Pyloroduodenal stenosis. Malignant ulcer

Pyloroduodenal stenoses are the result of scarring during the healing of an ulcer or a dense infiltrate in the area of ​​an active ulcer. With the clinic of the picture of stenosis, Schmiden’s deformities of the stomach can also occur. Most often, the stricture is located in the duodenal bulb or in the area of ​​the pyloric canal. Depending on the degree of violation of gastric evacuation, compensated and decompensated stenoses are distinguished. 

Compensated stenoses are characterized by a moderate violation of evacuation (barium is retained for up to 4-6 hours). In the beginning, even an accelerated evacuation from the stomach may be noted. In this period, there is an increased peristalsis of the hypertrophied muscles of the stomach. Due to this, despite the narrowing, although much more slowly, the stomach still copes with the evacuation of food. Clinically, at this stage, there is severity after eating in the epigastric region, sometimes peristalsis visible to the eye. Due to an increase in pressure in the stomach and gnpermotoriki, a picture of cardia insufficiency often develops (heartburn, regurgitation of food, belching). Vomiting may occur at times, but it is not yet regular. 

The disease can be suspected already when interviewing the patient. The diagnosis is confirmed by X-ray examination, which reveals a delay in the evacuation of barium and a hypermotorpix of the stomach. It is important to carefully study the area of ​​the narrowing, to determine the exact location of the stricture, its length and, if possible, especially in the presence of a pronounced pain syndrome indicating an active ulcer, to try to identify it. 

Decompensated stenosis is characterized by a sharp violation of gastric evacuation (barium is retained in the stomach for more than 6 hours, within a day or more), a sharp expansion of the stomach, its atony, a significant deterioration in the general condition of patients. Writing in the stomach stagnates: often in a sharply distended stomach contains several liters of stagnant, fetid contents, belching with the smell of rotten eggs appears. The patient complains of severe heaviness in the epigastrium, rotten eructation, regular vomiting, which occurs involuntarily at first. Later, with an increase in stomach atony, the patient himself induces vomiting. On an empty stomach, the symptom of “splash noise” is noted. Due to the loss of a large amount of fluid, protein and salt, patients are quickly depleted. Pains that were observed earlier often subside and symptoms of evacuation disorders prevail. In other cases, when the stenosis is due to ulcerative infiltration, the pain syndrome can be pronounced. There is a thickening of the blood, a decrease in the content of chlorides and potassium in the blood, and acidosis develops. Diuresis decreases. The acidity of gastric juice is usually increased with rP-metric. 

In the terminal stage, severe dehydration and exhaustion (cachexia) occur, severe enterocolitis develops, which is manifested by diarrhea, dermatitis, dementia. In some cases tetany may develop due to calcium loss. The prognosis in such advanced cases is very difficult to determine, but nevertheless, thanks to modern resuscitation measures, a number of patients will be able to be taken out of an extremely serious condition and successfully operated on. 

Usually, the diagnosis is easy to establish clinically, based on symptoms of impaired gastric evacuation and a history of peptic ulcer disease. X-ray examination determines the violation of evacuation from the stomach, its expansion and atony. The differential diagnosis should be carried out with a malignant tumor, in favor of which a short history and the absence in the past of the classic clinic of peptic ulcer disease can speak. The diagnosis is clarified by gastroscopic examination.  

Malignant ulcer

Stomach ulcers in 15-20% of cases undergo cancerous degeneration. Particularly unfavorable in this regard are ulcers of the greater curvature and of the prepyloric section of the stomach. About 90% of ulcers of greater curvature are malignant. Callous ulcers are more often malignant in patients over 40 years of age. An ulcer larger than 1.5 cm in diameter should be considered potentially malignant. Malignancy often begins at the edge of the ulcer, less often from the bottom. 

There are no completely reliable signs of cancerous degeneration . Its distinct symptoms, as a rule, appear too late. And yet, some signs can help the doctor establish the malignancy of the ulcer, in any case, suspect it and subject the patient to a thorough examination: 1) the localization of the ulcer (ulcers of greater curvature, prepyloric and cardiac should be considered potentially malignant and such patients should be examined especially carefully); 2) the diameter of the ulcer is more than 1.5 cm; 3) long-term ulcerative history; 4) proven reduction in gastric acidity. The last sign should be taken into account only if the study of gastric juice was carried out by sufficiently reliable methods (pH-metry, fractional study). An important indication of the possibility of malignancy is a change in the nature of the pain syndrome, which is usually manifested by the disappearance of its frequency and constant dull pain. Sometimes the pain disappears almost completely. In any case, any change in the nature of the usual pain should be taken into account, which patients usually note quite clearly. The ineffectiveness of a 4-6 week course of intensive treatment should also raise suspicion of malignancy.  

It must be remembered that the elimination of the ulcerative niche , established during the control X-ray examination, may occur as a result of its filling with a growing tumor. 

It is practically impossible to catch the initial signs of malignancy by X-ray. X-ray signs (undermining of the edges of the ulcer, infiltration, filling defect) appear later. The leading role in the diagnosis of the initial stage of malignancy belongs to gastroscopy with biopsy. For research, it is necessary to take pieces of tissue from several places of the ulcer, keeping in mind that malignancy can begin at any one point. A negative biopsy response does not mean that there is no malignancy, since the affected area may not be included in the biopsy area. If it is still impossible to exclude malignancy clinically, radiologically and endoscopically in such a patient, endoscopy and biopsy should be repeated. If even after a re-examination there are doubts, the patient should be operated on, since not only proven malignancy, but also a reasonable suspicion of it serves as an indication for surgery. Only such an approach will avoid fatal mistakes.

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