Gastric and duodenal ulcers develop deeper and can penetrate the stomach or duodenal wall, causing perforation. It is a common complication, accounting for 20% to 30% of hospitalized patients with gastric and duodenal ulcers. According to its clinical manifestations, it can be divided into acute, subacute and chronic. The type of perforation depends mainly on the site of the ulcer and secondly on the process of ulcer development and surrounding tissues and organs. The incidence of duodenal ulcers is higher than that of gastric ulcers. Duodenal ulcer perforation is mostly seen in young adults under 40 years old, while gastric ulcer perforation is mostly seen in middle-aged and elderly people over 50 years old.
I. Etiology
The occurrence of perforated gastric and duodenal ulcers is related to the following factors.
1.Mental state
Excessive mental tension can make the ulcer deteriorate and perforation occur.
2.Increased pressure in the stomach
If you eat too much or engage in heavy physical labor, the pressure in the stomach can suddenly increase, causing the weakness of the stomach wall to perforate.
3.Drug effect
Those who take aspirin, salicylic acid preparation or hormone for a long time often cause acute attack of ulcer and develop to perforation.
4.Insomnia, exertion
Can increase the tension of the vagus nerve, thus worsening the ulcer.
5.Smoking and alcohol consumption
Tobacco can directly stimulate the gastric mucosa, and alcohol can reduce the resistance of the mucosa to the attack of gastric acid and promote the occurrence of perforation.
Second, the clinical manifestations
Once the ulcer is suddenly perforated, the patient feels severe pain in the upper abdomen, which is unbearable, and the pain may spread to the back or right shoulder. If the top of the diaphragm is stimulated, the patient feels soreness in the shoulder; if the diaphragm and peritoneum behind the gallbladder are stimulated, the patient feels pain below the right scapula; if the small omental cavity is stimulated, the patient feels pain only in the corresponding lower back. When the gastrointestinal contents diffuse to the whole abdomen, it causes severe and continuous pain in the whole abdomen. Since a large amount of gastrointestinal content flows along the right paracolic sulcus to the right iliac fossa, the symptoms here are particularly pronounced and easily misdiagnosed as appendicitis. The onset of pain is accompanied by nausea and vomiting; if there is fresh blood in the vomitus, it is suggestive for the diagnosis of ulcer perforation. Since there are different clinical manifestations in different periods, it can be divided into three stages as follows.
1.In the early stage
In the event of perforation, due to the sudden and violent stimulation, causing immediate reflexes of the neurocirculatory system, shock symptoms can be produced, the patient’s face is pale, the limbs are cold, cold sweat, pulse is fast and weak, blood pressure drops, body temperature does not rise, shortness of breath. Generally, it does not take long to get better on its own.
2.Response period
1-4 hours later, abdominal pain is reduced, the patient feels good subjectively, at this time the patient can get up and move, think about drinking, but breathing is still difficult, refusing to involve the abdominal muscle movements.
3.peritonitis period
More than 12 hours after the perforation, more turn into bacterial peritonitis. The whole body is weak, with dry mouth, nausea, vomiting, erratic rebellion due to irritation of the diaphragm, elevated body temperature, palpitation and shortness of breath, decreased urine output, blood pressure starts to drop, and a state of shock. The patient is anxious, has dry lips, dry tongue with moss, and sunken eyes.
III. Diagnosis
Typical cases are relatively easy to diagnose. However, some patients may have smaller perforations, less pronounced muscle tension and subdiaphragmatic free gas, etc. Diagnosis needs to be made after excluding other similar diseases in conjunction with medical history. Smear microscopy can also be done by abdominal puncture and if food residue is found, it can assist in the diagnosis.
IV. Treatment
The treatment principle of ulcer perforation is mainly fasting, early surgery, anti-shock, anti-infection, etc.
1.Fastening
Prohibit eating any diet, including all kinds of drugs, and try to reduce gastric contents and secretion in the stomach.
2.Anti-pain
As the pain of ulcer perforation is severe and unbearable, some patients can go into shock due to pain. Pain relief injections such as intramuscular dulcolax can be given to relieve patients’ pain.
3.Gastrointestinal decompression
Place a gastric tube as early as possible to aspirate gastric contents, reduce gastrointestinal pressure and prevent continued contamination of the overflowing abdominal cavity.
4.Intravenous infusion
According to the patient’s vomiting severity, urine volume, temperature change, gastrointestinal decompression and blood pressure change, adjust the amount of fluids and electrolytes in time, and strengthen nutrition and other supportive treatment.
5.Anti-infection
Adopt antibiotics with strong antibacterial ability and wide antibacterial spectrum, such as vanguardycin, ampicillin, etc., and add anti-anaerobic drugs such as metronidazole or ornidazole, etc.
6.Surgical treatment
It is divided into perforated simple suture or major gastrectomy. Perforated simple suture is used for patients with more abdominal exudate, serious contamination, weaker body and poor general condition. When perforation suture is performed for gastric ulcer perforation, selective vagotomy plus pyloroplasty can be performed at the same time, which can solve the perforation problem and treat the ulcer fundamentally with better results. For those who are suspected to have cancerous gastric ulcer perforation, a major gastrectomy should be performed as far as possible and pathological examination should be taken to avoid misdiagnosis.
V. Prevention
All patients with a history of ulcer should be treated actively, standardized and systematically to prevent the occurrence of perforation complications.