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Perforated ulcer of the stomach and duodenum



Perforated (perforated) ulcer of the stomach or duodenum - the formation of an opening in the wall of the stomach or duodenum in a pre-existing ulcerative defect and the entry of gastrointestinal contents into the abdominal cavity.

ETHIOLOGY AND PATHOGENESIS

A perforated ulcer is preceded by an exacerbation of a peptic ulcer or the development of an acute ulcer. Perforations contribute to:

¦ alcohol intake;

¦ overfilling of the stomach with food;

¦ excessive physical stress.

CLASSIFICATION

A perforated ulcer is classified:

¦ on etiology:

? perforation of a chronic ulcer;

? perforation of acute ulcers (including drug, stress, uremic);

¦ by localization:

? in the stomach;

? in the duodenum;

¦ according to the clinical course:

? perforation into the free abdominal cavity (including covered);

? atypical perforation;

? in combination with gastrointestinal bleeding; and in combination with stenosis of the output section of the stomach.

CLINICAL PICTURE

For a perforated ulcer are characteristic:

¦ Sudden sharp and constant (“dagger”) pain in the epigastric region or right hypochondrium, rapidly spreading throughout the abdomen, more often along the right flank of the abdomen (95%).

¦ Muscle tension of the anterior abdominal wall - a “board-shaped" abdomen (92%). Patients take a forced position on their back or on their right side with their legs brought to their stomachs.

¦ A history of peptic ulcer disease (80%). During the disease, there are:

¦ period of shock (up to 6 hours from the onset of the disease);

¦ period of imaginary well-being (6-12 hours after perforation);

¦ period of progressive peritonitis (12-24 hours after perforation). Possible complications. The most common complication is peritonitis. With covered perforation, an abdominal abscess may form.

Differential diagnosis. Conducted with all acute diseases of the abdominal cavity, as well as myocardial infarction, lower lobe right-sided pneumonia.

TIPS TO THE CALLER

¦ Allow the patient to take a comfortable position.

¦ Do not give the patient food or drink.

¦ Find the drugs that the patient is taking and show them to the doctor or nurse assistant.

¦ Do not leave the patient unattended.

CALL ACTIONS

Diagnostics

Mondor Triad:

¦ the presence of ulcerative history;

¦ "dagger" pain;

¦ muscle tension of the anterior abdominal wall.


MANDATORY MATTERS

¦ When did the pain begin? Where does the abdomen hurt? What is the nature of the pain?

¦ Was there a history of peptic ulcer?

¦ The day before you overeat and / or take alcohol?

¦ Did you do hard physical work?

INSPECTION AND PHYSICAL EXAMINATION

¦ Assessment of the general condition and vital functions: consciousness, respiration, blood circulation.

¦ Visual assessment: a forced position lying on the back or on the right side with the legs brought to the stomach, a pained expression on the face, and the skin is covered with cold sweat.

¦ Pulse examination, measurement of heart rate and blood pressure (tachycardia, hypotension).

¦ On palpation, the abdomen is tense, plank-like.

¦ Percussion of the anterior abdominal wall: lack of hepatic dullness.

¦ Identification of symptoms of perforation of a stomach ulcer and duodenal ulcer:

? positive symptom of Shchetkin — Blumberg. It should be remembered that in patients older than 70 years, in 50% of cases when a stomach ulcer and duodenal ulcer is pierced, the pain is not intense, there is no acute onset, abdominal palpation is available (there is no muscle tension in the anterior abdominal wall).

Treatment

Indications for hospitalization. Patients with perforated ulcers need emergency hospitalization in the surgical department of the hospital. The patient is transported on a stretcher to ensure maximum peace.

FREQUENTLY MEETING ERRORS

¦ Prescription of narcotic analgesics.

¦ An attempt to rinse the stomach.

TREATMENT AT A PRE-HOSPITAL STAGE

The main task of the NSR with perforated ulcer is the emergency hospitalization of the patient in the surgical department of the hospital. It is necessary to provide venous access, monitor the vital functions of the patient and maintain them in accordance with general resuscitation principles. With signs of hypotension: iv solution of sodium chloride 0.9% - 400 ml.

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Perforated ulcer of the stomach and duodenum

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