I. Disease introduction
Gastric perforation is the development of gastric lesions to depth, thinning of the gastric wall, or coupled with a sudden increase in pressure in the gastric cavity, it can penetrate into the abdominal cavity, and food, gastric acid, duodenal fluid, bile, pancreatic fluid and other chemically stimulated gastrointestinal contents flow into the abdominal cavity, resulting in severe abdominal pain and causing acute diffuse peritonitis.
Second, disease classification
Ulcer perforation can be classified as acute, subacute and chronic according to its clinical manifestations. The type of perforation depends mainly on the location of the ulcer, and secondly on the process of ulcer development and surrounding tissues and organs. Ulcers located on the free surface, anterior wall or upper and lower margins of the stomach or duodenum often produce acute perforation, where the contents of the stomach and duodenum flow into the free peritoneal cavity, causing acute peritonitis. The perforation is very small or is quickly occluded, especially during fasting, and abdominal contamination is limited to the right upper abdomen; this perforation is often referred to as subacute perforation. Ulcers are located in the posterior wall of the stomach or duodenum and gradually form adhesions with the surrounding tissues as they progress to the depths, showing chronic penetrating ulcers, which are chronic perforations. Acute perforation is clinically common, followed by subacute perforation.
Causes
Gastric perforation is mainly seen in gastric ulcer perforation, and a small amount of gastric cancer perforation, occasionally seen in gastric lavage, gastroscopy, abdominal impact and other cases.
IV. Pathogenesis and pathophysiology
Acute ulcer perforation is mainly caused by necrosis of the basal tissue of the active ulcer, which penetrates the plasma membrane layer and causes the gastric cavity to communicate with the abdominal cavity. After ulcer perforation, gastroduodenal contents containing food, gastric juice, bile, pancreatic juice, etc. flow into the abdominal cavity, firstly, gastric acid, bile and other stimuli cause chemical peritonitis, resulting in severe and persistent abdominal pain. After a few hours, the outflow of gastrointestinal contents decreases, while the exudate due to peritoneal irritation increases, the gastrointestinal effluent is diluted, and the abdominal pain can be temporarily relieved. Usually after 8~12 hours, bacterial peritonitis is formed due to the growth and multiplication of bacteria in the abdominal cavity, causing intestinal paralysis, sepsis and toxic shock. In the case of chronic perforation, the ulcer gradually forms adhesions with the surrounding tissues as it progresses to the deeper part, manifesting as a chronic penetrating ulcer, gastrocholedochal fistula or duodenal cholecystic fistula.
V. Clinical manifestations
Most patients have a long history of ulcers and recent exacerbations, but about 10% of patients have no clear history of ulcers. Improper diet, emotional changes, etc. can trigger its occurrence. The clinical course of ulcer perforation can be divided into three stages.
1. Stage 1: sudden onset of severe abdominal pain, such as knife-like, with persistent or paroxysmal aggravation. The pain is initially located in the epigastric region or under the glabella, and soon spreads to the whole abdomen, still heavily in the upper abdomen, sometimes accompanied by radiation from the back of the shoulder. If the gastric contents flow along the right paracolic sulcus to the right lower abdomen, right lower abdominal pain may occur. Due to severe abdominal pain, pale face, cold extremities, cold sweat, rapid pulse, shallow breathing, etc., often accompanied by nausea and vomiting, may appear shock.
On examination, we can see the patient’s acute painful face, supine refusal to move, reduced abdominal breathing, whole abdomen with pressure pain, rebound pain, abdominal muscle tension can be “plank-like” tonic, hepatic turbid boundary reduced or disappeared suggesting the presence of pneumoperitoneum. Intestinal sounds are weakened or disappeared, and gastrointestinal contents can be extracted by laparotomy.
2, the second stage: 1~5 hours after perforation, because the patient’s abdominal exudate increases, the gastrointestinal contents flowing into the abdominal cavity are diluted, abdominal pain can be temporarily reduced, the patient feels better, pulse, blood pressure, face and breathing also return to normal. But still can not do the action of involving the abdominal muscle, abdominal muscle tension, pressure pain, intestinal sounds weakened or disappeared and other signs of acute peritoneal irritation still continue to exist.
3, Stage 3: After 8-12 hours of perforation, it mostly turns into bacterial peritonitis, with clinical manifestations similar to those of bacterial peritonitis from any cause. Patients present an acute and serious appearance, and may show symptoms of systemic infection poisoning such as fever, dry mouth, fatigue, accelerated respiratory pulse and decreased blood pressure. There is abdominal distention, total abdominal muscle tension, tenderness, rebound pain, and positive mobile turbid sounds. White or yellow cloudy fluid can be extracted by laparotomy. The disease is serious and those who cannot be rescued often die due to paralytic intestinal obstruction, sepsis or septicemia, and infectious toxic shock.
Diagnosis and differentiation
On X-ray, a crescent-shaped free gas under the diaphragm is seen in about 75% to 80% of cases. It is an important evidence for the diagnosis of gastric perforation, combined with the patient’s past history of ulcer and recent history of ulcer activity, the severe abdominal pain after perforation and the manifestation of acute diffuse peritonitis, and the digestive fluid containing gastrointestinal contents extracted by laparotomy, it is not difficult to make the diagnosis.
Seven, differential diagnosis
1, acute pancreatitis Abdominal pain is mostly located in the upper abdomen to the left and radiates to the back, abdominal muscle tension is mild, serum and abdominal puncture fluid amylase is elevated significantly, X-ray examination is no free gas under the diaphragm, CT examination shows pancreatic swelling, peripancreatic exudate, etc.
2, acute cholecystitis right upper abdominal colic or persistent pain paroxysmal intensification, accompanied by chills and fever. The signs are mainly pressure pain and rebound pain in the right upper abdomen, sometimes the enlarged gallbladder can be palpated, and the Murphy’s sign is positive. Ultrasound suggests stone or non-stone cholecystitis.
3.Acute appendicitis After ulcer perforation, digestive fluid flows along the right paracolic sulcus to the right lower abdomen, causing right lower abdominal pain and signs of peritonitis, which is easily confused with acute appendicitis. However, acute appendicitis generally has milder symptoms, no severe pain in the upper abdomen during the attack, and abdominal signs are not predominantly in the upper abdomen, but are usually confined to the right lower abdomen, with no free gas under the diaphragm on X-ray.
In addition, it should be differentiated from mesenteric ischemic disease, ectopic pregnancy rupture, ovarian cyst torsion, acute myocardial infarction, etc.
VIII. Treatment of disease
In principle, treatment of gastric perforation should be surgical as soon as possible. Delayed treatment, especially for more than 24 hours, significantly increases the incidence of mortality and comorbidity, and prolongs the hospital stay.
When the perforation is small in fasting, the perforation time is short, the clinical manifestations are light, the signs of peritonitis are limited or the diagnosis is not yet clear, the non-operative treatment can be closely observed first. Should strictly grasp the indications for non-operative treatment, must closely observe the patient’s symptoms and changes in abdominal signs, if the condition does not improve or worsen in 6-8 hours of treatment, should promptly surgical treatment.
IX. General treatment
Fasting, pain relief, oxygen, intravenous fluids, continuous gastrointestinal decompression, application of antibiotics, acid suppressants, etc.
10.Surgical treatment
The choice of surgical method should be based on the general condition of the patient, age, ulcer site, perforation time, degree of abdominal contamination and whether the frozen section result is malignant.
1.Simple perforation repair after biopsy around gastric perforation Patients with poor general condition, with serious diseases of heart, lung, liver and kidney organs, perforation time more than 8~12 hours, heavy intra-abdominal inflammation and severe edema of gastroduodenum and other patients estimated to be at greater risk of radical surgery, after negative biopsy around gastric perforation, are suitable to choose simple perforation repair. There are two types of repair: open repair and trans-laparoscopic repair.
2. Radical surgery The advantage of radical surgery is that the surgery solves both perforation and ulcer problems at the same time. It is suitable for patients with good general condition, perforation in 8~12 hours a pinch, light intra-abdominal infection and gastroduodenal edema, and no important organ coexisting disease can be considered for radical surgery.
3, its specific indications are.
①Long history of disease and recurrent episodes.
②History of ulcer perforation or bleeding.
(3) The perforation is accompanied by bleeding, pyloric stenosis or is prone to stenosis after repair.
④Suspected cancer.
4. Radical surgery includes.
①Gastrectomy of large part of the stomach.
(2) Perforation repair plus mural cell vagotomy.
(3) Perforation repair, vagotomy plus sinus resection or pyloroplasty. The first two types of surgery are more effective.
XI. Prognosis of disease
If the diagnosis and treatment are timely, patients generally have a good prognosis. If old and frail and combined with serious heart, lung, liver and kidney disease, perforation time is longer, serious abdominal cavity contamination, the prognosis is poor and mortality rate is higher.
Twelve, disease prevention
1.Patients with gastroduodenal ulcer should have an early gastroscopic survey to clarify the nature, location and severity of the ulcer and timely systemic medical treatment.
2. If the systemic medical treatment is ineffective or the ulcer recurs after healing, early surgical treatment should be performed.
3.Regular diet, eat less and more meals, avoid cold, brown, spicy and other stimulating foods, quit smoking and limit alcohol, relieve mental tension.
4, prohibit drugs that damage the gastric mucosa, such as aspirin, anti-inflammatory pain and other non-steroidal anti-inflammatory drugs, hormonal drugs, etc.. If it must be applied, should be added to protect the gastric mucosa drugs and acid-suppressing drugs.
XIII, dietary attention
1, eat less fried food: because this kind of food is not easy to digest, will increase the burden on the digestive tract, eat more will cause indigestion, but also will make the blood lipid increase, not good for health.
2, eat less pickled food: these foods contain more salt and certain carcinogens, should not eat more.
3, eat less cold food irritating food: cold and irritating food has a strong stimulating effect on the digestive tract mucosa, easily caused by diarrhea or inflammation of the digestive tract.
4, regular diet: research shows that regular meals, regular rationing, can form a conditioned reflex, which helps the secretion of the digestive glands and is more conducive to digestion.
5, regular rationing: to achieve the right amount of food at each meal, 3 meals a day at regular intervals, to the specified time, regardless of hunger, should take the initiative to eat, to avoid too hungry or too full.
6, the temperature is appropriate: the temperature of the diet should be “not hot and not cold” as the degree.
7, chew slowly: to reduce the gastrointestinal burden. The more times the food is fully chewed, the more saliva is secreted, which has a protective effect on the gastric mucosa.
8, drinking water timing: the best time to drink water is the morning fasting and one hour before each meal, drinking water immediately after the meal will dilute gastric juice, with soup soaking rice will also affect the digestion of food.
9, pay attention to the cold: the stomach will be damaged by the cold stomach function, so pay attention to the stomach to keep warm not to be cold.
10, avoid stimulation: do not smoke, because smoking makes the stomach vasoconstriction, affect the blood supply of the stomach wall cells, so that the gastric mucosa resistance is reduced and induced gastric disease. Should drink less alcohol, eat less chili, pepper and other spicy food.
11, supplement vitamin C: vitamin C has a protective effect on the stomach, the gastric juice to maintain a normal level of vitamin C, can effectively play the function of the stomach, to protect the stomach and enhance the stomach’s ability to resist disease. Therefore, it is important to eat more vegetables and fruits rich in vitamin C.