Bleeding in peptic ulcer disease is a dangerous complication.
Early signs of acute massive blood loss are:
sudden weakness dizziness increased heart rate lowering blood pressure fumigation
bloody vomiting (if the stomach is full of blood). The nature of the vomit (scarlet blood, dark cherry-colored clots or stomach contents of the color of "coffee grounds") depends on the transformation of hemoglobin under the influence of hydrochloric acid into hydrochloric acid hematin. Multiple bloody vomiting and the subsequent appearance of melena are observed with massive bleeding. Vomiting, repeated after short intervals of time, indicates a continuing bleeding; repeated vomiting of blood after a long period of time is a sign of resumption of blood flow. and then
melena - the release of altered blood with feces (tarry stools), observed during bleeding from the duodenum and massive gastric bleeding with blood loss reaching 500 ml or more.
Bleeding may be the first symptom of a stomach or duodenal ulcer, which had previously been asymptomatic (about 15-20%), or the appearance of an acute ulcer (stress ulcer).
Diagnostic and therapeutic endoscopy against the background of anti-shock measures and correction of blood loss plays a major role in the first stage of treatment. It allows you to identify the source of bleeding, perform endoscopic hemostasis and assess the likelihood of recurrent bleeding, depending on the location and size of the ulcer, the stage of bleeding activity.
Emergency surgery is indicated for patients with active bleeding (Forrest I), which cannot be stopped by endoscopic methods. Urgent surgery is indicated for patients after endoscopic stopping of active bleeding and in whom conservative measures did not allow stabilizing the patient's condition. VARIATIONS kpovotochaschey gastric required resection of the stomach, but in debilitated patients ppedpochtitelnee malotpavmatichnaya opepatsy - truncal vagotomy, gastpotomiya with excision of the ulcer and pilopoplastikoy. Finally, in an extremely serious general condition , gastrotomy with lancing of a bleeding vessel or excision of an ulcer with subsequent suture is acceptable. The risk of performing a gastric resection at the height of bleeding is very high. VARIATIONS kpovotochaschey dvenadtsatipepstnoy intestine ulcer ppoizvodyat one of vagotomy variants pposhivaniem kpovotochaschih vessels and pilopoplastikoy or duodenoplasty. Patients with a low risk of recurrent bleeding are operated on as planned after preoperative preparation, carried out for 2-4 weeks in order to heal ulcers or reduce periulcerous inflammation. Mortality after emergency surgery ranges from 5 to 15%.
Perforation of an ulcer - the occurrence of a through defect in the wall of the stomach or intestine with the release of the contents into the free abdominal cavity.
Liberation can also occur in cases of asymptomatic ulcers. The outflow into the ruby cavity of the contents of the duodenum or stomach quickly leads to the development of diffuse or confined peritonitis.
In the clinical course of ulcer perforation , three periods are conventionally distinguished:
The first period lasts 3-6 hours. In case of perforation (sometimes it is preceded by vomiting) in the epigastric region, an extremely sharp constant "dagger" pain suddenly arises, like a "stabbing", "burn with boiling water". Irritation of a significant receptor field by the poured out contents is often accompanied by a painful shock. To the extent of the depletion of the possibility of nervous receptors, a short period of imaginary well-being occurs. Following this, diffuse peritonite rapidly begins to develop.
The second period ("imaginary well-being") occurs 6-12 hours after the onset of the disease. Sharp symptoms are smoothed out, the patient's well-being improves, abdominal pain decreases. Improving the patient's condition can mislead both the patient and the doctor. However, when analyzing clinical data, it is possible to reveal an increase in signs of developing peritonitis (increased heart rate and respiration, increased body temperature, intestinal paresis, leukocytosis).
The third period (the period of widespread peritonitis) occurs after 12-24 hours. The patient's condition by this time becomes severe: independent abdominal pain is moderate, multiple vomiting appears. Body temperature is high (38-40 C), and sometimes lowered. Pulse 110-120 beats per minute, weak filling; arterial pressure is lowered. During this period, all the signs of a systemic reaction syndrome to inflammation are revealed, signaling the danger of the development of polyorganic insufficiency and septic shock.
Perforation of an ulcer into a free abdominal cavity is an absolute indication for emergency surgery. The earlier the diagnosis is made and the operation is performed, the greater the chances of recovery. The main goal of the operative treatment of a perforated ulcer is to save the patient's life, to prevent or start early treatment of peritonitis. Depending on the severity of the patient's condition, the stage of development of pepitonitis, the duration of the peptic ulcer and the conditions for the operation, suturing of the ulcer, excision of the ulcer with piloroplasty in combination with vagotomy is used, and for callous stomach ulcers - stomach resection. Suturing of an ulcer (palliative operation) is performed in case of widespread peritonitis, a high degree of operational risk (severe concomitant diseases, advanced age of the patient), and in case of distress and medicinal ulcers. Selective proximal vagotomy with suturing of a perforated ulcer or piloroplasty should be performed in specialized hospitals, where surgeons are well versed in the technique of organ-saving operations, if no more than 6-12 hours have passed since the moment of perforation and there is no peritonitis. Gastric resection is indicated in the case of the release of chronic callous gastric ulcer in the absence of peritonitis and increased operational risk, especially if the ulcer is suspected of malignancy.
The narrowing of the initial section of the duodenum or the pyloric section of the stomach develops in 10-15% of patients with peptic ulcer disease. The cause is often pyloric canal ulcers and pepilopic ulcers.
The formation of stenosis occurs as a result of ulcer scarring, in some cases - due to compression of the duodenum by an inflammatory infiltrate, obturation of the intestinal lumen with edema in the ulcer area.
The causes and degree of narrowing are determined using X-ray examination, gastroduodenoscopy and biopsy indications. In response to the complication of evacuation from the stomach, the muscular membrane of the stomach is hyper-hypertrophied.
In the clinical course of stenosis , three stages are distinguished: The stage of compensation has no pronounced clinical signs. Against the background of the usual symptoms of peptic ulcer disease, patients note in the epigastric region after eating food, prolonged pain, a feeling of heaviness and fullness; heartburn, burp. Occasionally there is vomiting, bringing relief to the patient, with the release of a significant amount of gastric contents. At the stage of subcompensation, the feeling of heaviness and fullness in the epigastrium increases, an ejection appears with an unpleasant smell of rotten eggs due to prolonged retention of food in the stomach. Often disturbed by colic-like pain associated with increased peristalsis of the stomach, accompanied by urging in the abdomen. Profuse vomiting occurs almost daily. Often, patients cause it artificially. The sweat masses contain an admixture of undigested food. The stage of decompensation is progressed by gastrostasis, atony of the stomach. The overstretching of the stomach leads to a thinning of its wall, the loss of the possibility of restoring the motor-evacuation function. The patient's condition deteriorates significantly. Multiple vomiting is noted. The feeling of distention in the epigastric region becomes painful, forcing patients to induce vomiting artificially or to rinse the stomach through a tube. Vomit masses (several liters) contain fetid, decomposing food leftovers from many days ago. The terminal stage of decompensated stenosis is characterized by a sign of three "D" - dermatitis, diarrhea, dementia. Patients with signs of peptic ulcer exacerbation with compensated stenosis undergo a course of conservative antiulcer treatment lasting up to 2-3 weeks. As a result, the edema of the mucous membrane of the adversary and the initial part of the duodenum may decrease, the periulcerous infiltrate decreases, and the permeability of the area of the adversary is improved. At the same time, water-electrolyte and protein disorders are corrected, after such treatment the risk of surgery is reduced. For pyloroduodenal stenosis, the operation of choice should be considered selective proximal vagotomy with various options for gastric drainage (pyloric, duodenoplasty, transverse gastroduodenostomy with decompensated stenosis). Long-term results of such surgical treatment of ulcerative pyloroduodenal stenoses do not differ from the results of treatment of uncomplicated ulcers.
A penetrating ulcer occurs when a destructive ulcerative process spreads beyond the wall of the stomach or duodenum into neighboring organs: liver, pancreas, omentum.
Most often, the ulcer penetrates into the lesser omentum, the head of the pancreas, the hepatoduodenal ligament.
The pain with a penetrating ulcer becomes constant, intense, loses its natural connection with food intake, does not decrease from taking antacid drugs. Increased nausea and vomiting. With the penetration of the ulcer into the pancreas, back pain appears , often taking on a girdle character. For a penetrating ulcer of the body of the stomach, pain radiates to the left half of the chest, the region of the heart. With the penetration of the ulcer into the head of the pancreas, hepato-duodenal ligament, obstructive jaundice may develop . The radiological sign of ulcer penetration is the presence of a deep niche in the stomach or duodenum that extends beyond the organ. The diagnosis is confirmed by endoscopic examination with biopsy of the edges of the ulcer. Conservative antiulcer treatment for penetrating ulcers is ineffective , surgical treatment is indicated. In case of duodenal ulcer, a selective proximal vagotomy is recommended with the removal of the ulcer or leaving its bottom on the organ into which it penetrated. With an ulcer of gastric localization - resection of the stomach.