Peptic ulcer or duodenal ulcer is a fairly common and serious disease. Its course can be complicated by the perforation of the ulcer, when the layers of the walls of the organ are completely destroyed. This condition is also called perforation. With a perforated stomach or intestinal ulcer , half-digested food begins to penetrate into the abdominal cavity, which causes severe pain and can lead to the development of a severe inflammatory process. Patients with such a diagnosis require immediate hospitalization and surgery, because among the consequences of perforation is a lethal outcome.   

Relevance and reasons

Doctors emphasize that in Russia the number of episodes of perforated ulcers is almost twice as large as in European countries. Therefore, perforation is an extremely urgent problem. A huge number of patients who came to the surgeon’s table with such a diagnosis did not even suspect that they had a stomach or duodenal ulcer. Young people and even middle-aged patients are in no hurry to seek medical help, therefore, they do not receive proper treatment that can prevent perforation. And a certain percentage of patients with a diagnosed disease do not follow the recommendations of physicians for therapy.    

Symptoms

Perforation of the ulcer is manifested primarily in severe pain, which can be compared in intensity with a dagger strike. The patient is also covered with a wave of pronounced weakness. Unbearable pain compels the patient to:

• lie motionless;
• take a bent position;
• bring bent legs to the stomach;
• sharply tighten the muscles of the anterior wall of the peritoneum (the abdomen becomes strongly drawn in and very hard);
• breathe less frequently and shallowly.

At first, the pain is limited to a specific area ( epigastrium or the right side of the abdomen). Further, it can spread to the entire abdomen. Painful sensations can be given in different directions, most often in the back and right side (including the shoulder and shoulder blade). Rarely enough, the pain radiates to the left.  

Other signs of a perforated ulcer include nausea, shortness of breath, palpitations, cold sweats, etc.  

Treatment

The appearance of a sharp pain in the abdomen requires an ambulance call. A patient with symptoms of a perforated ulcer is hospitalized for a number of diagnostic measures. If ulcer perforation is confirmed, doctors usually perform urgent surgical treatment. Most often, doctors resort to suturing the defect, but sometimes more serious intervention is required, for example, excision of an ulcer or even resection of the stomach (removal of part of an organ). The indication for resection is the presence of complications, for example, multiple ulcers, repeated perforations, significant size of the ulcer, etc.  

Surgery to suture an ulcer can be performed in an open way, when a doctor cuts through the tissues of the body with a scalpel. But it is also possible to use the laparoscopic technique. In this case, all manipulations are carried out through small incisions using special instruments under the control of a mini-camera ( laparoscope ), which broadcasts the image online to the monitor. Laparoscopic surgery is less traumatic : less tissue damage, less blood loss, and the patient can be discharged faster. But a perforated stomach or intestinal ulcer does not always allow such an intervention, because sometimes doctors need full-fledged open access to the perforation site.  

Is treatment possible without surgery?

Treatment of a perforated ulcer without surgery is rarely practiced. In the CIS countries, such an approach is possible only in exceptional cases, for example, if the patient refuses to undergo an operation or the operation simply cannot be performed (due to the high risk of death). However, Turkish doctors ( Department of General Surgery , Memorial Sisli Hospital , İstanbul-Turkey ) published an article in 2019 on the possibility of non-surgical treatment of perforated ulcer. Their study showed that conservative therapy is possible in a small number of patients who have normal vital signs and do not show signs of generalized peritonitis. As an alternative to surgery, doctors prescribed restriction of oral fluids and food, intravenous nutrition, antibiotics, and drugs that reduce stomach acid. All patients were discharged without complications. So the possibility of conservative treatment of perforated ulcers requires further study.