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Perforated gastric or duodenal ulcer


Perforation (perforation) is a difficult and frequent complication of peptic ulcer of the stomach or duodenum. The “perforated” peritonitis progressing at the same time proceeds so quickly that a belated or incorrect diagnosis is equivalent to a death sentence with negligible chances of salvation.
Perforation of ulcers, as well as their exacerbation, is more often observed in winter and spring. Often, several days before the disaster, they are preceded by increased pain in the epigastrium. However, in some cases, the ulcer present in patients is asymptomatic (“silent ulcer”), and only a sudden perforation is its first manifestation.
In some cases, the so-called acute ulcers perforate, often developing in patients who have been taking steroid hormones for a long time. Nevertheless, most patients have a long history of ulcer: epigastric pain in the past, heartburn, etc.
When an ulcer perforates into the free abdominal cavity, the clinical picture is bright, the leading symptom is pain that appears suddenly, extremely intense, reminiscent of a “dagger blow in the stomach." It is much stronger than with other abdominal disasters, due to irritation of the numerous nerve endings of the peritoneum with acidic gastric juice. Patients immediately take this or that forced position (horizontal or sitting), often with their legs brought to the stomach and bent at the knee joints and, afraid to move, try their best to keep it.
With perforation of gastric ulcers, pain is usually localized in the epigastric and umbilical region, and with perforation of duodenal ulcers in the right hypochondrium, and then, according to the spread of the outflowing fluid along the right side channel, in the right ileal region. However, the distinction of pain is possible only in the first hours. In the future, pain spreads and covers the entire abdomen. Common vomiting for most abdominal disasters is extremely rare with perforated ulcers. The phrenicus symptom is often noted (pain when pressing between the legs of the sternocleidomastoid muscle). The pain radiates to the right shoulder, under the right scapula, in the region of the right clavicle, which is explained by irritation of the diaphragmatic peritoneum, more often of its right dome, spilling out of the gastric contents.
The most important objective symptom of a perforated ulcer is, along with the appearance of symptoms of peritoneal irritation, a very sharp tension of the muscles of the anterior abdominal wall. With no acute disease of the abdominal cavity, there is such a strong tension of the abdominal muscles as with a perforated ulcer, they are often tonic reduced. In thin patients, both rectus abdominis muscles with characteristic transverse grooves from tendon ligaments usually loom. Muscle tension is characterized by the classic expression "board abdomen." This symptom, visible even before palpation of the abdomen, is extremely characteristic for perforation of ulcers and allows, as a rule, to immediately make the correct diagnosis. The result of a sharp stiffness of the abdominal muscles is a clearly expressed "scaphoid retraction of the abdomen." Often the patient keeps the body bent forward to reduce pain. Muscle tension is an early symptom. It weakens with the development of peritonitis, giving way to paretic bloating.
The release of air through the perforation, its accumulation under the diaphragm, causes the disappearance of hepatic dullness, characteristic of perforated ulcers.
With percussion from the bottom up, tympanitis above the abdominal organs immediately passes into a pulmonary sound above the right half of the chest.
The clinical picture of perforation of an ulcer in the free abdominal cavity is so characteristic that the diagnosis usually does not cause difficulties. However, in some cases (a small diameter of the perforation, the stomach empty before perforation, proximity of the liver or omentum), the perforation closes and the further flow of gastric contents ceases. “Imaginary well-being” may also be associated with the dilution of hydrochloric acid with exudate and the action of endorphins. Clinically, this manifests itself in the fact that the pain stops, the spilled board tension of the abdominal muscles disappears, and only a small area of ​​tension in the epigastric region and the right hypochondrium is noted. Nevertheless, in most cases, the cover is fragile, and “self-healing” is only temporary, and after a short break, the picture of a perforated ulcer with the development of peritonitis reappears.
Atypical perforations are rare. Their atypicality lies in the fact that perforation of the ulcer does not occur in the free abdominal cavity, but in the retroperitoneal tissue or between the leaves of the lesser omentum. The disease also develops sharply, but the pains are not so pronounced, there is no board-like muscle tension. The intake of air through the perforation in the retroperitoneal tissue and its further distribution cause the appearance of subcutaneous emphysema on the anterior abdominal wall, neck, and scrotum. In the future, the clinical picture develops as a septicemia, retroperitoneal phlegmon. Recognition of atypical perforations is extremely difficult. As a rule, perforations of bleeding ulcers are also diagnosed late, but a similar combination of severe complications of peptic ulcer is rare. Perforation complicating ulcerative bleeding in a weakened, anemized, and reactive patient usually proceeds hidden, sometimes manifesting only increased pain and light muscle protection in the epigastric region. Finally, the diagnosis of ulcer perforation can be difficult in patients intoxicated.
Thus, the sudden onset of severe abdominal pain, accompanied by a plank tension of the muscles of the anterior abdominal wall and a forced stationary state of the patient, serves as the basis for the diagnosis of perforated ulcers. Laboratory indicators can be within normal limits, high leukocytosis and a shift to the left appear only at the stage of development of peritonitis. An X-ray examination reveals a characteristic accumulation of air in the form of a "sickle", more often under the right, less often under both domes of the diaphragm.
Differential diagnosis - see Part I, Abdominal pain. The diagnosis or suspicion of a perforated ulcer dictates the need for urgent hospitalization of the patient and immediate surgery to confirm the diagnosis. The indications for hospitalization and surgery in patients with covered perforation are equally urgent, despite the subsidence of pain and good general condition. In cases where neither hospitalization of the patient nor emergency surgery on the spot is possible (for example, in off-road conditions and in bad weather), it is advisable to constantly aspirate the gastric contents with a gastric tube inserted through the nose and atropine injection to reduce secretion.
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Perforated gastric or duodenal ulcer

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