gastric ulcer perforation
Introduction
Introduction to gastric ulcer perforation Acute perforation is one of the most common serious complications of gastric ulcer. Hospitalized cases of ulcer perforation account for about 20% of hospitalizations for ulcer disease. It has been reported that the mortality rate of perforation of gastric ulcer is 27%. The older the patient, the higher the mortality rate. The mortality rate over 80 years old can rise rapidly. The mortality rate is related to the length of surgery after perforation. It is reported that after perforation for 6 hours. In the case of surgery, the postoperative mortality rate increased rapidly. basic knowledge The proportion of sickness: 0.0051% Susceptible people: no special people Mode of infection: non-infectious Complications: sepsis septic shock
Cause
Gastric ulcerative perforation
Tension and fatigue (20%):
Many adults are over-stressed or tired due to work stress, which increases the vagus nerve excitement and makes the ulcers heavier and perforated.
Overeating (20%):
Due to work factors, eating time is irregular, overeating, or obese people often eat too much to increase the pressure in the stomach, causing perforation of gastric ulcer.
Application of non-steroidal anti-inflammatory drugs (15%):
Non-steroidal anti-inflammatory drugs are closely related to the perforation of GU and DU, and observation of patients treated with such drugs shows that non-steroidal anti-inflammatory drugs are the main driving factors for DU perforation.
Immunosuppressant application (10%):
Especially the application of hormone therapy in organ transplant patients will promote the occurrence of DU perforation.
Other factors (15%):
These include increased patient age, chronic obstructive pulmonary disease, trauma, extensive burns, and multiple organ failure.
(two) pathogenesis
Perforation of gastric ulcer occurs mostly on the pathological basis of chronic ulcer. Under the influence of emotional stress, fatigue, diet or drugs, the active lesion of gastric ulcer can gradually deepen and erode the stomach wall from mucous membrane to muscular layer to serosal membrane. Finally, the perforation, the perforation is mostly located in the anterior wall, and the perforation of the gastric ulcer is mostly located in the front of the small curve or the anterior upper part. The perforation is mostly single, and even the perforation can be multiple. 70% of the perforation diameter is less than 0.5cm, and the perforation of 1.0cm or more 5% to 10%.
After the perforation of the ulcer, the contents of the stomach overflow into the abdominal cavity, and the highly acidic or alkaline content can cause chemical peritonitis. After about 6 hours, it can be converted into bacterial peritonitis. The pathogen is mostly Escherichia coli, and the posterior wall ulcer is eroded to Before the serosa layer, more and more adjacent organs have formed, forming a chronic penetrating ulcer, so acute perforation rarely occurs.
Prevention
Gastric ulcer perforation prevention
For doctors, what they can do is to control the symptoms of ulcer relief through drugs and surgery. For patients, they should pay attention to maintaining an optimistic attitude, develop good habits, rational diet, and actively cooperate with treatment. This will prevent the onset of ulcers to the greatest extent. Specifically, the following points should be noted:
1. Adjust your mindset, pay attention to rest, avoid excessive anxiety and fatigue;
2. quit smoking and alcohol, diet rules, should not be excessive;
3. Avoid eating irritating foods such as coffee, tea, chili, etc.
4. Eat less sweet and sour foods and fruits such as chocolate, ice cream, apples and oranges;
5. Eat foods that are prone to flatulence, such as sweet potatoes, alfalfa, potatoes, etc. with high starch content.
Complication
Gastric ulcer perforation complications Complications sepsis septic shock
Severe or septic shock can occur in severe cases.
Symptom
Symptoms of ulcerative perforation of the stomach Common symptoms Gastrointestinal dilatation and low pH in the small intestine. Abdominal pain, stomach cramps, pale, silent, abdominal, dull and dull, narrowed or disappeared, pneumoperitoneum, nausea and severe pain
70% of patients with acute ulcer perforation have a history of ulcers, 15% have no history of ulcers, and 15% of cases have short episodes of upper abdomen a few weeks before perforation. Patients with a history of ulcers often have a history of aggravation of general symptoms before perforation. However, a small number of cases can occur during the course of regular medical treatment, even during rest or sleep.
The typical symptom of DU perforation is sudden upper abdominal pain, which is cut into a knife and can be radiated to the shoulder. It spreads to the whole abdomen very quickly. Sometimes the digestive juice can flow down the right colon to the right lower abdomen, causing the right lower abdomen. Pain, patients often appear pale, cold sweat, limbs chills, pulse and other shock symptoms, accompanied by nausea, vomiting, patients often very clearly remember the exact time of this severe pain, 2 ~ 6h, a large number of infiltration in the abdominal cavity The liquid dilutes the digestive juice, and the abdominal pain can be slightly relieved. Later, the symptoms gradually increase due to the development of the bacterial peritonitis.
Signs: The patient is seriously ill, forced position, superficial respiratory, full abdominal tenderness, rebound tenderness, but the most obvious above the abdomen, showing a "plate-like abdomen". After gastric perforation, the air in the stomach can enter the abdominal cavity, standing or half-lying When the position is located, the gas is located under the armpit, and the dullness of the liver is reduced or disappeared, that is, the so-called "pneumoperitoneum sign". If the effusion in the peritoneal cavity exceeds 500 ml, the mobile voiced sound can be removed, and the auscultation of the bowel sound can disappear at the beginning. The so-called "silent belly" is usually high fever.
Examine
Gastric ulcer perforation examination
Blood routine examination
(1) White blood cell count: The white blood cell count is mostly at (15-20)×10 9 /L, mainly due to neutrophil enlargement.
(2) Hemoglobin and red blood cells: often due to dehydration, blood concentration and increase.
2. Serum amylase
It can be moderately elevated, but the serum amylase creatinine clearance ratio (CAM/CCr) is within the normal range.
Other auxiliary inspection
1. abdominal puncture or lavage
A turbid liquid can be obtained, especially when the stomach contents have food residue and bile, and the diagnosis can be made immediately.
2. X-ray inspection
In the abdominal plain film examination, 80% of the patients had a half-moon shape of free gas, and the perforation was large. The peritoneal fluid was found to be flat and the extraperitoneal fat line disappeared or blurred.
3.B-ultrasound
When the patient is supine, a strong gas echo can be seen in the anterior hepatic space between the anterior border of the liver and the abdominal wall. Multiple reflexes are often accompanied by a posterior position. The liver can display a gas echo between the top of the diaphragm and the liver.
Diagnosis
Diagnosis and differentiation of gastric ulcer perforation
According to the medical history, physical examination and abdominal wear, X-ray abdominal standing flat film, etc., can generally be diagnosed.
Acute gastric ulcer perforation needs to be differentiated from the following diseases:
1. Acute pancreatitis: severe abdominal pain, nausea, vomiting, peritoneal irritation, but acute pancreatitis pain is often left upper abdominal banded tenderness, back radiation pain, when the stomach perforation into the small omentum cavity also has a back Radiation pain, need to be carefully identified, pancreatitis often has a history of high-fat catastrophe before the onset of the disease, no "pneumonia sign" at the time of examination, laboratory blood, urine amylase is often elevated.
2. Acute appendicitis: perforation of gastroduodenal ulcer sometimes the contents of the stomach can flow along the right colon to the right lower abdomen, causing pain in the lower right abdomen, which is easily confused with appendicitis. Appendicitis begins with paroxysmal umbilical colic. Gradually worsened later, the signs of peritonitis are most obvious in the right lower abdomen. Before perforation, the lower right abdomen often shows tenderness and rebound tenderness. After perforation, there may be total abdominal tenderness, rebound tenderness and muscle tension, but still in the right lower abdomen and lower abdomen. The abdominal signs above the gastric perforation are the most obvious, appendicitis has no "pneumoperitoneum", and there is no shock symptoms, in short, no severe perforation of the stomach, abdominal wear and X-ray abdominal standing flat can be used as a reference.
3. Perforation of gastric cancer: rare, it is difficult to identify symptoms and signs alone, but the elderly patients with a short history of stomach should consider the possibility of this disease, intraoperative high-speed pathological examination, and should also be biliary tract disease such as necrotizing gallbladder perforation, and Identification of diseases such as intestinal necrosis and intestinal obstruction.
