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Perforated ulcer. Clinical picture and diagnosis of perforated ulcer

The frequency of perforated ulcers of the stomach and duodenum, according to various statistics, ranges from 3 to 20%. Among the patients, there is a clear predominance of men (10 times more than women). Most often, this complication occurs at the age of 30-50 years. 

The clinic of perforated ulcers in most cases is quite typical and, with careful questioning, allows you to accurately establish the diagnosis. The first thing that patients usually complain about are intense pains, often unbearable, that appeared suddenly, “like a dagger blow” (“dagger” pains). Even patients with long-term ulcers note that there has never been such severe pain before. The attack is especially frightening for patients who have not previously experienced pain, that is, those. who had so-called dumb ulcers. 

The latter are observed in about 10-20% of cases, more often in young people. In 10-15% of patients, there is a gradual development of pain syndrome. This is due to the fact. that against the background of the next, more often severe exacerbation of peptic ulcer disease, an even greater increase in pain is not perceived by the patient as a catastrophe. It is noticed that the faster the gastric contents are poured into the free abdominal cavity, the more intense the pain syndrome. The pain may become less severe at some time, which is associated with a blockage of the hole with an omentum or other organ (covered perforation) or a piece of food. 

If a large amount of fluid is poured into the abdominal cavity , then it rushes along the right lateral canal to the right iliac region, where it accumulates (together with exudate) and causes rather pronounced pain. This phenomenon is often the reason for the erroneous diagnosis of acute appendicitis. Such an error is all the more possible since the clinical picture of acute appendicitis often develops according to the same scheme: pain in the epigastrium, which then mixes into the right iliac region (Volkovich-Kocher symptom).  

Patients , trying to relieve suffering, take a forced position (sitting with knees drawn to the stomach, lying on their back or right side with legs bent at the knees).

The second very important sign is a tense , retracted, board-like abdomen that does not participate in breathing. The most pronounced tension is in the upper right quadrant of the abdomen. Feeling it is sharply painful. A positive peritoneal symptom of Blumberg is determined – Brushes on. This sharp muscle tension is very characteristic of a perforated ulcer and, together with the characteristic pain syndrome, should direct the doctor’s mind towards this diagnosis. A characteristic sign of perforation is the presence of free gas in the abdomen, which usually accumulates over the liver. 

The presence of gas is determined by percussion , which reveals the absence of hepatic dullness, or by x-ray examination. Patients usually complain of dry mouth, thirst, and gas and stool retention. In the first hours after perforation, the pulse is slow, and later, but as peritonitis develops, it becomes more frequent. Sometimes vomiting occurs. Emergency laparoscopy can provide some help in diagnosing perforation. 

To a large extent , the diagnosis is helped by indications of a history of gastric ulcer or duodenal ulcer, especially if perforation is preceded by an exacerbation with precursors of perforation – a sharp exacerbation of pain, severe dyspeptic disorders that appear several hours or days before perforation. V.V. Uspensky and G.F.  

Sometimes the clinic of distinct perforation then subsides; this is a covered perforation described by Schnitzlsrom (1912), which occurs in 2-5% of patients. This happens if the perforated hole, usually small, is covered by the organs lying next to it: the liver, pancreas, omentum. If the adhesion of organs is quite fatal, then the patient can sometimes recover without surgery. However, one should remember about the possibility of two-stage perforation – the discharge of the organ covering the opening in the stomach due to sudden movements or other reasons. 

If, for some reason, a patient with a perforated ulcer is not operated on in time, then the clinic of diffuse peritonitis develops in the future. In advanced cases, when the patient’s condition is extremely serious, it is often very difficult to establish the cause of peritonitis.  

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