Perforated gastric ulcer belongs to the category of serious, life-threatening diseases. Perforation occurs in the wall of the organ and the contents directly flows into the abdominal cavity. As a result, peritonitis develops, which requires immediate intervention by the surgeon.
Currently, in Russia, perforated ulcer is diagnosed in almost 3 million people. Relapse occurs in 6% of patients. Diseases are more likely to be men. The hormone estrogen produced by the female body has a restraining effect on the activity of the secretory glands of the gastric mucosa.
Causes of Perforated Gastric Ulcer
People suffering from chronic peptic ulcer disease and those who have suffered an acute form of the disease are at risk of a perforated defect.
To initiate perforation can:
Inflammations occurring around the main focus of mucosal damage,
Overeating (the stomach does not cope with a large amount of food),
Increased acidity of gastric juice (leads to an aggressive environment),
Excessive use of food seasoned with spices and alcohol,
Sudden physical exertion
Modern studies indicate that the causative agent of peptic ulcer disease is the bacterium Helicobacterpylori (which possesses initially aggressive strains). She infected almost 50% of all humanity. But contamination is not the only cause of peptic ulcer. Any violation of the protective functions of the body activates the pathogenic effect of microorganisms.
Factors that increase the risk of peptic ulcer disease:
Violation of the quality or duration of sleep, work in night shifts,
Acceptance of some drugs. Long-term treatment with nonsteroidal anti-inflammatory drugs (including aspirin) is not allowed; techniques, even short-term anticoagulants (warfarin, heparin), corticosteroids (prednisone), some chemotherapy drugs, can have a pathogenic effect,
Smoking (has a mediated effect on the increase in hydrochloric acid and impaired microcirculation in the mucous membranes)
Excessive use of alcohol (leads to a direct violation of the mucous membranes),
Disruption of food intake and quality of nutrition. Food temperature too high or too high, foods high in fat, smoked food, etc.
The presence of other pathologies of the gastrointestinal tract (eg, gastritis),
Symptoms of perforated gastric ulcers
A typical form of disease progression is accompanied by ingress of stomach contents into the free abdominal area.
There are three periods of development:
Period of chemical peritonitis. The duration of the flow time is from 3 to 6 hours. It depends on the diameter of the hole and the amount of discharge from the stomach. Accompanied by acute pain in the stomach. Possible severe pain in the umbilical segment and in the right hypochondrium. Subsequently, the entire abdomen area is covered. Perforation of the anterior wall of the stomach can manifest itself in pain in the left side of the abdomen and in the left forearm. Pain is characterized by the duration of manifestation. Vomiting occurs rarely. Blood pressure is reduced, but the pulse is usually within normal limits. Breathing becomes shallow and rapid. The skin turns pale, sweating increases. The muscles of the front of the abdomen are strained, in the abdominal cavity there is an accumulation of gases.
The period of bacterial peritonitis. Begins after 6 hours of perforation.The abdominal muscles relax, breathing becomes deeper and sharp pain disappears. The person feels relieved. At this phase, there is an increase in temperature, an increase in pulse rate and a further change in blood pressure indices. The period of increasing toxication begins, which leads to an increase in the volume of gases, paralysis of peristalsis. The tongue becomes dry, with a gray bloom on the front and side surfaces. The general behavior of the patient is changing. He experiences euphoria and relief, becomes uncritical to his condition, does not want to be disturbed. If during the period of increased intoxication no first aid is provided, then the person goes to the third, most severe stage of the disease.
Period of acute intoxication. It begins, as a rule, after 12 hours from the moment of the disease. The main manifestation is indomitable vomiting, leading to dehydration. Visually, you can note changes in the skin. They become dry. There is a sharp drop in body temperature. Raising to 38 ° -40 ° is replaced by lowering to 36.6 °. The pulse reaches 120 beats per minute. Upper arterial pressure drops to 100 mm Hg. The general condition of the patient is characterized by lethargy, indifference, slow response to external stimuli. There is an increase in the abdomen due to the accumulation of free gas and fluid. Violation of the process of urination, eventually stops altogether. If a person has reached this phase of peritonitis, then it is almost impossible to save his life.
Classification of perforated ulcer
According to the clinical course of the disease:
Typical shape. Characterized by leakage of stomach contents into the abdominal cavity,
Atypical form. Content gets into the stuffing boxes or stuffing box, possibly leaking into the retroperitoneal tissue or the inter-ligamentous area
Perforation with bleeding into the abdominal cavity or gastrointestinal tract,
By stages of peritonitis:
Stage of primary pain shock,
The stage of development of bacterial peritonitis, accompanied by seeding with microorganisms,
Stage of the inflammatory process, accompanied by sensations of imaginary well-being,
The stage of severe disease, accompanied by the occurrence of purulent peritonitis,
For pathological and anatomical signs:
Perforation of chronic ulcers (a complication of peptic ulcer),
Perforation of acute ulcers,
Perforation of the lesion of the wall of the hollow organ tumor formation,
Perforation in parasitic diseases,
The occurrence of a defect due to impaired local blood circulation,
Gastric ulcer (anterior, posterior wall, of lesser or greater curvature),
Combined ulcer (stomach and duodenum),
Diagnostic methods for perforated ulcer
Perforation is characterized by an attack of sharp, sudden pain. If there is a history of peptic ulcer, gastritis, etc., the task is easier. As a rule, the differential method is used for diagnostics.
It consists in examining the body in view of the presence / absence of the following pathologies:
Perforation of tumor formations
Dissecting abdominal aortic aneurysm,
Additional research methods are:
Radiological. The efficiency of diagnostics of filling the air in the abdominal cavity reaches 80%. But a similar picture can be observed in the case of intestinal airing or atony of the fallopian tubes,
Electrogastroenterographic. Allow to make a qualitative analysis of the evacuation function of the stomach and duodenum,
Endoscopy. It is used in case of negative results of X-ray studies, but in case of suspicion of perforation. Allows you to determine the presence of peptic ulcer disease, the localization of the outbreak. The study is conducted using air inflation, which helps to determine the true clinical picture,
Complete blood count (shows elevated white blood cell count),
Laparoscopy. Helps qualitative and quantitative analysis of effusion in the abdominal cavity. Has contraindications to use,
Laparoscopy is not used if the patient has:
Adhesions in the abdomen,
Violation of the integrity of the diaphragm,
Pathology of blood clotting,
The presence of large hernias on the front wall of the peritoneal region,
General severe condition
Treatment of perforated gastric ulcers
Perforated ulcers are treated surgically. Preoperative preparation is the removal of gastric contents and restoration of blood pressure. A study is also made to select further actions.
The time elapsed since the onset of the disease
Nature of origin, size and localization of the ulcer,
The severity of peritonitis and its area of spread,
Age features of the patient,
The presence / absence of additional pathologies,
Technical features of the hospital and the level of professionalism of doctors
Separate organ-sparing operations (closure) and radical (resection, excision of ulcers, etc.).
Sutured perforation hole is shown in the presence of widespread peritonitis, high operational risk (associated with the presence of comorbidities or the patient's age), the absence of ulcerative history in young people. The technique is to excise the edges of the ulcer and then stitch them with two rows of stitches. With this method of solving the problem, the shape of the organ and the diameter of its lumen are preserved. At the end of the operation, temporary drainage is installed. Further treatment with anti-ulcer drugs is prescribed.
Gastrectomy is an operation that results in the loss of a significant part of the organ. After transferring it is established disability. Indications are the presence of chronic, large-diameter ulcers, suspicion of the presence of malignant tumors, the patient's age is less than 65 years old in the absence of comorbidities in the decompression period, the development of acute inflammation and purulent peritonitis, 6-12 hours after the onset of the disease.
In the absence of peritonitis, it is possible to suture the wall of the perforated hole in combination with selective proximal vagotomy.
Excision of an ulcer with the use of stem vagotomy and performing pyroplasty is used in the presence of an ulcer in the pyloric part of the stomach, a combination of perforation with bleeding, stenosis.
The absence of surgery necessarily leads to death in the coming weeks after the development of the disease.
Statistics of deaths after the surgery shows that after 6 hours no more than 4% of patients leave, after a day - no more than 40%.
Diet after perforated gastric ulcer surgery
The first rule for recovery and reducing the risk of recurrence is strict adherence to doctor's instructions. The exception to the rule “if not, but really want to” does not work. In the postoperative period, a strict diet is established. It can last from 3 to 6 months. The diet is complicated gradually.
The basic principles of diet:
The daily number of meals up to 6 times in small portions.
All accepted products must be pure or semi-liquid.
Cooking should be steamed or boiled.
Salt should be taken in limited quantities.
You should also limit the intake of simple carbohydrates (sugar, chocolate, pastries) and liquids.
On the 2nd day after the operation, mineral water, fruit jelly, a weak, slightly sweetened tea are allowed to receive.
After 2-3 days, the ration is replenished with broth from the hips, wiped soups and cereal from rice and buckwheat. Vegetable soups, mashed potatoes of boiled carrots, pumpkins, zucchini, potatoes or beets. Allowed to receive a soft-boiled egg and steam soufflé of mashed cottage cheese.
On the 10th day after the operation, mashed boiled carrot, pumpkin, zucchini or potatoes are introduced into the ration. Steam patties, soufflés, mashed potatoes, dumplings, meatballs or zrazy from lean meats or fish are gradually introduced. Add cheesecakes, puddings, cottage cheese casseroles. You can also use fresh grated cottage cheese. In addition, whole milk and non-acidic dairy products (acidophilus, yogurt, matsoni) are introduced.
Only a month later it becomes possible to receive bread products: sushka, stale bread, crackers.
After 2 months it is allowed to add fresh sour cream to food and eat kefir.
The first days after surgery
Food after surgery, gastric ulcers should be strictly dietary. Obligatory condition - reducing the amount of carbohydrates consumed, fluids, and also salt. The first three days, hunger is recommended - in order for the stomach to become accustomed to a new state. On the fourth day, the patient can take fruit jelly in limited quantities. Drinks can be slightly sweetened.
After two or three days, you can add mashed on the water (without zazharki!), Soft-boiled eggs, slightly grated rice porridge. A week after the operation, you can gradually introduce vegetable puree, chicken cutlets and steamed fish. All food must be prepared without adding salt and oil.
List of approved products after surgery
Diet for perforated gastric ulcer after surgery should be strictly followed by patients. This is the main condition that will avoid complications and get better as soon as possible. Unfortunately, a strict diet will have to be observed throughout life - and only occasionally allowed to consume a small amount of "forbidden food" - and then, 2-3 years after surgery.
What natural remedies will speed recovery?
In addition, when a stomach ulcer should follow a diet, it is also necessary to continue the treatment of this disease. At the same time, it is not at all necessary to take any medication.
Perforated gastric ulcer belongs to the category of serious, life-threatening diseases. Perforation occurs in the wall of the organ and the contents directly flows into the abdominal cavity. As a result, peritonitis develops, which requires immediate intervention by the surgeon.
Currently, in Russia, perforated ulcer is diagnosed in almost 3 million people. Relapse occurs in 6% of patients. Diseases are more likely to be men. The hormone estrogen produced by the female body has a restraining effect on the activity of the secretory glands of the gastric mucosa.
Why do I need an operation with jab?
Before taking a closer look at what can and cannot be eaten in the postoperative period, it is important to pay attention to the surgical procedure itself. The operation is a necessity and its essence is to remove the accumulated contents of the stomach. After assessing the patient's condition, collecting the necessary data on age, pathologies and other details, the patient is prescribed closure or resection.
In the case of peritonitis, a resection procedure is carried out; if the infection has not yet begun, we can speak about closure.
Closure is necessary if peritonitis is formed in the body, if there is a high operational risk. The procedure is performed as excision of the edges of ulcers, after which they are sewn with special seams. Due to the closure, the organ and lumen diameter can be maintained. Further vital activity is possible only after the installation of drainage, maintenance of dietary intake and taking anti-ulcer drugs.
The resection leads to the fact that a person loses a significant part of the stomach, because further active activity is impossible. The operation is performed when the ulcers have a large diameter, are malignant, or if the person is less than 65 years old. Failure to perform a surgical procedure can be fatal.
What is better not to eat after the operation on the stomach?
After the operation, for a long time will have to give up fast food and alcohol.
The list of banned products, unfortunately, is quite large, therefore, it requires endurance and moral preparation from the patient. The patient will have to abandon the dishes that need long digestion, leading to irritation of the stomach, increasing the production of hydrochloric acid. In the postoperative period should be completely excluded reception:
- citrus fruits (mandarins, oranges, grapefruits, lemons),
- fried, fatty, spicy, canned, pickled, smoked food,
- chocolate and any other sweets: sweets, waffles, cakes, honey cakes, etc.
- fresh bakery products, rich and puff pastries,
- legumes, seeds, nuts, popcorn,
- onion, ginger and garlic,
- vegetables with a lot of fiber (this includes radishes, cabbage, zucchini, turnips, zucchini),
- fatty, rich and strong broths, soups,
- spicy and savory sauces, adzhika, marinade, mayonnaise, ketchup, vinegar, mustard,
- fatty fish and meat,
- strong tea, alcoholic and coffee drinks, soda, kvass.
These products will have to be excluded for life. Only with the permission of the attending doctor (after several years after the operation) some excesses and “harmfulness” can be allowed. Any spontaneity is completely prohibited.
What food to give preference after perforated gastric ulcer?
After a stomach operation, the following diet numbers are prescribed: 0 and 0b.
Despite the fact that the content of the food basket of a person after resection or suturing is not so great, it will still have to get used to using certain products in order to avoid relapses. Gastroenterologists claim that adherence to dietary recommendations can lead to remission. What to eat sick in the postoperative period?
- Uncoupled or ground porridges. Preference should be given to grits cooked in water. After some time and approval of the doctor, you can use butter and milk,
- Dietary meat (chicken and rabbit meat) cooked in a slow cooker, steamed, baked,
- Chopped and grated vegetable soups,
- Stale bread or crackers. Eating pies or buns can only be if they are based on unleavened dough,
- Low-fat varieties of fish. Suitable use of navaga, haddock, hake, cod, whiting, pollock, flounder, perch in boiled or baked form. Frying fish is strictly prohibited,
- Sweet ripe berries and fruits, peeled from the peel. It is better to grind products and cook from them all kinds of mashed potatoes, mousses, smoothies, etc.,
- Milk, dairy products, cottage cheese, milk puddings (make sure that the selected products are not fatty and sour),
- Soft boiled eggs, steam omelettes, proteins, poached eggs.
As for drinks, the best choice would be to receive decoctions of herbs and fruits, green tea, fruit compote. Carrot, banana, strawberry juice or cabbage juice, melons are considered the most useful.
Doctors can supplement the dishes with olive, sunflower or linseed oil, the amount of which should not be excessively large (not more than a tablespoon). The same applies to the elimination of salt from the diet - its intake is allowed in the amount of 5-6 grams per day.
Menu for 2 days after stomach surgery
After surgery, it is important to adhere to the rules of dietary food, exclude prohibited foods and use the list of recommended dishes.
As an example, you can use the following menu example for two days.
- Day number 1:
- Breakfast: ground apple with carrots, two boiled eggs, low-fat natural yogurt,
- Snack: crackers, weak tea drink,
- Lunch: a piece of boiled hake, lazy dumplings, rosehip decoction,
- Snack: fruit salad, cheesecakes cooked in the oven, dried fruit compote,
- Dinner: fish souffle or fruit casserole on kefir, several savory biscuits or loaves, a glass of skim milk,
- Bedtime: a handful of berries.
- Day number 2:
- Breakfast: semolina / barley porridge on the water, unsweetened fruit compote,
- Snack: Yesterday's Leaf Pie, Cranberry Mors or Carrot Fresh Juice with a Spoon of Olive Oil,
- Lunch: rice with vegetables, steamed meatballs, juice,
- Snack: boiled rabbit, vegetable stew, dry unsweetened biscuits, green unsweetened tea with honey,
- Dinner: omelet, vegetable salad, 40 grams of buckwheat, nonfat yogurt,
- Bedtime: a glass of mineral non-carbonated water.
Diet is an important and necessary measure, the observance of which helps the patient to recover faster and avoid unexpected complications. The clearer and more closely the instructions and recommendations of the doctor will be observed, the faster you can return to normal diet.
In the treatment of through defects of the gastrointestinal tract, an important place is occupied by the diet after the operation of perforated gastric or duodenal ulcers. To recover, after surgery and in parallel with postoperative therapy, the patient must adhere to strict rules and dietary restrictions.
Over time, the list of allowed products expands, the menu becomes more diverse. But, in order to avoid relapse, the basic rules of healthy eating should be followed after the recovery period.
What can and can not eat. What is the principle of the choice of products, how to prepare them. What are the rules of nutrition after perforated ulcers. Examples of the menu. About this article.
The perforated ulcer means the formation of a through hole in the stomach or duodenum. From the hole in the abdominal cavity flows their contents, causing serious damage to internal organs.
Thus, the phenomenon is dangerous not only as a serious damage to the digestive organs, but also extremely dangerous by the consequences of the leakage of their contents into the abdominal space. Therefore, it is very important to eliminate the perforation as soon as possible.
For this diagnostic methods need to make sure that there is a perforation. Next, the method of surgical intervention is chosen, an operation is immediately carried out to close the hole with subsequent postoperative therapy.
Further recovery depends on the patient. This is a limitation of physical exertion, especially at first, the emotional state also matters. The main thing with perforated gastric ulcer diet after the operation menu and diet.
Recovery takes a lot of time, so it will take a long time to follow the rules of nutrition. In difficult cases, restrictions remain for life. Also, have to give up alcohol and smoking.
Prohibited foods and unacceptable cooking methods
In order to avoid irritation of the mucous membranes of the gastrointestinal tract, and hence wounds, all products provoking an increased production of digestive juice are excluded from the diet after perforated gastric and duodenal ulcers. Banned coarse food with pronounced physical or chemical exposure.
- salty (including homemade pickles).
Any food prepared in this way is not suitable for a diet. Also banned the following products:
Do not eat too cold or hot food and liquids.
All of the above increases the load on the digestive organs, provokes an increased release of aggressive digestive juice. All sour leads to such an undesirable effect. Caffeine in tea and coffee leads to the same. Fatty foods, rich pastries, mushrooms are heavy food. Expressed aggressively sharp and bitter food.And in fast food, chips, crackers and other store products too much salt, sugar and chemistry.
Refusal of alcohol and smoking is due to the following:
Ethyl alcohol injures, destroys the mucous membranes of the digestive tract. The use of alcohol after the operation, with its burning effect, will cause severe pain, will prevent the healing of the wound with all the ensuing consequences, until the relapse.
Smoking also irritates the mucous with harmful substances of smoke (tar, nicotine, carbon monoxide, other harmful elements). They enter the stomach with saliva and partly in the form of smoke. Thus, smoking can cause serious postoperative complications.
Permitted drinks and food, cooking methods, rules of postoperative diet
An exemplary menu after surgery for perforated ulcer of the stomach or duodenum includes sparing, carefully selected and properly prepared products. Organized 5-6 single meals in small portions.
All products are prepared:
For easy digestion, the food should be liquid, semi-liquid, very soft or mashed. Also, it simplifies the work of the digestive organs to observe the rules of separate feeding, when one meal or one type of food, and another after one meal, is consumed.
The following drinks, products, meals are included in the postoperative diet:
Tea can be a little sweetened, better honey.
Cod, hake fillets, steers and other dietary fish are suitable for seafood. At first, after surgery, fresh vegetables and fruits are not included in the patient’s diet. But their subsequent use will contribute to a more rapid rehabilitation of the patient.
In order not to provoke increased secretion of the stomach, fruits should not be sour and rough. You can eat bananas, pears, melons, apples, sweet varieties. Soups and mashed potatoes can be cooked using potatoes, carrots, pumpkins, zucchini, beets.
After the operation of perforated gastric or duodenal ulcer, oatmeal, rice, and buckwheat porridge occupy a large place in the diet. From desserts can be a variety of jelly, souffle, mousse from permitted products.
Since fresh pastry is prohibited, the bread is consumed in dried form. Allowed to use a small amount of natural vegetable or butter. Permissible salt intake is up to 6 grams per day.
The rules of postoperative nutrition refer not only to the correct selection of products, but also to the regimen. It consists of 5-6 meals a day in small portions. Such crushing also reduces the load on the mucous membranes, prevents the dangerous expansion of their cavities, especially during the first time after surgery.
Based on the foregoing, a diet with perforated gastric or duodenal ulcer is formed in accordance with the following rules:
To comply with all standards of dietary food the most convenient option is home cooking.
Sample menu for the day
The following exemplary menu after surgery for perforated ulcer is used after two weeks after surgical suturing of perforation. It is based on the above rules. Namely:
- only valid products
- permitted cooking methods
- compliance with the rules and diet.
Despite all the limitations, the nutrition of the patient is quite diverse and, most importantly, provides the body with essential elements. Thus, the menu for the day might look like this:
Three options for breakfast:
- light chicken broth, green tea (you can sweeten with honey),
- vegetable cream soup, zrazy from dietary fish, juice,
- fruit jelly, broth hips.
- mashed potatoes with soft chicken cutlets, warm milk,
- pumpkin porridge, steamed beef patties, fruit and berry jelly,
- fish soup from low-fat fish with fresh biscuits, compote.
- low-fat beef broth with vegetables, dried white bread, jelly.
- turkey soup, fruit puree, fruit drink,
- viscous oatmeal soup, baked pumpkin, tea.
- milk cream soup, biscuits, tea with milk,
- mashed buckwheat porridge, jelly fish, herbal tea,
- mashed pumpkin and carrots, low-fat cottage cheese with sour cream, biscuits.
Three options for dinner:
- mashed potatoes with a little butter, steamed vegetable zrazy, warm milk,
- cod soup with chopped vegetables and a small amount of greens, crackers, berry juice,
- beef broth, home-made pate, dried bread, jelly.
Tea should not be strong, jelly sour or too sweet, dairy products only low-fat, low-fat broths, meat and fish dietary, premium bread, dried or in the form of crackers, a minimum of salt. Try to eat at the same time at intervals of 2.5-3 hours, but not more than 4 hours.
Far from all possible foods and foods from the dietary diet after perforated ulcer surgery are presented here, but already from the examples presented there is a general picture of the selection of products and their preparation. Based on this, you can further diversify the menu of the patient.
Thus, after a successful operation, further recovery of the patient depends on the diet. But even after a period of recovery, in order to avoid relapse, we should not forget about the main principles of healthy eating.
How is rehabilitation done after a stomach ulcer?
Currently, rehabilitation after gastric ulcer is carried out using the following methods:
- Spa treatment using mineral water (balneotherapy),
- Mud therapy,
- Diet therapy
The following exercises have an excellent rehabilitation effect:
- Rhythmic walking in place
- Respiratory exercises in a sitting position,
- Exercises for the hands in a sitting position,
- Throwing and catching a sword while standing
- Exercises on the hands in the prone position.
Acupressure represents the impact on various biologically active points with your fingers. The principle of acupressure is the same as that of acupuncture. Massage active points should be carried out daily. Moreover, it is better to find out the necessary points from an acupuncture doctor, and ask him to teach them how to massage them correctly.
Physiotherapy It has a positive effect in rehabilitation after gastric ulcer. The following methods are used for rehabilitation:
- Infrared, ultraviolet radiation,
- Polarized light
- Electrophoresis on the epigastric region with Novocaine, Plathillin, Zinc, Dalargin, Solcoseryl.
Mud therapy shown in the period of attenuation of exacerbation of gastric ulcers. For treatment apply silt mud at a temperature of 38-40 o C. The procedure is carried out at the beginning of 10 minutes, then extended to 20 minutes. The course of therapy consists of 10 to 12 procedures.
Diet therapy based on the observance of table number 1. Meals should be fractional (5 - 6 times a day) and in small portions.The ration should be based on lean meat and fish, from which they cook meatballs, meatballs, soufflé, quenelles and zrazy steamed. Also allowed are boiled sausages and sausages. In addition, in the diet include cottage cheese dishes (casseroles, souffles, cheese cakes, lazy dumplings) and other dairy products. Soups should be vegetarian, mucous, with dressing of boiled grated vegetables and well-boiled cereals. Kashi must be semi-liquid. Eggs are allowed boiled softly or in the form of a steam omelet. Fruits and berries are used in the form of mashed potatoes, jelly, mousses, jellies, compotes, jam, etc. You should eat yesterday's white flour. Also allowed are dry biscuits, biscuits, and rolls.
Excluded from the diet are mushrooms, broths, fatty meat and fish, poorly boiled lean meat, all roasted, strong tea, coffee, soda, spicy seasonings (mustard, horseradish, onion, garlic) and raw vegetables with coarse fiber (cabbage, turnips, radish, bell pepper, etc.). You also can not eat anything smoked, canned, spicy, fatty, soaked and fermented.
Phytotherapy helps to accelerate the onset of remission or to prevent an exacerbation of a stomach ulcer Excellent effect has cabbage and potato juice. Cabbage juice take 1 glass 3 times a day before meals. Potato juice taken in half a glass for 20 minutes before eating.
Principles of nutrition after surgery
The timing of recovery from gastric ulcer surgery depends on dieting. In order not to expose the digestive organs to excessive load, the diet is gradually expanded, changing the composition of dishes and methods of their preparation. Dietary intake is introduced in stages:
- During the first week after surgery, the patient is given only mineral water, weakly brewed tea and lean broths. During this period, ingestion of any food, even if it is wiped, can cause complications, since the microflora of the digestive organs is almost destroyed. So the food is simply not digested.
- In the second week, wiped dishes, mainly porridges boiled in water with a small amount of milk, and grated soups are introduced into the daily menu.
- In the third or fourth week after surgery, the patient is prescribed a regular pureed diet. In addition to pureed soups and slimy cereals, the menu includes the most shredded meat and vegetables.
- After three to six months, you can enter not pureed dishes into the menu, but the food should still be chemically neutral (without spices, salt or sugar).
The rules of nutrition after surgery are as follows:
- Solid food for about two months should be excluded from the diet. Even a small piece can be in the abdominal cavity, and to remove it will have to do another operation (even the probe does not help).
- An ideal dish is one in which there are no fast carbohydrates, cholesterol, spices, large pieces, carcinogens. In a word, the ingredients of a dish should not require the excretion of large amounts of digestive enzymes from the digestive organs.
- Portion size - with a fist. If more, the stomach can not cope with the task, and this is fraught with relapse.
- Eat at about the same time. So the stomach gets used to produce digestive enzymes. In addition, it is important to observe the same intervals between meals. The maximum interval between them is three hours. If less, the digestive organs may not yet cope with the previous portion. If more, self-digestion can be provoked (with a long absence of food, the stomach still begins to secrete digestive enzymes that eat away the mucous membrane).
Cooking need only steamed. Can I bake dishes? Not desirable. Even roasting during the first month after surgery is undesirable. But raw vegetables and fruits will also have to be abandoned for at least one or two months.Firstly, with proper heat treatment, they retain such a large amount of substances necessary for the body, and secondly, after minimal heat treatment, it is easier to digest the dish.
Rubbed Diet: Food List
The rubbed diet is observed during the first three months (in case of the risk of relapse, it is followed for six months).
What can you eat: only boiled on the water products, slimy porridges, lean soups. All the ingredients before serving are ground in a blender or served as a puree. During the recovery period, it is important that the protein food predominates in the menu, since the amino acids contained in it are the main building material for the body.
- pureed vegetable soups (except cabbage soup - long digested). You can add cereals (rice, buckwheat, millet, barley),
- lean broth from lean meat (chicken, turkey, fish),
- chopped lean meat (meatballs, dumplings, meatballs, soufflés, mashed potatoes) from lean meats and fish,
- soft-boiled eggs, steam omelets,
- non-sour and non-fat milk, sour cream, cream (no more than 10 grams per day), non-sour kefir and ryazhenka, non-spicy cheese and non-sour cottage cheese,
- dried bread made from wheat flour of the highest grade,
- puddings, souffles, cheese cakes, casseroles, lazy dumplings (honey should be added instead of sugar)
- boiled vegetables (cauliflower, carrots, zucchini, pumpkin, eggplant, potatoes),
- mess porridge on water or with milk in a ratio of 1: 2 (semolina, rice, oatmeal, buckwheat).
From desserts you can puddings and casseroles of boiled cereals (honey instead of sugar), mousses and fruit jelly (not earlier than one and a half to two months after the operation), fresh fruit and berries compotes.
Drinks can be weak tea (honey can be used instead of sugar).
You need to give up salt, all spices, simple carbohydrates (you can only honey). From pastry, offal, pickles, marinades. And also from smoked, spicy, roasted, spiced, preservatives.
What can and cannot be eaten after the operation of perforated gastric ulcer, what kind of diet is ahead?
Perforated ulcer is a serious disease. Postoperative recovery is quite a difficult period for the patient. In order for a person to quickly regain form, he needs a long-term treatment with drugs, bed rest, as well as adherence to a special diet. That diet is a fundamental factor in the recovery period.
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In case of perforated gastric ulcer in the order of emergency care, a life-saving operation of stitching the perforated hole is often performed.
The immediate results after this operation, as shown by the materials of the Institute. N. Century Sklifosovsky (Moscow), should be recognized in a significant percentage of cases quite satisfactory. When a perforated ulcer is localized in the initial part of the duodenum or in the prepyloric part of the stomach, often after suturing the ulcer, a relative narrowing of the duodenal lumen or stomach occurs, making it difficult for the food to pass from the stomach to the duodenum. This circumstance necessitates the forced imposition of a gastric discharge anastomosis with a loop of the jejunum (gastroenterostomy).
When examining patients in the long-term period after stitching a perforated stomach ulcer, good results decreased to 0, satisfactory - to 7.7%, and unsatisfactory - to 92.3%. Unsatisfactory results in the long-term period after stitching of a perforated ulcer are caused by a number of reasons. Among them, the most important is the recurrent ulcer after a bright gap, or at the site of stitching, or outside this zone, the penetrating ulcer. Cancer may occur at the site of a stitched perforated ulcer. This complication occurs in 2-3% of perforated ulcers and, as a rule, occurs after perforation of kaleznyh ulcers. The time interval between suturing a perforated ulcer and the appearance of cancer on the spot varies from several months to several years. Sometimes after stitching, late profuse gastroduodenal bleedings are observed.
In the long-term period after the operation under consideration, deformation of the stomach may develop: when the ulcer is located in the pylorus area, along with narrowing the exit from the stomach, in some cases, the pylorus has an eccentric position in relation to the duodenum. Both of these complications violate the evacuation function of the stomach. In this group of patients there is a feeling of heaviness under the spoon, frequent vomiting, belching rotten, abdominal pain.
Perigastritis, periduodenitis are also a frequent complication in the long term after surgery. One of the reasons for the development of these complications is the ingress of food particles into the abdominal cavity at the moment of ulcer perforation. True, the operation itself on the organs of the abdominal cavity often leads to the development of perivisceritis. All the complications of perforated gastric ulcer and duodenal ulcer can be divided into two groups:
1. Complications caused by the ulcer itself: recurrent ulcer, unhealed ulcer, new ulcer, penetration of the ulcer, bleeding from the ulcer, repeated perforation of the ulcer, polyposis of the stomach, development of cancer at the site of the wound ulcer.
2. Complications associated with the operation: stenosis of the output section of the stomach or the initial part of the duodenum, stomach deformity, perigastritis and periduodenitis, gastro-duodenitis, duodenal and stomach diverticula (I.I. Neumark, 1958).
Despite some shortcomings, the above classification is useful because it helps to better understand the pathogenesis of late complications after stitching a perforated ulcer. All late complications after stitching a perforated gastric ulcer and duodenal ulcer caused by an ulcer, are subject to first conservative treatment, and if the last re-operation fails, resection of the stomach. As for complications associated with the operation, some of the complications are subject to surgical treatment: stenosis, gastric deformity, gastric and duodenal diverticula, and others to therapeutic treatment and physiotherapy (gastroduodenitis, perigastritis and periduodenitis).
Gastroenterostomy as the main operation for gastric ulcer and duodenal ulcer is now used very rarely, because the mass experience of using it for over 30 years has discredited it: in the near future, after the imposition of the anastomosis, significant relief occurs in many patients, and then most of the symptoms a peptic ulcer disease recurs and even a new symptom complex arises, called “gastroenterostomy as a disease” (Pribran, 1923). The basis of the development of this symptom complex is the effect of active gastric juice on the intestinal mucosa and often the development of peptic ulcer of the intestine at the site of the anastomosis or near it. Patients complain of constant empty belching, heartburn, occasionally vomiting, pain in the stomach, especially after eating.
Clinically and radiographically, the symptom complex of a gastroenteroanastomosis is very close to that in duodenal stasis observed with organic changes in the duodenum and outside of it, which makes it difficult to empty it.
Research G. L. Shapiro (1951) found that the distribution and intensity of the most common form of "illness of the operated stomach" - gastro-yunit depends on the degree of trauma of the nervous apparatus of the organ.
It is advisable to consider separate early and late complications after operations on the stomach.
The complications observed in the first days after surgery on the stomach include severe bleeding, divergence of gastric sutures with subsequent peritonitis, insertion of small intestine loops into the omentum bag through the opening of the posterior gastrojejunoanastomosis in the mesentery of the transverse intestine with subsequent pinching, entry of the small intestines into the cavity of the stomach through the anastomotic hole. These complications require emergency surgery. The last two complications are very rare, with regard to bleeding and seam divergence, they should be prevented by careful operations.
One of the most dangerous, although infrequent, early complications of a gastroenterostomy is the so-called vicious circle - circulus vitiosus. The disease is often complicated by anterior gastroenterostomy. On the 2-3rd day after the operation, persistent vomiting occurs with large amounts of fluid mixed with bile, accompanied by an extreme drop in the patient's strength. On examination of the abdomen in the left hypochondrium, a colossally swollen stomach with a sunken abdomen is seen. In half of the cases it ends in death. Occasionally the vicious circle is chronically.
The essence of the disease is explained in three ways. According to one opinion, the expansion of the stomach occurs due to the formation of a mechanical obstacle due to the valve-like bend of the diverting loop of the intestine. The contents of the stomach, plus the bile and pancreatic juice, not having access to the intestines, returns back to the stomach. The leading segment of the intestine is overfilled, the abductor is empty. However, during operations performed on this complication, organic barriers were often not found. Other obstruction was explained by spasm of the abdomen discharge segment. Still others view the vicious cycle as the primary atony of the stomach.
Treatment consists of washing the stomach, mainly in the constant active suction of the contents of the stomach using a water jet or electric suction device. Subcutaneous or intravenous administration of large quantities of physiological saline is necessary. If the aforementioned measures soon eliminate the vicious circle fails, surgical treatment is resorted to, which consists in the imposition of an anastomosis between the leading abdominal discharge segment.
Acute dilation of the stomach, see below.
Anastomosis is an inflammatory process in the region of the gastrointestinal anastomosis, usually accompanied by perianastomositis, often with the formation of infiltration and deformation of the anastomosis. Symptoms: acute pain and vomiting due to delayed passage of stomach contents into the intestine. Often, re-laparotomy, dissection of adhesions and the imposition of an anastomosis between the afferent and abductive loops of the anastomotic gut or the second gastrojejunostomy is necessary.
Fistulas of the stomach and duodenum are formed shortly after the operation with the divergence of the gastric sutures and the opening of the resulting abscess to the outside. Gastric and intestinal fistulas sometimes close spontaneously, in other cases surgery is required, which consists in excision of the fistula and stitching a hole in the stomach.
The narrowing of the gastrointestinal anastomosis develops, apparently, as a result of the contraction of the scar ring that forms around the anastomosis or after the healing of postoperative peptic ulcer. Rarely observed.
Extensive postoperative adhesions also adversely affect the function of the gastrointestinal fistula.
Postoperative peptic ulcer is formed after operations on the stomach for ulcers, but not cancer, and is usually a complication of gastroenterostomy, rarely resection with an anastomosis. Soon after surgery, the ulcer develops rarely, usually it develops after a few months or years. The peptic ulcer is located in the area of the anastomosis or at its edge on the discharge loop, often accompanied by the formation of infiltration, progresses rapidly and has a tendency to perforation. Sometimes a fistula is formed that communicates the stomach with the transverse colon, allowing direct food from the stomach to enter the colon and causing fetid belching, fecal vomiting and diarrhea. Communication of the stomach with the transverse colon can be direct or carried out through the small intestine.
The appearance of peptic ulcers contributes to the high acidity of the gastric juice and the seam of non-absorbable material, when the gastric juice gets access to the suture canals.
The symptoms are the same as in a stomach ulcer, with the only difference that the pain point is lower, the pain is especially strong, it comes late, sometimes an infiltration is felt. The diagnosis is confirmed by x-ray examination. Spontaneous healing of peptic ulcers is observed, but not often.
Initially, you should experience therapeutic treatment, especially spa (Zheleznovodsk). In case of failure, surgery is resorted to, which consists in degastroenterostomy or, better, in a wide resection of the stomach, including an intestinal loop with anastomosis.
Peptic ulcer has many unpleasant and dangerous consequences. One of them is the perforation of the ulcer of the wall of the specified organ. As a result, the gastric contents are poured into the abdominal cavity, which can lead to the development of peritonitis (inflammation of the peritoneum) that threatens a person’s life.
The indicated dangerous condition is called perforated gastric ulcer and requires mandatory urgent surgical intervention. Causes are chronic and acute gastric ulcers. Certain factors contribute to the perforation of the organ wall:
- lack of treatment of acute ulcers,
- gross violations of the diet,
- severe overeating
- frequent stressful situations, constant mental and mental stress,
- heavy exercise and increased pressure inside the abdominal cavity,
- long-term use of glucocorticosteroids and salicylic acid preparations.
Ulcers located on the anterior wall of the stomach in the pyloric and pre-pyloric regions are most susceptible to perforation.
Signs of perforated gastric pathology
The symptoms of perforated ulcers and their severity depend on the clinical form of perforation. She may be:
- typical (into the free cavity of the peritoneum, including the covered one),
- atypical (in the space behind the peritoneum, between its sheets, in the inter-lumen region).
The classic picture of signs of perforated ulcer is observed when perforation in the free abdominal cavity, occurring in 90% of cases. It distinguishes 3 periods:
- primary abdominal shock (chemical inflammation)
- latent period (bacterial),
- diffuse purulent peritonitis.
Each of the periods has its own particular symptoms. The primary shock phase, which lasts 6-10 hours, is characterized by the appearance of a sudden sharp "dagger" pain in the epigastric region, often diverging along the phrenic nerve to the zone of the right shoulder, shoulder blade and the outer part of the neck.
Externally, a sick person looks pale, haggard, with sunken eyes. A characteristic sign is the forced motionless position of the body, lying on its side, with the legs brought to the stomach. Breath superficial and frequent, on the forehead cold sweat. "Doscoobraznoe" tension of the abdominal muscles, which is not involved in the act of inhaling and exhaling.
The phase of bacterial peritonitis is also called the period of imaginary well-being. There is a decrease in the symptoms of pathology, the cessation of pain. The face becomes normal in color, pulse and breathing are normalized. When palpation remains pain in the epigastric region and signs of muscle tension in the abdomen.
After 12-24 hours from the moment of perforation, the picture of diffuse peritonitis unfolds. Symptoms are resumed with a new force, the patient's condition worsens. The pains are sharply intensified, repeated vomiting, nausea, and hiccups occur. Breathing is frequent and superficial, the pulse quickens, the body temperature rises, the abdomen is inflated.
Ulcer therapy methods
Perforated gastric ulcer of any form and localization is an absolute indication for emergency surgical intervention. Therefore, when people, once in the hospital with the specified diagnosis, are asked if the operation is mandatory, there can be no other answer than the affirmative. And the sooner it is produced, the better the prognosis and the lower the probability of complications.
Treatment without surgery is carried out in extreme cases, when a person is categorically against surgery. It consists in constant aspiration of the contents of the stomach through a probe against the background of intravenous injection of water-salt solutions and antibiotics. The effectiveness of this method is possible at the earliest stages of the development of the disease, when the contents of the stomach did not have time to pour into the abdominal cavity. But often these activities only waste precious time and have no effect. For this reason, as a result, the person consents to the operation, but it happens that it is too late.
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Treatment at the prehospital stage in case of suspected perforated gastric ulcer includes intravenous infusions of saline solutions, drugs, narrowing vessels, oxygen inhalation. Narcotic pain relievers can not be entered, as they "smear" the true picture of the disease. For this reason, an incorrect hospital diagnosis can be made. Before surgery, gastric lavage is performed with a probe to remove all its contents.
In the surgical treatment methods are used:
- perforation closure,
- removal of part of the stomach (resection),
- excision of the ulcer with vagotomy (dissection of the vagus nerve).
Usually, operative access to the organ is carried out by laparotomy. With the necessary equipment, it is possible to perform operations endosocally, under the control of the videoscope, through several openings in the abdominal wall, without a wide incision. If in the course of detected diffuse peritonitis and intra-abdominal inflammatory process, proceed to a laparotomy.
The choice of the operative method is carried out in accordance with the patient's condition, age, type of ulcer, presence of concomitant diseases, time from the beginning of the perforative process. Any chosen method aims to cure the sick and save his life.
Closure of perforation is used, if more than 6-12 hours have passed since the beginning of its formation, in young people with a newly developed stomach ulcer, in elderly people, with a general serious condition of a person.
Removal of part of the stomach (resection) is carried out with:
- a long-existing ulcer that cannot be cured by medication,
- detection during the operation of the old ulcer, which can not be sutured,
- suspected malignant ulcers,
- perforation of several ulcers simultaneously.
Treatment after surgery includes:
- taking anti-ulcer drugs (Kvamatel, Zantak, Maalox, Almagel),
- use of antibacterial agents (Ampioks),
- receiving proton pump blockers (Omez),
- intravenous administration of solutions to improve microcirculation and wound healing (Trental, Actovegin, Reopoliglyukin, Solcoseryl).
After completion of any of the selected methods produce a rehabilitation and ensuring the outflow of inflammatory fluid from the abdominal cavity (drainage). Sometimes they put two probes: in the jejunum - for food, in the stomach - for decompression.
In the postoperative period, early activation of the patient, carrying out respiratory exercises and exercise therapy is recommended. Contribute to the restoration of health walks in the fresh air, rest, elimination of physical exertion and emotional tension, good nutrition according to the rules of the necessary diet.
With the help of modern methods of laser therapy, scars formed after surgery are removed. Such activities can be carried out only with complete healing of the postoperative wound, in the absence of any complications, after control gastroscopy.
Features diet after surgery
Often the relatives of the patient have a question, what kind of food is shown after the perforated ulcer is removed. On the first day, it is only allowed to drink water from a spoon in a small amount, the next day, give 200-250 ml of liquid food (porridge). On the third day, the volume of food is 500 ml, then it increases to 1 l.
After 7 days, the patient is transferred to the main diet, similar to the treatment table used in the exacerbation of gastric ulcer. It is a diet table number 1a by Pevzner. After a week, go on a diet number 1b, and then, after 10-12 days, on the table number 1, which you need to adhere to 8-12 months.
When eating in accordance with diet No. 1a, food is consumed in boiled, grated, steamed, and maximally liquefied form. Excludes all vegetables, bakery, dairy and confectionery products, raw fruits, spices, snacks, carbonated drinks, coffee.
When switching to diet No. 1b, steam patties, filler fish, baked apple, or grated raw are added. Treatment table number 1 is not as strict as number 1a. It allows the use of non-rigid meat and fish pieces, wheat bread from high-grade flour, boiled and pureed vegetables, subacid kefir, cottage cheese, yogurt. Cooking methods remain the same - cook, simmer, steam, hard food to wipe.
Complications of the disease and prognosis
The earlier the accurate diagnosis of perforated gastric ulcer is made, the higher the probability of getting rid of this serious condition. With proper timely diagnosis (in the first 12 hours) and carrying out the necessary surgical treatment, the prognosis is favorable.
Complications after surgery develop infrequently and can be represented:
- purulent processes (abscesses under the diaphragm, between the intestinal loops, in the subhepatic space),
- violation of the exit of food from the stomach,
- intestinal obstruction
- bleeding (gastric or in the abdominal cavity).
Each of these conditions with any degree of severity of symptoms requires careful treatment and, if necessary, re-operation.
Prevention of bronchopneumonia is facilitated by washing the trachea and bronchi, removing fluid from the pleural cavity, early activation of the patient and breathing exercises. In case of violation of the passage of food through the stomach from it remove all the contents through the inserted probe. At the same time, they are struggling with the slowing down of the bowels, giving a large amount of fluid and injecting proteins and electrolytes intravenously.
While preserving gastric obstruction, gastroscopy is performed to detect the cause of a malfunction of the stomach, a possible mechanical obstruction that has arisen during the operation or as its complication, and to resolve the issue of the need for repeated surgical intervention.
An unfavorable outcome is usually observed as a result of late appealing to a person for medical help, when the symptoms are clearly pronounced.Fatal outcomes occur due to diffuse purulent peritonitis, postoperative pneumonia and associated serious diseases. In recent years, mortality among people diagnosed with a perforated ulcer during surgical treatment has decreased significantly to 5-7%.
Remote complications of the operation depend on its type and the correctness of the choice of method. Repeated perforations of the gastric wall occur in less than 2% of operated people.
The purpose of our site is, first of all, to enlighten readers in the field of gastroenterology. We want to protect you from possible errors that occur during self-treatment, to help recognize the beginning of the disease. This in no way negates the need for specialist consultation and an accurate diagnosis. It is only a doctor who should treat the patient according to his individual characteristics and control the course of the disease!
Features and Causes
A stomach ulcer develops in a person against the background of inflammatory processes occurring in his mucous membranes. The main cause of the pathology is infection with the pathogenic microorganism Helicobacter pylori. This pathogenic bacterium penetrates the body, provided that the immune system is weak and unable to resist the negative environmental factors.
In the early stages of gastric ulcer, small local changes are noted regarding the structure of the internal walls of the organ. On the mucous membranes are formed damaged areas of various shapes and sizes. They can be randomly scattered in all parts of the stomach or concentrated in one of its parts.
Ulcerations on the inner walls appear due to the fact that an aggressive environment is forming inside the stomach. This is due to the pathological activity of Helicobacter pylori. Microbes are capable of producing a chemical compound that readily cleaves mucus, which plays a protective role. It is she who normally protects the inner walls from being eroded by hydrochloric acid, which acts as an activator of digestive enzymes. For this reason, in the presence of bacteria in the gastrointestinal tract mucous membranes are damaged. Already at this stage, the patient begins to experience the first symptoms of the pathology, which serves as a signal to be examined and to choose medicines that help cure the disease.
If a person ignores the signs of the disease, it continues to progress. At first, the size of local lesions increases, and later hydrochloric acid begins to act on the deeper layers of the stomach walls. This is not the peptic ulcer itself, but its serious complication, which can lead to undesirable consequences. The condition, accompanied by the partial destruction of muscles, experts call perforation. Sometimes in parallel with it bleeding into the abdominal cavity or other organs opens.
Even an inexperienced specialist can suspect a typical perforated gastric ulcer at one glance at a patient. In order to somehow reduce the unbearable pain, such a patient is forced to tighten his legs. He is pale, covered with cold sweat. The patient cannot breathe freely without pain. The stomach is retracted, not involved in breathing. When feeling due to muscular tension, it resembles a hard board. When tapping, the zone of hepatic dullness disappears or shortens (this phenomenon is explained by the air penetrated into the abdominal cavity).
But the final diagnostic verdict can be made only after instrumental examination. Ulcer perforation detection helps:
- general abdominal radiography (the main diagnostic study, which detects free gas that has penetrated with the gastric contents into the abdominal cavity),
- Ultrasound (the method also reveals excess air in the stomach),
- fibroesophagogastroscopy (endoscopic examination is used mainly in case of suspected development of covered perforation),
- laparoscopy (this method is mainly used in incomprehensible situations, sometimes it is also supplemented by breakdown with air, which is pumped through a special probe).
Unfortunately, no pills and shots yet can not fix the formed defect in the gastric wall. The only treatment for perforated ulcers is surgery. Depending on the clinical circumstances, surgeons produce:
- ulcer closure
- removal of the stomach or its department,
- vagotomy (targeted cutting of the vagus nerve, stimulating ulceration, with pyloroplasty).
In recent years, doctors have tried not to cut the abdominal wall, but to resort to laparoscopic surgery. It eliminates the extensive operating wounds, since 4 punctures are sufficient for carrying out all the manipulations. Through them, special instruments and endoscopic equipment are introduced into the abdominal cavity, and then they perform the necessary surgical effects. Laparoscopic access provides better patient tolerability and faster postoperative rehabilitation.
Foreign experts have developed an even more sparing technology of operation, which allows to do without damage to the abdominal wall. Surgical instruments lead through a special fibrogastroscope, and then through punctures in the stomach wall itself.
Which doctor to contact
In case of sudden sharp abdominal pains, it is necessary to call an ambulance, which will take the patient to the surgical hospital. With a typical picture, laparoscopy is performed, during which you can not only see, but also suture an ulcer. In the future, the patient must be under the supervision of a gastroenterologist or therapist. It will be useful to consult a nutritionist on nutrition issues for peptic ulcer.
Perforated ulcer and perforated ulcer are synonyms of the same concept in medicine. Perforated (perforated) gastric ulcer and duodenal ulcer is not a separate type of ulcer disease. This is the name of a dangerous complication characterized by the formation of a through hole at the site of ulcer localization, through which food masses from the stomach or duodenum enter the abdominal cavity.
In case of perforation, it is very important to immediately seek medical attention. Gastric duodenal flow into the abdominal cavity causes inflammation of the internal organs and tissues (peritonitis).
This phenomenon is very dangerous for its consequences, the high speed of their development. Therefore, it is important for patients from this risk group to know the signs and symptoms of perforation of ulcers.
This article describes the causes, symptoms, classification of perforated ulcers of the stomach and duodenum. Diagnosis and treatment of perforated ulcers, as well as nutrition after perforated ulcer surgery, respectively, are described in the following articles:
Gastrointestinal ulcers, in one form or another, occur in about 10% of the total adult population of the planet. In 70-80% of cases, the disease develops at the age of 20-50 years. In men, the disease is more common than in women. In particular, women are protected by sex hormones estrogen, which can reduce the acidity of the stomach.
Perforated or perforated ulcer is a dangerous complication of gastric or duodenal ulcer, when a hole is formed at the site of the ulcer, through which gastro-duodenal contents (food particles, microorganisms, gastric juice, bile) flow into the abdominal cavity. Usually, perforation looks like a hole with a diameter up to 5 mm round and smooth.
The outflow from the stomach or duodenum causes a chemical burn of the internal organs, accompanied by severe pain. Possible infection. As a result, peritonitis develops, to eliminate the consequences of which, and the perforation itself, immediate medical assistance is needed.
In the esophagus, small intestine and colon, this phenomenon occurs very rarely. Perforated ulcers are characteristic of the stomach and duodenum. Therefore, the concept of "perforated (perforative) ulcer" is associated with them.
There is a pronounced relationship of perforated ulcer localization with the patient's age:
- In 80% of cases, perforation is observed in the duodenum in men aged 20–40 years. At the same time, the ulcerative defect can develop rapidly, and its perforation often catches, unaware of the person, by surprise.
- Cases of perforation of gastric ulcers, are more common in persons over 50 years. In these cases, chronic ulcers are more often perforated.
According to different data, perforation is observed in 3-35% of patients with gastrointestinal ulcer. This indicator depends on various factors: from the climatic conditions of the country of residence, the level of development of medicine, food traditions and ending with individual food preferences and bad habits. For patients in the post-Soviet space, this indicator, according to some data, is approximately 8%.
Causes of the disease
In most cases, the cause of the perforation becomes a complication of a chronic or acute ulcer. That is, perforation (perforation) occurs when a chronic ulcer is brought to such a state that all layers of the organ wall will be eroded through. Or bring to a similar state of acute ulcers.
Often the cause of bringing the disease to a critical state is due to the patient himself, his insufficiently serious attitude to treatment. Neglect of doctor's recommendations: diet, diet, bad habits. This, for example, when the patient continues to consume alcohol, even after the discovery of ulcers.
No small role is played by seasonal exacerbations. So, exacerbations of peptic ulcers in spring and autumn, respectively, lead to an increase in the cases of perforation of ulcers during these periods.
In up to 20% of cases, asymptomatic development of the disease or without obvious symptoms becomes the cause of ulcer perforation. With such a course of the disease, the ulcer may already be found on the fact of perforation.
The following negative factors can provoke perforation:
- Increased aggression on ulceration from the side of gastric juice (increase in acidity).
- Sudden increase in intrauterine pressure.
- Non-compliance with the diet: the use of harmful food and beverages.
- Alcohol use, smoking.
- Damaged diet.
- Chemical poisoning.
- Nonsteroidal anti-inflammatory drugs (aspirin, ibuprofen, ketonal, etc.), some chemotherapeutic drugs, corticosteroids, anticoagulants.
- Strong emotional stress.
- Exacerbation of the underlying disease.
- Hereditary tendency to disease.
- Infection with Helicobacter pylori bacteria.
- Overeating in the presence of ulcers.
- Active physical activity in the period of acute peptic ulcer. And also, significant physical exertion immediately after a meal.
Destructive effects can be either direct - direct physical or chemical effects of food, beverages and other substances on the gastrointestinal mucosa. And indirectly, when impaired protection of the walls of the stomach and duodenum leads to violations of the production of hormones and other substances in the body.
There are factors that simultaneously combine several harmful effects. This, for example, smoking. Direct damage to the mucous membrane is caused by the ingestion of saliva with harmful substances dissolved in it by smoke and the partial release of smoke itself into the stomach. And the harmful effects of smoke elements entering the body through the lungs into the blood.
These same negative factors are the original causes of defects of the mucous membranes of the gastrointestinal tract. Details about this are described in the article ““. The various negative factors described in it can also provoke the perforation of already existing ulcers.
Symptoms and description of the development of the disease
The development of the disease during perforation with the outflow of gastro-duodenal contents into the free abdominal cavity is considered typical. At the same time, there are 3 periods of the development of the disease, each of them is accompanied by its own symptoms.
However, with atypical development of the disease, the symptoms are very different. But cases of atypical development of the disease are rare, make up about 5% of the total number of cases of perforation of ulcers.
The first period - pain shock (chemical peritonitis)
Depending on the intensity of outflow of gastro-duodenal contents into the abdominal cavity, the first period can last from 3 to 6 hours. It depends on the diameter and location of the perforation, the degree of fullness of the gastrointestinal tract with food.
So, usually peritonitis develops faster with perforation of the anterior wall of the stomach. In some cases of perforation of the duodenum, extensive peritonitis may develop with a significant delay.
At the first stage after perforation, a complex of symptoms of “acute abdomen” develops, caused by serious injuries of the internal organs.
The first obvious symptom of perforation is severe “dagger” pain in the epigastric region (the Dielafua symptom). The pain occurs due to chemical burns of the internal organs and tissues of hydrochloric acid of the digestive juice. The patients themselves call it unbearable.
First, the pain is felt in the stomach. Then it descends on the right or, more rarely, on the left side and then seizes the entire volume of the abdomen.
Unbearable pains are aggravated by any movement. Therefore, the patient tries not to move. It usually lies on its side, often right, and with a force presses knees bent to the chest.
There is a characteristic symptom of a pronounced “plate-like” abdomen - a strong constant muscle tension of the anterior abdominal wall. The abdomen is slightly retracted, the patient tries not to use it when breathing, and does not allow doctors to touch it.
During perforation of duodenal ulcers, a painful symptom may occur around the navel and right hypochondrium. Pain can be given (irradiate) in other organs and parts of the body. Thus, pains in pyloroduodenal perforations can be felt in the right scapula and collarbone, or in the left - during perforation of the stomach (an Eleker symptom).
A clear symptom of ulcer perforation is the presence of gas in the abdominal cavity, which enter it, like the food masses, through the opening. The presence of gas is judged by the disappearance of hepatic dullness, which is determined by percussion (tapping the surface of the abdomen) by the characteristic sound. Gas is more often concentrated under the right dome of the diaphragm, and, depending on the position of the body, it can be localized in other places of the free abdominal cavity.
Perforation is accompanied by the following symptoms:
- slow pulse immediately after perforation (Grekov's symptom),
- shallow, rapid, intermittent breathing,
- face constantly tense, sunken eyes,
- pallor, cold sweat, cold limbs,
- blood pressure lowered.
Emetic urges during perforation are not peculiar. However, in 20% there is single vomiting immediately before perforation.
A characteristic symptom of acute peritonitis during perforation is Shchetkin-Blumberg symptom, defined by palpation. To do this, the doctor gently shallowly presses his fingers on the stomach and after a few seconds abruptly withdraws his hand. In the presence of peritonitis, such actions will sharply increase the pain.
Symptom Shchetkina-Blumberg with a clear tension of the abdomen can not be checked. But in the elderly, overweight people, and those who are intoxicated with such a sign of perforated ulcer, as the tension of the abdominal muscles may be absent or weakly manifested. In this case, Shchetkin-Blumberg symptom becomes an important indicator of patient diagnosis.
Second period - imaginary well-being
The period of false well-being is characterized by the weakening of acute symptoms, lasts about 8-12 hours. The name comes from the false feeling of the patient that the disease has receded.
For this period, the following features are characteristic:
- The pains subside or disappear completely.
- The tension of the abdominal muscles weakens, breathing is restored with the participation of the abdomen.
- In the behavior of the patient, a state of euphoria is traced — a characteristic state after suffering severe physical pain.
The pain disappears as a result of the neutralization of the hydrochloric acid of the gastric juice by abdominal exudate (fluid released into the abdominal cavity from small blood vessels during inflammation) and weakening the sensitivity of nerve endings. It is regarded by patients as an improvement.
Taking painkillers makes the period of false well-being more pronounced.
However, the condition continues to deteriorate. The following symptoms indicate the continuation of intoxication:
- temperature rise,
- dry mouth, gray on the tongue,
- a rapid increase in the number of leukocytes in the blood,
- increased heart rate, may develop arrhythmias,
- signs of gas in the abdomen become more pronounced
- the appearance in the abdominal cavity fluid
- development of flatulence (accumulation of gases in the intestines) in connection with the development of intestinal paresis (partial or complete cessation of food movement in the intestines).
Despite the significant weakening of pain, there is an involuntary tension of the abdominal muscles, as well as a positive symptom of Shchetkin-Blumberg.
Thus, in the period of false well-being, the disease continues to develop rapidly, but with a temporary weakening or disappearance of pain, which misleads the patient.
The third period - a sharp deterioration (development of acute peritonitis)
After the second, latent period of the disease, a sharp deterioration of the condition occurs:
- Nausea, severe vomiting - the first sign.
- Dehydration of the body: the skin and mucous membranes become dry.
- Diuresis (the volume of urine produced) is significantly reduced, up to anuria (stopping the flow of urine into the bladder).
- Stomach tension is preserved.
- Breathing again becomes superficial, frequent.
- The volume of the abdomen is increased due to accumulated gas and fluid.
- The temperature rises sharply to 38–40 ° C with a further drop to 36.6 ° C and below.
- The pulse increases to 100-120 beats, the blood pressure decreases significantly.
- The oral cavity is very dry, on the tongue a bloom of crusted scurf.
- The patient becomes inhibited, lethargic, restless.
A characteristic sign of diffuse peritonitis and depletion of the “Hippocratic Face”:
- idle expression
- sagging lower jaw
- dim, sunken eyes,
- sunken cheeks, pointed nose,
- pressed-in temples, dry forehead,
- the skin is pale gray, covered with fine cold sweat.
Manifestation of systemic inflammatory response syndrome. Abdominal distention occurs due to progressive intestinal paresis. Progresses leukocytosis. The blood increases the content of hemoglobin and red blood cells. Hyperkalemia develops (an increase in potassium in the blood, which plays an important role in the contraction of the body’s muscles, including the heart). And other disorders of the body.
As N.N. Samarin (1952), "... both the diagnosis and surgical care in this period are usually already overdue."
Covered perforation: symptoms and progression of the disease
Covered form is found according to various sources 2-12% of all cases of perforation of ulcers. It occurs when the perforated hole is closed by a neighboring organ or gland (fold of peritoneum). This phenomenon is possible under the following conditions:
- small diameter perforated hole
- a small amount of food masses in the stomach during perforation,
- the close proximity of the liver, intestine, omentum, gallbladder.
The clinical development of covered perforation is similar to the typical case of ulcer perforation. It is divided into 3 stages:
- ulcer perforation, with the occurrence of pain,
- blunting the symptoms
- development of peritonitis.
First stage . Owing to the outflow of gastro-duodenal contents into the abdominal cavity, severe pain suddenly arises in the area of the epigastrium. This is followed by:
- sudden weakness, cold limbs,
- decreased blood pressure, poor blood supply to the organs,
- skin pale, cold sweat.
The abdomen is tense, usually local to the source of the pain. Symptom Shchetkina-Blumberg positive.
Second phase . Pain symptoms begin to subside after covering the perforation, as a result of which the outflow of food masses stops, and also, due to neutralization of hydrochloric acid exudate. This is usually observed 30–60 minutes after perforation.
The presence of the disease is indicated by such symptoms as:
- temperature rise,
- development of leukocytosis,
- the presence of a small amount of gas under the diaphragm,
- signs of peritoneal irritation and more.
If the perforation is covered sufficiently reliably, and the volume of the leaked mass from the stomach or duodenum 12 is insignificant, then with appropriate treatment, recovery is possible. But often the cover is temporary.
Third stage characterized by the development of complications. These are limited abscesses (purulent inflammation of the tissues) in the area of perforation. In the case of an intensive release of gastro-duodenal contents, diffuse peritonitis develops.
Sometimes symptoms with a covered perforation are mistakenly regarded as the usual exacerbation of the disease.
Symptoms appear slower if the perforation is obscured by a small omentum. In this case, the patient experiences intense pain. There are signs of the formation of an abscess of the small omentum. With the help of ultrasound, a limited area of the inflammatory infiltrate (accumulation of cell elements with blood and lymph) is detected.
Atypical development of the disease
Atypical development occurs rarely, about 5% of cases. Such a course is not due to the direct entry of gastro-duodenal contents into the abdominal cavity through the perforated hole, but into confined spaces.
Atypical development of the disease occurs during the perforation of ulcers:
- cardiac stomach,
- the posterior wall of the stomach in contact with food masses in the cavity of the omentum,
- the posterior wall of the duodenum, etc.
It also makes the disease mild outflow of the perforated hole in the closed areas formed by adhesive processes. And in some other cases.
The atypical course of the disease is characterized by the absence of pronounced symptoms of typical perforation: the absence of “dagger” pains, a “plate-like” abdomen, and the rapid development of peritonitis.
Patients may feel nagging pain without clear localization. Body temperature rises, weakness is felt.
If the symptoms of atypical perforation are not promptly detected, the disease will be complicated by purulent inflammation of the accumulation space of the gastro-duodenal contents: the cavity of the glands, the retroperitoneal space, etc. In the event of a breakthrough of accumulated masses into the free abdominal cavity, peritonitis will develop.
Timely diagnosis of the disease is difficult. Identification of an atypical form of perforation may be hampered by the following:
- hepatic dullness remains normal,
- the absence of free fluid and gas in the abdominal cavity.
Cardiac perforation of the stomach can cause subcutaneous emphysema (gas accumulation) of the left supraclavicular region (Podlag symptom), and perforation of the posterior duodenal wall causes emphysema at the navel (symptom of Vigiatzo).
The outflow of gastro-duodenal contents into the abdominal tissue causes sharp pains in the epigastric region, giving way to the back.Further, the pain subsides. Within 48 hours develop phlegmon (acute spilled purulent inflammation), provoking a fever, chills. On the right, at the level of the thoracic vertebrae, swelling occurs, with a palpation of which a characteristic crisp sound (crepitus) arises. X-ray examination reveals a gas - the most important symptom indicating a perforation.
About 12% of cases of ulcer perforation are accompanied by bleeding, sometimes intense. This is due to perforation of the duodenum 12 in the pancreatic head. If there is reflux, (discharge of the duodenum content back into the stomach) vomiting of blood is possible. Bleeding makes it difficult to diagnose. Pain, symptoms of peritonitis, abdominal tension are mild or absent. It also becomes the cause of late detection of the disease.
With implicit symptoms, the presence of perforation can be detected only by a comprehensive examination: ultrasound, X-ray, FGDS procedure. In doubtful cases, laparotomy is used.
Perforated gastric and duodenal ulcers (also known as perforated ulcers) are extremely serious and life-threatening conditions (with enormous mortality) that require emergency medical care (usually surgery). It is also worth noting that ulcer perforation is often referred to as “ulcer perforation”.
Without timely medical care, perforation of the ulcer of the stomach or duodenum in the shortest possible time leads to the death of the patient. But even urgent and adequate medical care can not always save the patient, especially if we are talking about a patient of old age.
In this article we will talk in detail about how this disease is treated in a modern way and what its first signs are. We will also talk about the causes of perforated gastric and duodenal ulcers.
If you do not resort to a very complex and strict medical terminology, then perforated gastric and duodenal ulcer (WPC) is, in fact, a through defect in the gastric wall or in the duodenal wall. Danger of such a defect not only in massive bleeding, but also in the leakage of the contents of the gastrointestinal tract into the free space of the abdominal cavity.
This is a very serious disease that develops rapidly and can lead to massive purulent damage to the abdominal cavity within a few hours (so-called peritonization). At the first symptoms of perforation, emergency medical care is required, since such a disease heals on its own only in the rarest of cases.
Such perforative diseases are relatively common. So, for 3.1 million people with peptic ulcer and 12 duodenal ulcers (approximately as many ulcers exist in Russia), 10–15% of patients with a perforated ulcer in history are accounted for.
Despite the fact that modern medicine is able to perform high-tech operations (for example, the closure of a through defect), the mortality rate for this disease is very high. With a delay in the operation, it is 60-70%, and with an adequate and timely performed operation - 5-18%.
Conditionally favorable prognosis (with timely treatment started) are patients under the age of 45 years.
Elderly patients fall into the category of patients with conditionally unfavorable prognosis. Also, an unfavorable prognosis is observed in patients with chronic systemic diseases (AIDS, diabetes, autoimmune diseases of the gastrointestinal tract).
Causes of ulcer perforation
The causes of this disease are numerous. Sometimes it happens that after the development of perforation and its successful relief, it is simply impossible to find the cause. And such cases are not uncommon (especially in young patients).
In general, the perforated ulcer has the following reasons for development :
- mechanical damage to the gastric mucosa or duodenum with a foreign object,
- eating fatty, fried, spicy or smoked dishes on the background of acute gastric ulcer and duodenal ulcer,
- the development of associated diseases of the gastrointestinal tract, indirectly affecting the state of the ulcer,
- abdominal trauma,
- chemical poisoning (including chemical burns),
- infectious invasion of the gastrointestinal tract,
- reception of a large amount of alcohol on the background of chronic ulcerative pathology,
- complications of taking certain medications (as a rule, we are talking about the so-called non-steroidal anti-inflammatory drugs),
- in rare cases - physical overstrain of the abdominal cavity (usually when lifting weights),
- ignoring the chronic or acute course of the peptic ulcer (in other words, the absence of its treatment or inadequate treatment),
- the presence of concomitant ulcers of systemic chronic diseases (AIDS, cancer, diabetes, autoimmune diseases, and so on).
Symptoms of perforation of the ulcer
Symptoms of perforation of the ulcer are non-specific and require additional differential diagnosis (acute appendicitis, heart attack and renal colic should be excluded). In general, the symptoms of perforation are pronounced and it is impossible not to notice them.
Perforated ulcer has the following symptoms :
- fever (temperature can vary from 37 degrees to terminal 40-41 degrees Celsius),
- strongest arching and dagger pains in the abdomen, often spreading to the limbs and lower back,
- indomitable and completely unreliable vomiting of blood masses,
- diarrhea with blood masses,
- loss of consciousness, hallucinations, stupor,
- reflex and uncontrolled patient's taking a forced posture (knees bent on chest, arms pressed to legs, face make-up grimace of pain),
- in some cases, uncontrolled urination is possible,
- metallic taste in the mouth.
Also, with typical perforation, there are characteristic consistent signs:
- Acute onset of severe pain, often leading to shock and sopor.
- After some time, there is a period of so-called imaginary lull, when the pain intensity decreases and the patient feels well in general, considering that the disease has passed him.
- After an imaginary lull, the third phase of the disease begins, accompanied by even more pronounced symptoms than in the first phase, and the development of purulent peritoneal lesion (peritonization).
What is dangerous perforation ulcers?
The danger after the development of a perforated ulcer is not at all in painful shock, as many people might think.
The main problem is massive bleeding, complemented by the penetration of the contents of the gastrointestinal tract into the free abdominal space.
Massive blood loss quickly leads to serious neurological abnormalities. The patient ceases to feel reality, he begins to delirium, hallucinations are not uncommon. The next stage is short-term, and then prolonged loss of consciousness. They are followed by a coma, and then, in the absence of adequate treatment, death.
The penetration of the contents of the gastrointestinal tract into the abdominal cavity threatens the development of purulent peritonitis. This disease causes general blood infection (sepsis), abdominal vascular thrombosis and other serious complications.
First aid in case of perforation is ineffective, since it simply has nothing to do (if we consider the means at hand and the composition of the usual home first aid kit). When the first symptoms of this condition should be in the shortest possible time call an ambulance brigade and help visiting medical staff to transfer the patient to a resuscitation vehicle.
Treatment of perforation is possible only in a hospital. Home treatment with folk remedies, as well as ignoring the symptoms of the disease, in 100% of cases leads to the death of the patient.
Methods of treatment of perforated gastric ulcer, duodenal ulcer
The postoperative diet is very strict and excludes absolutely most of the usual food to the average city dweller. The diet prohibits eating fried, spicy, smoked, salty, fatty and pickled foods.
In terms of drinks, the diet prohibits the use of any caffeinated and alcoholic beverages, including stimulants (the so-called energy drinks). Assigned fractional meals (about 8-10 meals during the day) and the absolute rest of the patient (any physical activity, except for a short walk, is prohibited).
Perforated gastric ulcer does not apply, according to the classification of diseases, to an independent disease. Pathology is considered a dangerous consequence of the lack of therapeutic effects on the ulcerative state of the gastric mucosa. The course of the disease is a fairly described form with an intensive degree of symptoms. Dangerous is due to the high mortality rate of the population with not timely medical care.
The term "perforated" means the defeat of the gastric wall with a violation of tightness through, with the content of the digestive organ in the abdominal cavity. Doctors also replace the term “perforated” with “perforated”, which is synonymous with medicine.
The first period of the appearance of a through hole for symptoms lasts up to 6 hours. A more accurate time depends on several factors, including the most obvious - the amount of food mass found in the digestive organ and the area of the affected surface, in the place of which perforation will develop. The period of outpouring the contents of the stomach into the abdominal cavity differs from the same stage when the duodenum is perforated by a bright symptom, in contrast to the asymptomatic chemical stage of intestinal perforation.
The start of pathology can be considered a sudden sharp pain in the epigastric region, comparable in patients with the penetration of a dagger into the stomach or a burn of boiling resin. The nature of the pain the patient does not confuse with another disease, if one day the cutting pain was experienced by him. If painful sensations are localized more frequently in the navel or in the liver region, a perforation of the ulcer in the duodenum is suspected. The pain is often localized in the right part of the abdominal cavity, seeking to spread to the entire abdominal area.
With the displacement of gases under the right side of the diaphragm, the reflection of pain can be felt in the right limb. Before the perforating process, the patient may experience vomiting, but after perforation this symptom is excluded.
The appearance of a sick person indicates a painful condition: the skin is cold, pale, covered with sticky sweat. The convex features of the face become pointed, the eyeballs look sunken stronger in the sockets.
In attempts to occupy a position of the body in which it is easier to bear the pain, the patient chooses a bent position with the legs pressed to the body. The pain subsides a little when lying on the right side.
Systolic pressure and heart rate are reduced. Slow contraction of the ventricles of the heart indicates arousal of the parasympathetic nerve. Mixed breathing is replaced by chest. Respiratory rate with shallow breaths increases. Visually there is a lack of full breath, followed by an additional one with a small pause. Such changes in the respiratory mechanism are due to spasms of the diaphragm.
The symptom of Shchetkin – Lumberg contributes to the rapid diagnosis of the disease. With a positive test, the patient does not allow to touch the skin of the abdomen, even for the purpose of soft palpation. The muscles of the abdominal wall are in constant tension. In medicine, it is customary to designate the state of muscular tension of the abdomen as "scaphoid."Clearly palpable and visible tendon threads across the entire muscular surface of the anterior abdominal wall. The last group of symptoms is found only in people without strong overweight, only in a sober state. With intensely expressed subcutaneous adipose tissue and alcohol intoxication, the tension of the muscle layer of the abdominal wall is not visible.
An impressive perforated ulcer is shown on a surgical specimen.
The symptom that manifests itself in most cases - the sound of tympanitis when tapping the abdominal cavity in the region of the first hypochondrium in patients lying supine is not typical in the presence of bowel adhesions. At the stage of chemical peritonitis, the peristaltic movement of food is not disturbed yet. Symptom Spizharsky - knocking in the armpits when lying down on the left side of the body is a specific sign of a perforated ulcer.
A symptom found in 100% of women with perforated ulcers is pain in the digital examination of the vagina, which is an irradiation pain that develops immediately after perforation of the digestive organ. In men and women, a rectus symptom is also a guaranteed sign, together with the described symptomatic complex, when the palpation of the rectal area brings intense pain to the patient. The occurrence of discomfort is due to the reflection of pain in the pelvic region of the abdominal cavity during the migration of pathological fluid in the lower sections of the peritoneum.
Perforated ulcer 6 hours after perforation enters the bacterial period. At this point, the multiplication of pathological prokaryotes reaches its maximum. The intensity of the pain and other unpleasant symptoms is sharply reduced. The patient makes a conclusion about the successful completion of the disease. But the pathological process enters a new stage, bringing new sensations: increased body temperature, rapid heartbeat, decrease in systolic pressure. Attempting to hear the tympanic sound does not bring positive results, which is explained by the violation of the peristaltic movements of the intestine and the formation of intestinal smooth muscle paresis. The level of leukocytes becomes the highest.
Changes are also noted in the patient's behavior. Comes calm, bordering on a mild euphoria, obtained by the absence of pain after prolonged action. The danger of the situation to the sick is not realized, his only desire is to be at rest. The “pre-shaped” condition of the muscular wall of the abdominal wall disappears, the palpation of the abdominal area does not cause much suffering. The abdomen is soft on palpation.
If the omentum of the abdominal cavity covers the through hole of the stomach, in the second period of peritonitis the painful sensations in the epigastric region disappear completely. The danger of the period lies in the double misconception of the doctor and the patient. A patient who has not told the doctor about the previous condition, gives non-principal symptoms that may indicate another disease. During the initial observation of a patient in the bacterial period, the doctor may make a mistake in diagnosing, guided only by detectable signs.
Vaginal-rectal palpation continues to be accompanied by pain, a positive test also gives Shchetkin-Lubmerg's symptom. On the course of the second period of peritonitis after perforation of the digestive organ indicates timpany, obtained by percussion of individual parts of the abdomen. The tongue of the patient is dry and has an off-white bloom. When untimely radical medical care perforated ulcer enters a period with a high percentage of death.
Ulcer perforation treatment
The patient or his relatives must consent to radical intervention. Only this method gives a chance for successful treatment and patient survival.In the absence of consent to the operation, survival with conservative treatment is extremely low.
The method without surgical treatment of perforated gastric ulcer proposed by Taylor and includes the following types of procedures:
- intramuscular administration of antibiotics throughout the week,
- contact of the abdominal area with an ice bubble,
- drip infusion of drugs to improve blood biochemical parameters and eliminate symptoms of intoxication,
- placing the gastric probe for several days in the digestive organ to drain the contents,
- after removal of the probe, a control injection of a contrast solution is carried out to detect leaks from the stomach.
Surgical treatment is prescribed based on several factors that determine the type of surgery:
To date, the following types of operations are performed:
- suturing the edges of the perforation with the imposition of double-row stitches,
- resection of the organ in severe conditions of ulceration and the presence of a malignant tumor that caused perforation,
- excision of perforation with subsequent expansion of the pyloric orifice and cutting of the branch of the parasympathetic autonomic nervous system,
- ectomy of the part of the stomach adjacent to the pylorus with a sharply enlarged lumen of the duodenum. It is performed with the vagotomy of a large parasympathetic branch.
Recovery and Prevention
In the rehabilitation period, adhere to general preventive measures. With regard to nutrition, a strict diet is indicated for patients with perforated ulcer in the postoperative period. Salty, spicy and other heavy digestion products are excluded. In the first 30 days after the elimination of the perforation, a poor drinking regime is used (up to 1 liter per day of total fluid). On the 3rd day in a clinical setting, the patient is offered unsweetened kissel. Soups and pureed vegetables are allowed to eat in small portions on the 15th day. Little by little, the patient begins to use bread and meat steam products only a month after the operation.
Patients who applied for help within the first 6 hours after the first onset of the first symptom of a perforated ulcer have a chance of recovery in 96-100 cases, subject to agreement on surgery. Seeking medical help, which was late for a day, reduces the chances of recovery by up to 40%. In the absence of surgery, death occurs at 6-7 days after ulcer perforation.
Perforated gastric and duodenal ulcers are serious complications in the stages of the stomach, often leading to the appearance of extensive peritonitis.
Ulcers, which are formed in the stomach or duodenum, are very often prone to perforation in male patients, whose ulcer history does not exceed three years. Usually, perforation of gastric and duodenal ulcers is more often observed in the autumn-winter period. The pathogenesis of the disease, its pattern is due to the aggravation in the off-season months of gastric ulcer. The frequency of ulcer perforations directly depends on an unfavorable emotional background and unhealthy nutrition; during all kinds of disasters and crises, the level increases rapidly.
Perforations are susceptible to patients of any age. Cases of development of perforation of an ulcer in ten-year-old children and over the age of 80 are described. Men from 20 to 40 years old are most often affected by this disease. Young patients are susceptible to perforation of ulcers of the intestines, the elderly - stomach ulcers.
In 10% of all clinical cases, bleeding occurs. It does not develop from the perforation site, since in the perforation area the vessels are obliterated and necrosis of the stomach wall develops. The blood begins to flow from an ulcer located mirror on the opposite wall, the ulcer is obtained through. Usually in the duodenum mirror ulcer grows into the pancreas.
Perforated gastric and duodenal ulcers have several different gradations, formed by various signs:
- Based on the etiological factor, acute (symptomatic) and chronic ulcers can perforate.
- The opening of the ulcer can be located in different departments, which affects the classification.
- By localization in the duodenum, pathological changes are divided into bulbar or postbulbar.
- According to the type of perforation, perforation is typical or covered, when the contents from the cavity of the stomach are poured into the abdominal cavity, and atypical, when perforation is performed between the leaves of the omentum, peritoneum, and retroperitoneal space.
- They are classified according to the phase of peritonitis - the stage of primary toxic, pain shock, the phase of false well-being, the stage of abdominal sepsis.
Clinic and course
They provoke the development of the clinic of perforation overeating, violation of the diet, alcohol intake. Symptoms characteristic of perforated gastric ulcers, depending on the stage of development of the process.
The periods of perforated gastric ulcer or duodenal ulcer correspond to the periods of peritonitis, have distinctive features, pathognomonic clinical signs:
- The stage of abdominal shock lasts up to six hours.
- The period of imaginary well-being or development of fibrinous-serous peritonitis lasts from 6 to 12 hours.
- The stage of diffuse peritonitis, severe septic shock is stated twelve hours after the ulcer perforation.
If a patient has an atypical form, the symptoms of a perforated gastric ulcer are often erased and atypical. If the perforation is atypical in nature, fluid is released into the stuffing box or retroperitoneal space. A similar course occurs in 5% of cases from the others. The pain is less intense. Localization of pain is non-specific and diffuse, reducing the ability to quickly make a reliable diagnosis. If the disease is diagnosed incorrectly or untimely, severe purulent complications may develop.
Principles of treatment
If a patient has a perforated gastric or duodenal ulcer, treatment should be urgent and prompt. Conservative treatment is prescribed for the patient’s categorical refusal of the operation.
Conservative treatment is carried out according to the method of Taylor. A special gastric tube is inserted into the stomach cavity, through which contents are removed from the stomach, under local anesthesia. Then a new probe is introduced transnasally, through which a continuous aspiration is carried out. The patient is prescribed detoxification therapy intravenously, antibiotics with a wide range, in large dosages.
This method of treatment does not guarantee a favorable prognosis at all - there is a high risk of purulent complications in the abdominal cavity reaching sepsis.
Surgery to remove the effects of perforation of the ulcer is the only effective method. Before starting, conduct thorough training. The patient is injected probe, clear the contents of the perforated stomach. Carry out catheterization of the bladder and preparation for the operation of the surgical field.
For the implementation of surgery, the patient is given general anesthesia. In some cases, taking into account the patient’s state of health, epidural anesthesia may be used. Local anesthesia for perforated gastric ulcer is used in exceptional cases.
The most frequent access is median laparotomy. An abdominal wall incision is made, the surgeon assesses the condition of the abdominal cavity, and detects the localization of perforation. If it is impossible to determine visually, a palpatory examination is performed. It must be remembered that perforation could occur in a number of places at the same time.
The abdominal cavity is cleared of leaked contents and the formed exudate, necessary sanitation and disinfection with the use of an antiseptic solution.
The nature is determined based on the patient's condition, the complexity of the disease, the extent of the damage. The operation can be radical and palliative.
The hole that was formed in the perforation of the gastric ulcer is sutured with two rows of muscle sutures. Sutures must be applied transversely, not longitudinally, to prevent the development of cicatricial stricture. Carrying out the suturing can be carried out with the presence of appropriate equipment and a clear localization of the site of perforation, as well as the absence of signs of diffuse peritonitis.
Closure of perforated gastric ulcer is more effective in young or middle age, when perforated gastric ulcer is caused by stress disorders. Relapses often develop after suturing. In case of gastric ulcer chronization, gastric resection will be the best method of treatment. After surgery, the abdominal cavity is sanitized and drainage is established.
In the postoperative period, antibiotics, detoxification treatment, blood substitutes are prescribed. The patient is prescribed a strict diet.
Symptoms and signs
Perforated gastric ulcer is a dangerous condition that threatens not only the health, but also the life of the patient, so it is important to know on what grounds this pathology is diagnosed and what they do for its successful treatment. One of the diagnostic methods is MRI of the stomach. Experts list several symptoms that indicate that a person suffers from ulcer perforation:
1. Pain If in the early stages of the pathology, when the size of the damage is minimal, there may be no discomfort, the perforated ulcer is always accompanied by unpleasant sensations. However, they are localized in the central part of the abdomen and are cutting or piercing character.
2. Metallic taste in the mouth. This symptom indicates the presence of bleeding. The symptom is related to the content of hemoglobin in this biological fluid, which is an iron compound.
3. Heartburn and burning. These symptoms of perforated ulcers are characteristic of the early stages of the disease, but if the muscle layer of the stomach is damaged, they become unbearable.
4. Nausea. Emetic urges are also characteristic of the initial stages of gastric ulcer. This is a kind of protection of the human body, since the intense secretion of hydrochloric acid, which destroys the walls of the gastrointestinal tract, begins after the intake of food.
5. Increase in body temperature. Special attention should be paid to this symptom, since it is usually caused by the spread of inflammation to the entire cavity of the stomach and its exit beyond the limits of the organ.
6. Pale skin. Anemia is characteristic of patients diagnosed with internal bleeding with a perforated ulcer. This is due to a strong drop in hemoglobin level - a complex responsible for the saturation of all organs and tissues with oxygen.
A stomach ulcer is a dangerous condition, sometimes fatal. For this reason, with the development of characteristic symptoms, it is necessary to take urgent measures aimed at treatment. Deaths of patients with this pathology are related to the fact that at a certain stage all unpleasant symptoms subside. Human well-being improves, he often refuses medical care. It is forbidden to do this, because the absence of discomfort is provoked only by the destruction of the nerve receptors responsible for the perception of pain. After a few hours, the situation will change dramatically, and the patient will begin to suffer from fever, weakness, fever and gastrointestinal upset.
Each person should know that the best solution for suspected perforated ulcer is to contact specialists. The patient is immediately hospitalized and further treatment is carried out under the strict supervision of doctors.However, first aid to the victim should be provided before the ambulance arrives.
Before the arrival of physicians, it is important to provide a person suffering from a perforated ulcer with complete rest. It is better if he takes a horizontal or semi-sitting position. This will help save power.
Experts warn that you should not take any drugs before the arrival of doctors. Any analgesics are highly undesirable due to their effect on the receptors. The pains in the stomach ulcers are intense, so getting rid of them at home is difficult. The Baralgin tablet or any of its analogs based on metamizole sodium can dull the discomfort, but it will distort the overall clinical picture. As a result, the diagnosis of pathology becomes difficult, and treatment begins only when the doctor is completely sure that the patient has a perforated ulcer.
Treatment at the prehospital stage involves maintaining all the vital functions of the body. If the condition is severe, then you need to monitor blood pressure, which often decreases. After being placed in the hospital, the doctor will assess the patient's well-being and determine the further tactics of therapy. Perforated form of the disease requires an operation. To cure it by conservative methods is impossible.
Diet before and after surgery
Proper nutrition is an essential element in the treatment of any pathologies of the gastrointestinal tract. When diagnosing perforation should be especially careful, as the recommendations relate not only to the recovery period, but also the time before the operation.
Before excision of an ulcer or resection of the stomach is required to completely refrain from eating. The human gastrointestinal tract should be empty at the time of surgery. Only in this case, the specialist will perform the operation as qualitatively as possible, which reduces the risk of complications.
It is necessary to refuse food for several days after the manipulation. This requirement must be observed to quickly restore the entire digestive tract. For the same reason, treatment after surgery involves a sparing diet.
After 4-5 days after the elimination of perforation, liquid foods and drinks are introduced into the patient’s diet. This diet is designed to reduce peristaltic activity, as well as reduce the secretion of digestive enzymes and, accordingly, their activator - hydrochloric acid. Aggressive effects on sensitive mucous membranes will be minimal. An easy option for a patient after suturing a perforated form of a peptic ulcer will be light vegetable soups or broths on lean meat. As for drinks, it is best to prefer water or jelly. This diet is required to adhere to at least 5 days, after which the menu is expanded to include:
- vegetable puree,
- steam omelets,
- rice porridge
- cutlets from dietary meat.
Your doctor will warn you that diet is an effective tool to restore normal functioning of the gastrointestinal tract, therefore, it is imperative that you strictly follow the nutritional guidelines.
Most of the usual products remain banned, not only in the rehabilitation period after excision of perforation, but throughout life. To avoid the recurrence of peptic ulcer disease, a person is forced to follow a special diet, which excludes the use of:
- fatty meat
- smoked products
- canned food
- sour vegetables and fruits
- carbonated drinks
- of alcohol.
Food with perforated ulcers is designed to ensure minimal stress on the gastrointestinal tract by reducing the residence time of food in the cavity of the stomach and reducing the concentration of hydrochloric acid, which eats away the walls of the organ.
Possible complications and prognosis
Perforated gastric ulcer is a serious condition in which a person suffers from severe pain.Many are interested in whether an operation is necessary if the examination shows the presence of damage to the muscle walls. Gastroenterologists answer that without urgent surgical intervention the chances of recovery are minimal. Inflammation quickly spreads throughout the abdominal cavity, which is fraught with purulent peritonitis. It is this pathology that ultimately leads to death, observed in 5% of all registered cases.
Complications after surgery are rarely fixed. They can be associated with poor-quality suturing, which provokes an abscess or sepsis in the abdominal cavity. Sometimes there is a relapse of perforation, which forces specialists to carry out the excision procedure again.
Any form of peptic ulcer is dangerous to health, so measures should be taken at the first symptoms. Treatment without surgery is possible if the muscle layer is not damaged. In this case, the doctor will select drugs that will prevent further damage. The agents acting on the causes of the pathology - pathogens will be assigned. If the disease continues to progress, then it is not advisable to treat it with drugs. Perforation requires urgent surgery and subsequent dieting.