disappearance of the "fatigue" 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, sub-diaphragmatic or intercigitic abscess, giving a vivid clinic. In this case, the leading role in the diagnosis of complications of peptic ulcer disease is history (the presence of signs of the disease, a characteristic two-phase process) and dynamic observation of the patient. To confirm the diagnosis, laparoscopy is indicated, if it is not possible to perform it, it is better to perform a laparotomy than to allow the formation of peritonitis or ulcers in the abdominal cavity.

Atypical perforations, when the perforation opens into the gland, and then through the veneer opening, the gastric contents spread through the abdominal cavity or when the 12 duodenum is sampled, the contents are poured into the retroperitoneal space, are rare and do not give a typical picture, are detected in the formation of peritonitis or in laparoscopy.

Bleeding, as a complication of peptic ulcer disease, occurs in 15-20% of patients and is in the first place for reasons of mortality from this disease. Quite often they are combined with other complications, especially with perforation and penetration.

Penetration of an ulcer is the germination of an ulcer into neighboring organs, with which it is intimately connected by a scar tissue: liver, pancreas, small omentum, intestine, gallbladder, etc. There are 3 degrees of penetration:

• I - formation of a cull ulcer and periprocess;
• II - germination of the ulcer on the entire thickness of the wall of the stomach or duodenum and the formation of adhesions with neighboring organs;
• III - germination of ulcers in adjacent parenchymal organs with the formation of niches in them or in hollow organs with the development of internal fistulas.

Clinic complications of peptic ulcer significantly changes, the seasonality of pain disappears and the daily cyclicity of their occurrence, there is no dependence on the intake of food, the pain becomes permanent, the clinic of inflammation of the organ is attached to which the ulcer penetrates, and often Achilles is formed. The diagnosis is confirmed by FGS and fluoroscopy of the stomach.

Cicatricial stenosis of the pylorus develops gradually as a result of cicatricial deformation of the pyloric and disruption of the motor-evacuation function of the stomach. The picture of complication of peptic ulcer: the pains acquire a stupid character, become permanent, intensify towards the evening and disappear after vomiting; they are accompanied by a feeling of raspiraniya in zpigastria, a sense of passage through the pylorus; there is a burpiness rotten, nausea and progressively increasing vomiting of food eaten the day before, and in the subsequent immediately after a meal. Patients progressively lose weight and weaken.

There are 3 degrees of stenosis:

• I - compensation - the condition of patients does not suffer significantly, there is no weight loss, with the X-ray of the stomach, the evacuation is not changed or reduced slightly;
• II - subcompensation - the general condition worsens, fatigue, weakness, weight loss due to frequent vomiting, evacuation from the stomach of a barium suspension is delayed up to 6-12 hours;
• III - decompensation - weakness, weight loss is pronounced, dehydration and disturbance of water-electrolyte balance, hypochloraemia, barium evacuation from the stomach is slowed by more than 12 hours.

The same picture is observed with stenosing ulcer pyloric stomach (usually either giant or callous), at which the motor-evacuation function is reduced due to pylorospasm. With her, all the typical symptoms of the disease persist.

Malignancy - is noted mainly in the localization of the pathological process in the stomach, ulcers of the duodenum are rarely malignant. When malignancy, pain decreases, becomes permanent, connects heartburn with eating, loss of appetite, characteristic of weight loss patients.

The most commonly malignant cuneiform ulcers and long-term cicatrizing ulcers. For the timely detection of complications of peptic ulcer during FGS it is necessary to take a biopsy, and from three points of ulcers - from the edges, walls and bottom.

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