Perforated gastric ulcer – end-to-end damage to the stomach wall that occurs at the site of an acute or chronic ulcer. This condition refers to the symptom complex acute abdomen. It is clinically manifested by intense pain in the abdomen, dosing of the anterior abdominal wall, fever, tachycardia, and vomiting. Esophagogastroduodenoscopy, ultrasound and CT of the abdominal organs, radiography of the abdominal organs, diagnostic laparoscopy will help to establish the correct diagnosis. The treatment is primarily surgical, supplemented by antisecretory, detoxification and anti-helicobacter therapy.
Perforated gastric ulcer is formed mainly in people of working and elderly age. Fortunately, this complication is quite rare – no more than two cases per 10,000 population. Despite the improvement in the diagnosis and improvement of H. pylori therapy, the frequency of perforations in peptic ulcer disease increases over the years. Among all the complications of gastric ulcer, perforated ulcer takes at least 15%, and in general this condition develops in every tenth patient with an ulcer history. Among patients with gastric perforation, the ulcerative genesis of men is ten times more than women. Perforation of the stomach is one of the main causes of death in peptic ulcer. Studies in the field of gastroenterology show that perforation of gastric ulcer develops three times more often than perforation of duodenal ulcer. A retrospective analysis of case histories indicates that about 70% of perforated ulcers are “dumb,” that is, prior to perforation, they are not clinically manifest.
The risk factors for this condition include the presence of an acute or chronic gastric ulcer, a verified Helicobacter pylori infection (in 60-70% of patients). More rare causes of perforated gastric ulcers include impaired activity of the endocrine glands, atherosclerosis, circulatory failure, severe respiratory disorders with the development of ischemia of the internal organs.
Perforated gastric ulcer occurs in three stages. The initial stage lasts up to 6 hours after perforation; In this phase, the acidic juice from the stomach enters the abdominal cavity, causing severe chemical damage to the peritoneum, manifested by a sudden intense abdominal pain. The second phase (6-12 hours after perforation) is characterized by intensive production of exudate, which dilutes hydrochloric acid, which leads to a decrease in abdominal pain. In the third phase (from 12 hours to days after perforation) purulent peritonitis develops, inter-intestinal abscesses form.
Perforated gastric ulcers are classified by:
- etiology (perforation of chronic or acute ulcers);
- location (on the curvature of the stomach, in the antrum, cardia or pylorus, the body of the stomach);
- clinical form (classic – a breakthrough into the free abdominal cavity; atypical – into the omentum, fiber of the retroperitoneal space, the cavity delimited by adhesions; combination with gastric bleeding);
- peritonitis stage (chemical, bacterial, spilled purulent).
Symptoms of perforated gastric ulcer
Perforated gastric ulcer has several symptoms: a history of gastric ulcer, sudden intense abdominal pain, early abdominal tension of the abdominal wall, significant pain during palpation of the abdomen. During the survey, approximately one out of five patients noted an increase in stomach pain a few days before perforation. Irradiation of pain depends on the position of the perforated gastric ulcer: in the arm (shoulder and shoulder blade) to the right for a pyloroduodenal ulcer, to the left – when a defect is located in the area of the bottom and the body of the stomach. When an ulcer of the back wall of the stomach breaks through, hydrochloric acid is poured into the tissue of the retroperitoneal space or omentum bag, so the pain syndrome is practically not expressed.
On examination, the forced position with the knees brought to the stomach, the suffering expression of the face, increased pain during movements attracts attention. The transverse grooves on the rectus abdominis muscles become more pronounced, the abdomen is drawn in while inhaling (paradoxical breathing). Hypotension is accompanied by bradycardia, shortness of breath. In the first hours of the disease there is marked pain during palpation in the epigastric region, which subsequently extends to the entire anterior abdominal wall. Symptoms of peritoneal irritation are sharply positive.
An urgent consultation of a gastroenterologist and a surgeon is shown to all patients with suspected perforated gastric ulcer. The goal of all instrumental examinations and consultations (including an endoscopist doctor) is to identify free fluid and gas in the abdominal cavity, ulcers and perforations.
Panoramic radiography of the abdominal organs in the vertical and lateral position allows you to identify free gas in the abdominal cavity, sickle located above the liver or under the side wall of the abdomen. This study is informative in 80% of cases. For a more accurate diagnosis using CT scan of the abdominal cavity (98% of information content) allows you to detect not only free fluid and gas, but also a thickening of the gastric and duodenal ligaments, directly perforated gastric ulcer.
During an ultrasound examination of abdominal organs, it is recommended to visualize not only gas and fluid in the abdominal cavity, but also a hypertrophied section of the gastric wall in the perforated gastric ulcer. Ultrasound is one of the most accurate and affordable methods for detecting covered perforations.
Esophagogastroduodenoscopy makes it possible to establish the diagnosis of perforated gastric ulcer in nine out of ten patients. Conduction of EGD is especially indicated for patients with suspected perforated gastric ulcer who do not detect pneumoperitoneum (free gas in the abdominal cavity) during X-ray – air injection into the stomach during the study leads to the release of gas into the abdominal cavity and positive results of repeated X-ray examination. EGDs allow visualization of double perforations, bleeding from the ulcer, multiple ulcerations, malignancy of the stomach ulcer. Also fibrogastroscopy helps determine the optimal tactics of surgical intervention.
Diagnostic laparoscopy is the most sensitive method for detecting perforated gastric ulcer, gas and effusion in the free abdominal cavity. This study is shown to all patients with dubious findings of the surveys already conducted (X-ray, ultrasound, endoscopy, abdominal CT scan). Differentiating perforated gastric ulcer is necessary with acute appendicitis, cholecystitis, pancreatitis, abdominal aortic aneurysm, myocardial infarction.
Treatment of perforated gastric ulcers
The goal of perforated gastric ulcer therapy is not only to save the patient’s life and eliminate the defect in the stomach wall, but also to treat a stomach ulcer, diffuse peritonitis. In the practice of the gastroenterologist and the surgeon there are cases of conservative management of perforated gastric ulcer. Conservative treatment is used only in two cases: with decompensated somatic pathology and the patient’s categorical refusal of the operation. Conditions for conservative treatment: less than twelve hours from perforation, not more than 70 years old, no intense pneumoperitoneum, stable hemodynamics. In the complex of conservative treatment include pain relief, the introduction of antibiotics and antisecretory drugs, anti-Helicobacter and detoxification therapy.
In the surgical treatment of perforated gastric ulcer, there are three main approaches: closing the perforation, excision of the gastric ulcer, resection of the stomach. In most patients, the perforation is closed by tamponade, sealing with an omentum or suturing. Indications for closure of perforated gastric ulcer: asymptomatic perforation, disease duration more than 12 hours, signs of peritonitis, extremely serious condition of the patient. The beginning of treatment later than a day from perforation increases mortality by three times. Antihelicobacter and antisecretory therapy in the postoperative period allows to improve the results of the perforation closure operation.
Excision of perforated gastric ulcer is performed only in every tenth patient. This operation is indicated in the presence of stenosis of the stomach, bleeding, ulcers with kaleznymi edges, large perforation, with suspected malignancy of the ulcer (excision is necessary for pathological examination).
Gastrectomy can be performed in patients with a perforated ulcer if it is impossible to perform a simpler operation and to carry out postoperative anti-Helicobacter and antisecretory therapy. Usually, such indications occur in complicated ulcer disease (celiac, penetrating and peptic ulcer; multiple ulcers), suspected malignant process, repeated perforation of gastric ulcer, huge sizes of perforated opening (over 2 cm).
In approximately 10% of patients, minimally invasive surgical procedures are used: laparoscopic and endoscopic treatment of gastric ulcers. The use of laparoscopic operations allows to significantly reduce the incidence of postoperative complications and mortality. Different methods of operations can be combined with each other (for example, laparoscopic with endoscopic) and with vagotomy (selective proximal vagotomy, truncal vagotomy, endoscopic vagotomy).
If vagotomy was not performed during surgery, anti-ulcer therapy is prescribed in the postoperative period (proton pump inhibitors and H2-histamine receptor blockers, anti-helicobacter drugs).
Prognosis and prevention
The prognosis for perforated gastric ulcer depends on many factors. The risk of death is significantly increased when the patient is over 65 years of age, severe concomitant pathology (cancer, AIDS, cirrhotic transformation of the liver), large perforated opening, long history of perforated gastric ulcer prior to surgery. 70% of deaths in gastric ulcer are caused by perforated gastric ulcer. The only method of prevention of this condition is the timely detection and treatment of gastric ulcer.