Bleeding stomach ulcer. Perforated stomach ulcer
The largest number of diagnostic errors is observed in the first hours of the disease, when symptoms appear (nausea, vomiting, diarrhea, abdominal pain, weakness, chills, low-grade fever), characteristic of both foodborne diseases and bleeding ulcers of the stomach and duodenum. Gastroduodenal bleeding is most often due to peptic ulcer disease.
At the same time, the frequency of bleeding complicating peptic ulcer disease varies from 4.2 [Janelidze Yu.Yu., 1937] to 34.8% [Monroe R., 1935]. In 70% of patients, ulcerative bleeding is associated with damage to the duodenum and in 30% – with damage to the stomach.
Under our supervision, there were 42 patients aged 20 to 60 years (29 men and 13 women), referred to the hospital with a diagnosis of food toxicoinfections, who were diagnosed with a bleeding ulcer of the stomach or duodenum. In the anamnesis, 24 patients had peptic ulcer disease or chronic gastritis, 25 patients complained of pain in the abdomen before the onset of bleeding. During the period of bleeding, the pain stopped and did not bother.
Vomiting was observed in 40 patients: in 36 it was repeated, in 5 – with an admixture of scarlet blood and in 35 – the color of “coffee grounds”. The stool in 28 patients was liquid in the first hours of the disease, in 9 – shaped, but black, in 16 – tarry (melena), in 3 patients – liquid, dark cherry color. Pallor of the skin and mucous membranes was observed in 30 patients, dizziness – in 34, short-term loss of consciousness – in 14. On admission to the hospital, normal or low temperature was detected in 15 patients, subfebrile – in 20, above 38 ° C – in 7.
The temperature remained subfebrile in the following days in 33 patients, chills on the first day were detected in 7, tachycardia – in 38, a decrease in blood pressure in 29 patients. In 5 patients, the disease was complicated by hemorrhagic shock. A decrease in the level of hemoglobin below 80 g / l was noted in 26, below 50 g / l – in 8 patients. In 23 patients, leukocytosis was more than 10.0 * 109 / l, including 8 – more than 20.0 * 109 / l. In all cases, the diagnosis of a bleeding ulcer was made in a timely manner and hemostatic therapy was carried out in full. In bacteriological studies of feces, negative results were obtained.
Perforated stomach ulcer
A perforation of a stomach or duodenal ulcer can cause errors in the diagnosis of foodborne diseases. Perforation of the ulcer is more common in men aged 20-40 years. For a young age, perforation of the duodenum is more characteristic, for the elderly – perforation of a stomach ulcer. many patients have a history of “dyspeptic past”. In 8-10% of patients, perforation of ulcers occurs against the background of complete well-being, without previous symptoms of peptic ulcer disease. The greatest diagnostic difficulties are noted when the patient turns to the doctor after 1-2 days from the onset of the disease. Most often, an acute onset is observed – with the appearance of extremely sharp (“dagger”) pain in the epigastrium.
However, some authors note the appearance immediately before the perforation of the ulcer of prodromal symptoms (increased pain in the abdomen, nausea). The pain is localized in the epigastrium with perforation of the gastric ulcer and to the right of the abdomen line – with perforation of the duodenal ulcer. It spreads fairly quickly throughout the abdomen. Sometimes there is an irradiation of pain to the right scapula. Vomiting at this time is not typical, it appears later, when signs of peritonitis appear.
The patient’s appearance is characteristic : he lies motionless, often on his side, with the lower limbs brought to the stomach and avoids changing the position of the body. The face is pale, with a frightened expression, sometimes cold feet protrude. The body temperature is lowered, bradycardia and arterial hypotension are noted. The tongue may remain moist and uncoated until peritonitis develops. The abdomen does not participate in breathing, but the tension of the anterior abdominal wall is clearly expressed. Shchetkin’s symptom becomes positive.
Characterized by the disappearance of hepatic dullness with percussion (Spijarny symptom), dullness of the percussion sound in the right iliac region (de Quervain’s symptom) and a positive phrenicus symptom (Georgievskaya’s symptom – Mussi). With digital rectal or vaginal examination, there is a sharp soreness of the pelvic peritoneum, with X-ray – free gas in the subphrenic region between the right dome of the diaphragm and the upper surface of the liver, and more rarely between the left dome of the diaphragm and the shadow of the stomach (in 75-80% of patients with a perforated ulcer).
The patient ‘s condition worsens 6-12 hours after the perforation. The development of peritonitis is accompanied by repeated vomiting. There is an increase in body temperature, tachycardia, arterial hypotension. The tongue becomes dry and coated. Bloating is pronounced, in its sloping parts during percussion the dullness of sound is determined. Peritoneal symptoms are sharply positive. Increased leukocytosis in the peripheral blood.
We observed 32 patients (30 men and 2 women, mainly between the ages of 25 and 40) who were referred to an infectious diseases hospital with a diagnosis of foodborne toxicity, in whom a perforated ulcer of the stomach or duodenum was revealed. In the first 6 hours from the onset of the disease, 23 patients were hospitalized, within 6-12 hours – 6 and after 12 hours – 3. In the history of patients – peptic ulcer (5) and chronic gastritis (9); 19 patients denied a history of diseases of the gastrointestinal tract.
Acute onset of the process was noted in all observed patients, minor prodromal phenomena were observed in only one of them, nausea – in 23, vomiting – in 18, loose stools in 3 patients 2-3 times a day, chills in one. Normal body temperature was at admission in 20 patients, within 37-38 C – in 10, above 38 ° C – in 2 patients. Acute pain in the abdominal region, localized mainly in the epigastrium, was noted in all patients, tension of the anterior abdominal wall – in 31, Shchetkin’s symptom was positive in 30 patients. Spijarny’s symptom was detected in 9 patients, de Quervain’s symptom – in 6 and a positive phrenicus symptom – in 8 patients. X-ray examination revealed artificial pneumoperitoneum in 9 out of 11 patients with perforated gastric and duodenal ulcers.
Peripheral blood leukocytosis in 27 patients exceeded 10.0 * 10 9 / l (in 4 – more than 20.0 * 10 9 / l). On the operating table, perforation of gastric ulcers was detected in 12 and duodenal ulcers – in 20 patients.