Probodny stomach ulcer
Probodny stomach ulcer – the through damage of a wall of a stomach arising on the place of a sharp or chronic ulcer. This state belongs to simptomokompleks of "a sharp stomach". It is clinically shown by intensive belly-ache, doskoobrazny tension of a forward belly wall, fever, tachycardia, vomiting. The ezofagogastroduodenoskopiya, ultrasonography and KT of abdominal organs, a survey X-ray analysis of abdominal organs, a diagnostic laparoscopy will help to make the correct diagnosis. Treatment is mainly surgical, it is supplemented with antisekretorny, dezintoksikatsionny and antikhelikobakterny therapy.
Probodny stomach ulcer
Probodny stomach ulcer is formed generally at persons of able-bodied and advanced age. Fortunately, this complication meets rather seldom – no more than two cases on 10000 population. Without watching improvement of diagnostics and improvement of antikhelikobakterny therapy, the frequency of perforation at stomach ulcer over the years increases. Among all complications of stomach ulcer of a stomach the perforative ulcer occupies not less than 15%, and in general this state develops at every tenth patient with the ulcer anamnesis. Among patients with perforation of a stomach of ulcer genesis of men is ten times more, than women. The perforation of a stomach is one of the leading causes of death at stomach ulcer. Researches in the field of gastroenterology show that the perforation of stomach ulcer develops three times more often than perforation of an ulcer of DPK. The retrospective analysis of clinical records indicates that about 70% of probodny ulcers are "mute", i.e. before perforation clinically are not shown in any way.
Reasons of probodny stomach ulcer
Belong to risk factors of this state existence of sharp or chronic stomach ulcer, the verified helikobakterny infection (at 60-70% of patients). Refer violation of activity of endocrine glands, atherosclerosis, insufficiency of blood circulation, heavy respiratory frustration with development of ischemia of internals to more rare reasons of formation of probodny stomach ulcer.
Probodny stomach ulcer proceeds in three stages. The initial stage lasts till 6 o'clock after a perforation; in this phase sour juice from a stomach gets into an abdominal cavity, causing the strong chemical damage of a peritoneum which is shown sudden intensive belly-ache. The second phase (6-12 hours after a perforation) is characterized by intensive production of exudate which dilutes hydrochloric acid that leads to reduction of belly-ache. In the third phase (from 12 hours to one days after a perforation) purulent peritonitis develops, interintestinal abscesses are formed.
Probodny stomach ulcers classify on:
- etiologies (perforation of a chronic or sharp ulcer);
- to arrangement (on curvature of a stomach, in an antruma, a sebesten or a pylorus, a stomach body);
- to clinical form (classical – break in a free abdominal cavity; atypical – in an epiploon, the cellulose of zabryushinny space delimited by solderings a cavity; a combination with gastric bleeding);
- peritonitis stages (the chemical, bacterial, poured purulent).
Symptoms of probodny stomach ulcer
Several signs are inherent in Probodny stomach ulcer: stomach ulcer of a stomach in the anamnesis, sudden intensive belly-ache, doskoobrazny tension of a belly wall, considerable morbidity at a stomach palpation. At poll approximately every fifth patient notes strengthening of pains in a stomach some days before perforation. Irradiation of pain depends on the provision of probodny stomach ulcer: in a hand (a shoulder and a shovel) on the right at a piloroduodenalny ulcer, at the left – at a defect arrangement in the field of a bottom and a body of a stomach. At break of an ulcer of a back wall of a stomach hydrochloric acid streams in cellulose of zabryushinny space or a bag of an epiploon therefore the pain syndrome is almost not expressed.
At survey the compelled situation with the knees given to a stomach, a suffering look, strengthening of pain at the movements attracts attention. Cross furrows on direct muscles of a stomach become more expressed, there is a retraction of a stomach on a breath (paradoxical breath). Arterial hypotonia is followed by bradycardia, short wind. During the first hours diseases the expressed morbidity at a palpation in epigastralny area which in the subsequent extends to all forward belly wall is noted. Symptoms of irritation of a peritoneum sharply positive.
Diagnosis of probodny stomach ulcer
Urgentny consultation of the gastroenterologist and surgeon is shown to all patients with suspicion of probodny stomach ulcer. The purpose of all tool researches and consultations (including endoscopist) – identification of free liquid and gas in an abdominal cavity, ulcer defect and a perforative opening.
The survey X-ray analysis of abdominal organs in vertical and side position allows to reveal the free gas in an abdominal cavity which is crescently located over a liver or under a stomach sidewall. This research informatively in 80% of cases. For more exact diagnostics use KT of abdominal organs (98% of informational content) – allows to find not only free liquid and gas, but also a thickening gastric and duodenal sheaves, directly probodny stomach ulcer.
During performing ultrasonography of abdominal organs it is recommended to visualize not only gas and liquid in an abdominal cavity, but also the hypertrophied site of a gastric wall in the field of probodny stomach ulcer. Ultrasonography is one of the most exact and available methods of identification of the covered perforation.
Ezofagogastroduodenoskopiya gives the chance to establish the diagnosis of probodny stomach ulcer at nine patients from ten. Carrying out EGDS is especially shown to patients with suspicion of probodny stomach ulcer at whom does not come to light (free gas in an abdominal cavity) during a X-ray analysis – forcing of air in a stomach during the research leads to gas discharge in an abdominal cavity and to positive results of a repeated radiological research. EGDS allows to visualize double perforation, bleeding from ulcer defect, multiple ulcerations, a stomach ulcer malignization. Also the fibrogastroscopy helps to define optimum tactics of surgical intervention.
The diagnostic laparoscopy is the most sensitive method of detection of probodny stomach ulcer, gas and an exudate in a free abdominal cavity. This research is shown to all patients with doubtful conclusions of already conducted examinations (a X-ray analysis, ultrasonography, EGDS, KT of abdominal organs). It is necessary to differentiate probodny stomach ulcer with an acute appendicitis, cholecystitis, pancreatitis, aneurism of a belly aorta, a myocardial infarction.
Treatment of probodny stomach ulcer
The purpose of therapy of probodny stomach ulcer is not only rescue of life of the patient and elimination of defect in a stomach wall, but also treatment of stomach ulcer of a stomach, the poured peritonitis. In practice of the gastroenterologist and the surgeon cases of conservative maintaining probodny stomach ulcer meet. Conservative treatment is used only in two cases: at dekompensirovanny somatic pathology and flat refusal of the patient of operation. Conditions for performing conservative treatment: less than twelve hours from perforation, age no more than 70 years, lack of an intense pnevmoperitoneum, stable haemo dynamics. Include anesthesia, introduction of antibiotics and antisekretorny medicines, antikhelikobakterny and dezintoksikatsionny therapy in a complex of conservative treatment.
In expeditious treatment of probodny stomach ulcer allocate three main approaches: perforation closing, excision of stomach ulcer, stomach resection. At the most part of patients closing of perforation by its tamponada, cover by an epiploon or an ushivaniye is carried out. Indications to closing of probodny stomach ulcer: asymptomatic perforation, duration of a disease is more than 12 hours, existence of symptoms of peritonitis, critical condition of the patient. The initiation of treatment later, than in a day from perforation, increases a lethality three times. Antikhelikobakterny and antisekretorny therapy in the postoperative period allows to improve results of operation on perforation closing.
Excision of probodny stomach ulcer is made only at every tenth patient. This operation is shown in the presence of a stenosis of a stomach, bleeding, an ulcer with kallezny edges, the big amount of perforation, at suspicion on an ulcer malignization (excision is necessary for carrying out a patomorfologichesky research).
The resection of a stomach can be made at patients with a probodny ulcer at impossibility of implementation of simpler operation and performing postoperative antikhelikobakterny and antisekretorny therapy. Usually such indications arise at the complicated course of stomach ulcer (the kalezny, penetrating and peptic ulcer; multiple ulcers), suspicion on malignant process, repeated perforation of stomach ulcer, the huge sizes of a perforative opening (more than 2 cm).
Approximately at 10% of patients low-invasive techniques of surgical intervention are applied: laparoscopic and endoscopic treatment of stomach ulcer. Use of laparoscopic operations allows to reduce authentically the frequency of postoperative complications and a lethality. Various techniques of operations can be combined among themselves (for example, laparoscopic with endoscopic) and with a vagotomiya (a selective proximal vagotomiya, a stem vagotomiya, an endoscopic vagotomiya).
If during operation the vagotomiya was not carried out, in the postoperative period antiulcer therapy (inhibitors of a proton pomp and blockers of H2-histamine receptors, antikhelikobakterny medicines) is appointed.
Forecast and prevention of probodny stomach ulcer
The forecast at probodny stomach ulcer depends on many factors. The risk of a lethal outcome considerably increases at age of the patient 65 years, the heavy accompanying pathology (oncological diseases, AIDS, tsirrotichesky transformation of a liver), the big sizes of a perforative opening, the long anamnesis of probodny stomach ulcer before operation are more senior. 70% of lethal outcomes at stomach ulcer of a stomach are caused by probodny stomach ulcer. The only method of prevention of this state is timely identification and treatment of stomach ulcer of a stomach.