A stomach or duodenal ulcer with perforation is an acute surgical disease resulting from the through destruction of the wall of the stomach or duodenum in the ulcer zone.

When the stomach or duodenum is perforated, contents that are highly acidic enter the free abdominal cavity, causing irritation of the peritoneum.

Symptoms

Therefore, the main symptom of a perforated stomach ulcer or duodenal ulcer is a sharp, sudden (“as if struck with a dagger in the stomach”) pain in the epigastric region (in the upper abdomen). Nausea, vomiting, a drop in blood pressure, heart palpitations, and increased sweating may also occur. In patients with obesity, weakened immunity, taking steroids, as well as in patients with a low level of consciousness, the elderly and in children, the clinical picture may be less pronounced.

An objective examination reveals pain on palpation of the abdomen. The pain intensifies during movement, the abdominal muscles are ” board-like ” tense, the patient’s position is forced – he lies on his side or on his back, his knees are pulled up to his stomach, his face is suffering, the skin is pale, the lips are cyanotic (cyanotic), the limbs are cold, the facial features are pointed, rare pulse and low blood pressure are recorded. With abdominal percussion, there is a sharp pain. Symptoms of peritoneal irritation are positive. With auscultation of the abdomen, peristalsis is weakened and the Gusten triad is determined : the spread of heart sounds to the level of the navel, peritoneal friction (similar to the friction noise of the pleura in the subcostal or epigastric region), metallic ringing – a sound that appears during inhalation due to the release of gas bubbles from the stomach.

With the development of peritonitis, the tension of the muscles of the anterior abdominal wall increases, an increase in temperature, chills may appear.

Forms

Perforated ulcers are classified:

• By localization: stomach ulcers, duodenal ulcers;
• According to the clinical form: perforation into the free abdominal cavity (typical, covered), atypical perforation (into the omental bursa, the small or large omentum – between the sheets of the peritoneum, into the retroperitoneal tissue, into the cavity isolated by adhesions), a combination of perforation with other complications of the ulcerative process (bleeding , stenosis, penetration, malignancy).

Perforated ulcers are also classified according to the severity of peritonitis.

The perforation site can be covered with a wall of an adjacent organ or an omentum for a short time, in which case the perforation is called covered. If the contents of the stomach or duodenum continues to flow freely into the abdominal cavity, or for some reason there is a delay in treatment, a complicated form of perforated ulcer may develop.

Causes

While the presence of an imbalance between protective and damaging factors is the cause of ulceration, it is still unclear why some patients experience perforation (perforation of all layers of the lining of the stomach or duodenum), while others do not. There is a diurnal peak of perforated ulcers with a large number of perforations occurring in the morning, which is possibly related to the circadian rhythms of acid production. The risk of perforation increases with fasting, for example, perforation increases during Ramadan, which may also be due to acid exposure more pronounced during fasting. It has been noted that ulcer perforation occurs after bariatric surgery, after cocaine or amphetamine use, after chemotherapy. Patients with acid hypersecretion, including those with gastrinoma ( Zollinger- Ellison syndrome ), are also at a higher risk of perforation.

Diagnostics

Diagnosis of a perforated stomach or duodenal ulcer is carried out by a surgeon based on anamnesis, clinical examination, collection of complaints and instrumental examination methods.

To diagnose a perforated gastric or duodenal ulcer, imaging methods are used – ultrasound examination of the abdominal cavity (the diagnostic accuracy of ultrasound is estimated at about 80.0%), radiography of the abdominal cavity (diagnostic accuracy is about 80%), computed tomography (diagnostic accuracy of CT in case of a perforated ulcer is 98 %), fibrogastroduodenoscopy . These examination methods make it possible to register the characteristic signs of a perforated ulcer: the presence and localization of an ulcer, free gas in the abdominal cavity, free fluid in the abdominal cavity, a perforated hole.

The presence of air or a large amount of liquid usually indicates perforation. However, in 30% of cases of perforated gastric or duodenal ulcer, X-ray of free fluid or air in the abdominal cavity is not detected. In these cases, a computed tomography (CT) scan of the abdomen may be performed. Ultrasound of the abdominal organs is not widely used for the diagnosis of perforation, since it largely depends on the qualifications of the researcher. For the purpose of a detailed study of the perforation hole and assessment of the presence of peritonitis (inflammation of the peritoneum), diagnostic laparoscopy (the most accurate diagnostic method) and fibrogastroduodenoscopy (the diagnostic value of FGDS in establishing the presence of an ulcer is 90%) are performed .

If the above methods are not informative, the diagnosis of a perforated stomach or duodenal ulcer can be supplemented by a laparoscopic examination, during which not only the diagnosis is clarified, but the perforation can also be sutured.

General and biochemical blood tests help in assessing the inflammatory response, and also rule out differential diagnoses, such as, for example, acute pancreatitis. In a clinical analysis of blood, signs of an inflammatory process are determined – leukocytosis (an increase in the number of white blood cells).

For the purpose of differential diagnosis with acute pancreatitis, amylase activity is determined in a single portion of urine and in blood serum (amylase activity is lower with ulcer perforation and increases gradually).

At the stage of diagnosis, it is necessary to carry out differential diagnosis with a number of diseases, but it is especially important to exclude rupture of an aneurysm (bulging and thinning of the wall) of the abdominal aorta or acute pancreatitis (inflammation of the pancreas). The first is because of its high mortality rate associated with delayed treatment; the second – because of the need for intensive conservative therapy in the intensive care unit.

Differential diagnosis is also carried out with other acute surgical diseases – appendicitis (inflammation of the appendix of the cecum), cholecystitis (inflammation of the gallbladder), perforated stomach cancer, myocardial infarction (heart attack), acute intestinal obstruction, acute pleurisy (inflammation of the pleura).

The main laboratory tests used:

• Clinical blood test (complete blood count, leukocyte count, ESR);
• Biochemical blood test (including determination of amylase activity);
• Biochemical analysis of moths (urine diastasis).

The main instrumental studies used:

• Abdominal ultrasound (detection of free gas and liquid);
• X-ray of the abdominal cavity;
• Computed tomography of the abdominal cavity;
• Fibrogastroduodenoscopy ;
• Diagnostic laparoscopy.

Treatment

Treatment of perforated gastric or duodenal ulcers is prescribed by a surgeon and gastroenterologist. The results of the treatment of perforated gastric or duodenal ulcers directly depend on the early diagnosis of the rapid initiation of intensive care. There are several treatment strategies depending on the patient’s condition. In most cases, the treatment of a perforated stomach or duodenal ulcer consists in suturing the perforated defect, followed by a course of antiulcer therapy. The operation can be performed both open and laparoscopically (through a small opening in the abdominal wall). The success of surgical treatment is maximum if the operation was performed within the first 6 hours after perforation. During this time, the acidic contents of the stomach delay the development of peritonitis (inflammation of the peritoneum).

Patients with minimal or localized symptoms and in good clinical condition may choose to be monitored and conservatively treated. In this case, treatment should include intravenous antibiotics, nasogastric intubation (insertion of a tube through the nose into the stomach), antisecretory and anti-acid drugs, and a series of control X-ray studies using water-soluble contrast agents to confirm the absence of contrast release into the abdominal cavity. However, when choosing the tactics of conservative treatment, it should be remembered that every hour of delay in the operation increases the number of complications and deaths.

Complications

With a delay in diagnosis and initiation of therapy against the background of the continuing flow of gastric or intestinal contents into the abdominal cavity, it is possible to develop diffuse peritonitis (inflammation of the peritoneum), the formation of abscesses (cavities with purulent contents), bacteremia and sepsis (blood poisoning).

Prophylaxis

Prevention perforated ulcer of the stomach or duodenum is timely diagnosis and comprehensive treatment of gastric ulcer or duodenal ulcer, a diet, quitting smoking and drinking alcohol, taking protect the mucous of the gastrointestinal tract drugs medication use, if necessary, having ulcerative (damaging the mucous membrane) effect (such as, for example, non-steroidal anti-inflammatory drugs).

What questions should you ask your doctor

Do you need an operation in this case or can you do without it?

What should be done so that such complications do not recur in the future?

Patient advice

The selection of drug therapy for gastric ulcer and duodenal ulcer should be carried out by a gastroenterologist. It is also necessary to coordinate with him the reception of all other drugs that doctors of other specialties can prescribe for “their” concomitant diseases.

Avoid spicy foods, alcohol, caffeine, control stress, and quit smoking cigarettes.

It is impossible to independently and uncontrollably take non-steroidal anti-inflammatory drugs (“for pain – on the advice of friends”). They can irritate the stomach lining!