Perforated duodenal ulcer: symptoms, diagnosis, treatment of perforation

A disease such as a perforated ulcer can develop at any age, against the background of stressful events and non-compliance with recommendations regarding dietary rules.

According to statistics, perforation in the intestinal tract is more common at a young age, and in older people, in most cases, the disease affects the tissues of the stomach.

Etiology

Perforated duodenal ulcer by morphological characteristics does not differ significantly from gastric ulcer. Outwardly expressed as a through hole in the walls of the vessel.

Speaking about the reasons for the appearance of perforation, there are several fundamental triggers:

• Availability stomach ulcers history;
• gastritis, gastroduodenitis;
• acid-base imbalance.

Overeating, controlled physical activity, bad habits (alcoholism, smoking) can cause peptic ulcer disease in the initial part of the small intestine. Often, perforation foci can be recorded in people suffering from eating disorders, as a consequence of the complication of bulimia or aplotriophagia.

Not infrequently, a perforated duodenal ulcer is observed in combination with such diseases of the digestive tract, such as gallstone disease, inflammation of the appendix or cholecystitis, or infiltration with Helicobacter bacteria Pylori.

Classification

The typology of this disease includes distribution according to the main points that are reflected in the clinical picture:

• Due to the occurrence - the discovery of a chronic ulcer, exacerbation of peptic ulcer disease against the background of hormonal disruptions or the mental state of the patient.
• By location - in various parts of the stomach, in the parts of the duodenum.
• By type of obstruction - typical ulceration directly into the abdominal cavity, atypical with perforation in the omentum, in combination with bleeding in the gastrointestinal tract.
• By the degree of development of the inflammatory process - in violation of chemical reactions, in violation of the bacteriological background, peritonitis with pronounced purulent discharge.

According to the current classification, there are several main periods of development and course of peritonitis. Each of them has certain differences in the flow process. The phase of abdominal shock, observed during the chemical stage of peritonitis, lasts about 6 hours, the next stage (bacterial) up to 12, the phase with the spillage of purulent contents occurs in the next half days.

Symptoms

In accordance with the period of development of perforation, the symptoms of pathology develop. The first symptoms of a perforated ulcer are acute painful sensations in the epigastric region, after which they spread to the upper abdomen. With perforation of the stomach, pain may radiate to the shoulder or collarbone. In the case of the duodenum, pain is given to the pelvic area. If tissue rupture occurs with a full stomach, vomiting occurs with possible blotches of blood or bile.

The main manifestations of pathology also include the appearance of the patient. It is distinguished by pallor of the skin, sunken eyeballs, and rapid shallow breathing. When taking readings, the state of the initial bradycardia is recorded, the pulse drops to 55 beats, and the blood pressure decreases.

On external examination, the tone of the muscles of the press is felt, the participation of the abdomen is not observed in the respiratory process (in patients of young and middle age). As a result of the appearance of free gases in the abdominal cavity, palpation of the liver becomes impossible.

With the onset of the second period, a false normalization of the patient's condition can be ascertained: pallor goes away, blood pressure and heart rate and respiration are leveled. With this, the tongue changes its state - there is a feeling of dryness and stiffness.

On internal examination (palpation of the anus), one can notice the overhang of one of the walls of the rectum, when it is completed, an acute pain arises.

The third stage is characterized by a rapid deterioration in the general condition of the patient. Vomiting begins, dehydration of the mucous membranes occurs, the temperature rises, gradually drops, a dry plaque appears on the tongue, the abdomen swells up, on palpation, you can feel the fluid in the abdominal cavity.

With an atypical form of perforation, subcutaneous emphysema appears in the navel or in the chest area.

In the case of perforation in the omentum and its sections, the inflammatory process begins, which manifests itself as moderate pain, and the tension in the abdomen is practically not felt during palpation.

Clinical manifestations

A perforated duodenal ulcer is characterized by a rather polymorphic clinical picture. The manifestation of pathology is mainly carried out in an individual manner and depends on such factors as age, concomitant health problems, standard of living and psycho-emotional state of the patient.

At the beginning of the pathological process, all symptoms appear acutely and, as a rule, are already associated with existing functional disorders of the gastroduodenal system, the so-called pre-ulcerative condition. It is conventionally divided into 2 types - functional failure of the gastrointestinal tract and chronic erosion forming pathologies (gastritis, duodenitis).

The main description for the clinical picture of peptic ulcer disease is pain, which can subside, go into a latent period, and then return seasonally.

In practice, several types of ulcer pain are distinguished - late and hungry, with a different nature of intensity and duration of manifestation. The presence of an ulcer is also indicated by frequent bouts of heartburn, belching, discomfort after eating and vomiting. 50% of patients have problems with defecation.

Diagnostics

The main source of information in the process of determining this pathology is the patient himself, since the first stage of diagnosis first of all, the patient is interviewed, after which he is assigned all the methods necessary according to the existing symptoms survey.

The importance of talking with the patient lies in the fact that a perforated ulcer, according to its symptoms, is practical identical with signs of acute appendicitis, except for the antecedent main symptoms phenomena. These include: fever, nausea, chills.

With regard to diagnostic methods, the doctor decides on the direction of certain procedures, after an external examination and palpation of the abdomen.

X-ray examination reveals the presence of free gas in the abdominal cavity, which is a direct basis for the diagnosis of gastrointestinal organ perforation.

If the X-ray results are controversial, an endoscopic examination is prescribed. In fact, even preparation for fibrogastroscopy can give an accurate diagnosis, since when air is pumped into an organ that has undergone perforation, the patient will feel acute pain.

An abdominal ultrasound is used to determine the presence of liquid contents.

If all of the above methods did not make it possible to accurately establish the diagnosis or determine the localization of the pathogenic process, laparoscopy is performed.

Duodenal ulcer perforation: treatment and prevention

Ulcer perforation suggests emergency hospitalization of the patient. If all the grounds for curing the diagnosis are identified, the further actions of doctors completely depend on the patient's condition.

If the patient is in a difficult physical and emotional state (acute pain, shock), he is given a dropper with a complex of anti-inflammatory and analgesic drugs. At the same time, strong antipsychotics are not used so as not to blur the clinical picture and not to disorient the operating surgeon in the future.

After registration of the patient in a surgical hospital, a number of examinations are carried out aimed at registration of indicators of the patient's condition in order to exclude complications during surgical interference.

A confirmed diagnosis of perforation of a duodenal ulcer, regardless of the patient's condition, is direct and without an exceptional indication for surgery. Conservative therapy in this case is ineffective and carries a risk of death.

The operation for perforation of the duodenum is carried out in several stages:

• Training - consists in aspiration of the contents of the stomach by inserting a probe into the esophagus, catheterization of the bladder and hygienic treatment of the surgical site with an antiseptic.
• Anesthesia - the operation is performed under general endotracheal anesthesia. Local anesthesia is possible, but it is used in rare cases when the patient has a direct contraindication to general anesthesia.
• Direct intervention is carried out by the method of upper median laparotomy. The localization of the through hole in the tissues is determined by the characteristic hiss of air, the surgeon raises the stomach towards the outgoing streams and looks for hyperpigmented areas of manifestations. In rare cases, the opening of not one, but two ulcers may be revealed. The surgeon removes the pus and rinses the wound, after which he eliminates the main pathological process, that is, sutures the perforation site. Then it sanitizes the affected area and the accessible areas of the abdominal cavity.

Complications

In the postoperative period, rarely, but complications such as peritonitis or postoperative pneumonia do occur. The reason for such phenomena is a late visit to a doctor or an initially incorrectly diagnosed or old age of the patient.

To date, statistics show that complications with a fatal outcome in the case of ulcer perforation make up no more than 5% of all reported visits to the clinic.

Forecast

Perforation of a duodenal ulcer is a manifestation of chronic pathologies of the gastrointestinal tract, respectively in in most cases, doctors do not risk giving too positive predictions, due to the risk of repeated perforation.

If the indicated diet is followed after elimination of the focus, the likelihood of repeated perforation remains on 15-20%. That is why patients need to undergo a comprehensive examination every six months so that the doctor can correct the list of medications used and the principle of nutrition.

Prophylaxis

To avoid perforation of the stomach or duodenum, if you have a history of gastroreflux abnormalities, it is possible if you follow the basic rules: correct eat, monitor the state of the acid-base balance, have a normal daily routine and regularly take medications that are prescribed by doctors treating existing ones disease.

It is important for people at risk to realize that at the first signs of complications of ulcerative illness, you need to rush to the doctor, a timely appeal to the surgeon without exaggeration can save you a life.