Perforation of an ulcer of a stomach and duodenal intestine.

In frame of acute
surgical diseases of organs of an abdominal cavity at the adult population the perforated ulc
of a stomach and duodenal intestine makes 1,6 — 3,4 %, and in relation to personal structu
of army and navy this parameter is 4,5 — by neighboring organs (large omentum, the bottom
surface of a liver, gallbladder etc.) or dense particles of nutrition, that promotes limitation o
inflammatory process and formation of a limited peritonitis quite often in the form of an
inflammatory infiltrate. If the perforative aperture is posed in a duodenal intestine or distal
department of a stomach, and contents, given vent from a lumen, flow down on the right
lateral canal of a peritoneum in ileocecal area with the subsequent development of a limited
or diffuse peritonitis in the right ileal area, that in series of cases frames difficulties of
differential diagnostics with an acute appendicitis.
Pathological anatomy. Chronic ulcers of a stomach and duodenal intestine perforate
more often during phase of an exacerbation of inflammatory process. Histologically in such
ulcers the attributes of a chronic or acute inflammation and mucoid edema are revealed.
Characteristic morphological feature of perforated ulcers is the diffusion of a necrosis only
in depth of tissues in the field of an ulcer. In a submucous layer, according to a fundus of an
ulcer, mature fibrous connective tissue with attributes of a hyperplasia after available in the
last seasonal exacerbation frequently is found out. Alongside with it, as a rule, there are
placing on of a young connective tissue containing a plenty of fibroblasts. Observable in
series of cases elastolysis in the field of a fundus of a perforated ulcer confirms a role of
peptic factor in a pathogeny of a perforation.
On microscopic sections of small soft perforated ulcers there is a young granular tissue
the sequestration of sites of a necrosis and almost not changed muscular layer, that provides
a fast adhesion of such ulcers after ulcerorrhaphy.
The perforation of an ulcer most frequently occurs at its localization in a
pyloroduodenal zone, especially on a forward wall of a duodenal intestine. In a stomach
ulcers of small curvature perforate more often and much less often — of a cardial
department. The diameter of a perforative aperture in most cases does not exceed 5 mm.
Classification.There distinguish three kinds of perforations — open, covered and
atypical. Open perforation is perfpration, at which gastric or duodenal contents are free
given vent through a perforative aperture in a free abdominal cavity. The covered
perforation is designated when the perforative aperture immediately or soon after its
formation is covered with the next organ or alimentary particles. At atypical perforation the
ulcer is localized, as a rule, on a back wall of a stomach or duodenal intestine and the
duodenal (gastric) contents, given vent at perforation, get in a retroperitoneal fat, cavity of
an omentulum, layer of ligamentous apparatus of a stomach (depending on localization of
an ulcer).
Clinic.The clinical picture of a perforation differs by the large dynamism. In this it is
accepted to distinguish a phase of a shock, apparent remission («of imaginary well-beings)
and peritonitis.
The perforation of the ulcer of a stomach (duodenal intestine) comes suddenly,
frequently on a background of an exacerbation of a peptic ulcer, as at attentive study of an
anamnesis more than 90 % of the patients marks unpleasant sensations or pains in epigastri
area, quite often combined to a heartburn, nausea, vomiting during last 4 — £ days before
perforation. Therefore each exacerbation during an ulcer of a stomach 01 duodenal intestin
should be regarded as a condition dangerous by occurrence o' perforation. The perforation
of so-called «dumb ulcer» meets only in 8 — 10 % of cases and the retrospective analysis
shows that more than 60 % of these ulcers are chronic.
At the moment of perforation there is a sharp "knife-like" pain in epigastric area which
can be so intensive, that shock-like condition develops quite often with a loss o
consciousness, owing to what the patient loses ability to any activity. The pain sensations
are localized in the beginning in the top half of abdomen, and then are distributed on al
abdomen, sometimes moving in the right ileal area. A nausea and vomiting are not specific
a perforated ulcer and meet changeably. Paleness of seen mucosas andinteguments
derma
frequently is clearly shown, the bradycardia is marked which, apparently, i; caused by an
irritation of the .terminations of vagus nerves owing to influence o gastrointestinal contents
and reaction of a peritoneum.
At survey of the patient there are abdom en, involved in the top half, sharpa strain of
forward abdominal wall ("plank-like" stomach), sometimes with a distinct relief of
intermuscular tendinous intersections of direct muscles. The palpation of abdomen cause
sharp morbidity. There are expressed signs of a boring of a peritoneum. pathognomonic
The
attribute of perforation of a caval organ of abdomen is occurrence of gas in an abdominal
cavity, owing to what disappearance of hepatic dullness quite often is marked, that is cause
by a clump of gas, penetrated in a free abdominal cavity, above liver. At a percussion in thi
area there can be defined thympanitis. The clump of appreciable quantity of the liquid, give
vent from a perforative aperture, in inferior places of an abdominal cavity causes shot
percussion sound above these zones.
The phase of a pain shock lasts about 3 — 6 hours, then the pain sensations can a little
decrease and there comes the period « of imaginary well-being », or apparent remission. Th
period proceeds from 4 till 6 hours, and sometimes and more,dangerous,
and is because it
can frame at the doctor, for the first time examining patient, impression of absence of acute
surgical disease of organs of an abdominal cavity and to cause loss of time for operative
treatment in optimum terms, that considerably burdens prognosis.
the
After a phase of an apparent remission, as a rule, there are attributes of a developing
purulent peritonitis and the condition of the patient is progressively worsened.
The clinical picture of the covered perforation has essential features complicating
recognition of this kind of complication. Characteristic sign for the covered perforation is
"breakage" of a pain syndrome, so the same sudden or fast disappearing of pain sensations,
as well as their occurrence. The covered perforation can be finished by self-treatment,
however more often a purulent peritonitis nevertheless develops or the abscess of an
abdominal cavity is formed.
The atypical perforation meets seldom and mainly at a locating of an ulcer on
extraperitoneal departments of a wall of a stomach (duodenal intestine)'— a cardial
department of a stomach, back wall of a stomach and duodenal intestine. The moment of
perforation in these cases is expressed not so clearly. Frequently there is no strain of a
forward abdominal wall and the insignificant rigidity of its muscles is defined only.
Diagnosticsof a perforated ulcer of a stomach and duodenal intestine is based on the
clinic-anamnestic data, from which conducting importance have:
— The presence of a peptic ulcer in an anamnesis, especially of attributes of its
exacerbation per previous days (but the absence of the anamnestic data does not exclude
presence of a perforated ulcer);
— Sudden occurrence of intensive ("knife-like") pains in the top department of
abdomen or its right half: with an irradiation in the right shoulder girdle;
— Immovability and sharp strain of a forward abdominal wall ("plank-like" involved
stomach with a precisely appearing relief of direct muscles);
— Positive signs of an irritation of a peritoneum (sign of Schetkin — Blumberg, sign
A.P. Krimov — morbidity at research of a navel or outside aperture of the inguinal canal
with end of a finger, morbidity in area of Duglas' space at digital research of a rectum etc.);
— Disappearance of hepatic dullness at a percussion of a forward abdominalinwall or
a position on the left side; a zone of a high thympanitis between a xiphoid process
navel and
(sign of I.K. Spigarny);
— Delay of stools and gases.
Except for the listed above signs other attributes have cumulative importance in
diagnostics of a perforated ulcer: strong, unquenchable thirst, dryness of mucous coat of
labtums and oral cavity; superficial, intermittent and hurried breathing; compelled,
frequently motionless position of the patient on a back or edgewise with legs snuggled up t
a stomach; diffusion of a zone of auscultated cardiac tones on a forward abdominal wall up
to a level of a navel (Guiston), friction of murmur of a diaphragm under a costal arch
(Brunner etc.). At the same time some patients can not have such cardinal attribute of a
perforated ulcer as a strain of an abdominal wall. This sign can be absent or be weakly
expressed at exhausted or long hungry patients, as it was observed in blocked
Leningrad in Great Domestic war (E.S. Drachinskaya). This sign also can be absent at
the patients of advanced age with a very flabby abdominal wall and it is very difficultly
found out in thevery corpulent patients.
The changes in the laboratory analyses of a blood and urine at a perforated ulcer
are unspecific, but these data are necessary for differential diagnostics.
At survey X-ray inspection of an abdominal cavity the pneumoperitoneum is a
characteristic attribute of perforation of a caval organ. For its detection frequently
laterography is prefered in a position of the patient laying on the left side after 15-
minute stay in this position, when the gas has time to move in most high-located
departments ofan abdominal cavity. At suspicion of an opportunity of a perforated
ulcer and absence of attributes of free gas in an abdominal cavity the
pneumogastrography is applied: in a stomach the thick gastric probe is entered and
after the greatest possible aspiration of gastric contents up to 1000 — 1500 ml of air are
entered, and then roentgenography is made . In case of a perforated ulcer the
pneumoperitoneum is found out. Contraindications to a pneumogastrography are the
esophageal stenosis and stenosis of cardial department of a stomach handicapping to
entering of a probe, and common serious condition of the patient.
The introduction in a stomach of water-soluble radiopaque substances and
subsequent roentgenologic control of the possible their efflux through a perforative
aperture can help in diagnostics with doubtful cases, that can give the information and
about localization of an ulcer Use with this purpose of a baric suspension is
inexpedient, as its penetration in a free abdominal cavity causes formation of dense,
long not resolvinginfiltrates and conglomerates.
 From instrumental methods of research, especially at the covered perforation of an
ulcer of a stomach or duodenal intestine, fibrogastroscopy in a combination to a
dynamic tonometry of a stomach allows to receive the greatest information for
diagnostics of a perforated ulcer. It was fixed, that the maximal intragastric pressure at
an endoscopy makes 26 + 2 cm of water, and at a cough shove it grows almost twice.
At perforation of an ulcer of a stomach or duodenal intestine the intragastric pressure
does not exceed 6 — 8 cm of water and at tussis it only quickly reaches 10 — 12 cm of
water. Before and after an endoscopy general roentgenography of an abdominal cavity
should be carried out, and the occurrence of a pneumoperitoneum after
fibrogastroscopy is an absolute attribute of perforation, as the detection of a perforative
aperture at endoscopic inspection frequently fails.
When with the help of uninvasive methods it fails to reject suspicion on an
opportunity of perforation of a gastroduodenal ulcer, the application of a diagnostic
laparocentesis and laparoscopies is justified. Allocation of gas from an abdominal
cavity at the moment of its opening testify to presence of perforation. Character of a
peritoneal exudate has he large diagnostic importance. With the purpose of revealing in
an exudate of an impurity of Amylum, that is characteristic for gastric contents, the
iodine assay is applied: on tampon, moistened by a peritoneal exudate, 2 — 3 drops of
a solution of lodum are put. The staining of tampon in dark blue colour testifies to
presence in an exudate of gastric contents, and consequently, and about existence of
perforation. The laparoscopy allows to find out attributes of a developing peritonitis,
and sometimes perforative aperture.
Differential diagnostics.The perforated ulcer of a stomach and duodenal intestine
is necessary to differentiate with all acute surgical diseases of organs of an abdominal
cavity, acute myocardial infarction, inferiolobular pneumonia, pleuritis, alimentary
intoxications, acute gastritis. In differential diagnostics of a perforated ulcer with an acute
myocardial infarction an estimation of data of an anamnesis, of character and localization o
pains, absence at an infarct of a strain of a forward abdominal wall and signs of an irritation
of a peritoneum have the large importance. The results of electrocardiograph^ research hav
decisive meaning.
The chill, tachycardia, fervescence, dyspnea, hyperemia of face (instead paleness,
of as
at a perforated ulcer) is characteristic for pneumonia and pleuritis. Besides there are
appropriate pathological changes which are found out at physical inspection of organs of
respiration. The X-ray inspection of a thorax can help with differential diagnostics
in these
cases.
The clinical picture of an alimentary intoxication is enough characteristic: the
anamnestic connection with reception of substandard nutrition, disorder of stools, nausea,
vomiting, tachycardia, a fervescence is possible. At realization of differential diagnostics it
is necessary carefully to analyse a beginning, duration and character of current of disease.
The perforated ulcer begins with the expressed pain syndrome accompanied with a delay of
stools and gases. The alimentary intoxication is usually shown by nausea, vomiting and
disorders of stools, that quite often is also its first clinical displays. Strain of an abdominal
wall and presence of other attributes of irritation of a peritoneum is not characteristic for a
toxinfection. Besides at an alimentary intoxication and toxinfection the pain syndrome does
not occupy a conducting position in clinic of disease.
 Differential diagnostics of a perforated ulcer of a stomach and duodenal intestine with
an acute appendicitis is most difficult, as in both cases the pain can arise originally in
epigastric area with its subsequent moving in the right ileal area. However at a perforated
ulcer the sharp pain occurs suddenly, and then through 4 — 6 hours decrease usually a little
At an acute appendicitis the pain amplifies gradually (excepting the obstructive forms of an
acute appendicitis) and reaches maximum in some hours. At a perforated ulcer the sharp
strain of a forward abdominal wall is marked in the top part of abdomen (motionless,
involved "plank-like" stomach), and muscular defance in the right ileal area is characteristic
for an acute appendicitis. Besides the attributes of inflammatory process are peculiar to an
acute appendicitis — a fervescence, leukocytosis with shift of the leukocytic formula of a
blood to the left, rising of a leukocytic index of intoxication — and they are poorly
characteristic for a perforated ulcer.
The laparocentesis and research of a peritoneal exudate can help difficult cases of
differential diagnostics with acute surgical diseases of organs of an abdominal cavity: the
hemorrhagic character of an exudate testifies to an acute pancreatitis, pancreatonecrosis or
clottage of mesenterial vessels; an abundance of a bile in an exudate — about gangrenous
perforative cholecystitis. At an acute appendicitis the exudate can be purulent, ichorous wit
a fetor smell. The muddy exudate without a smell, with an impurity of slime, nutrition,
sometimes bile with positive iodine assay is characteristic for a perforated ulcer.
Treatment.At a prehospital stage the suspicion on perforation of an ulcer stomach
of a
or duodenal intestine is the absolute indication for immediate evacuation of the patient at
laying position, by medical ambulance in the nearest surgical hospital. At presence of the
indications before transportation the cardiotonic agents, vascular
cardiac
and analeptics are
injected. The application of anesthetizing agents is forbidden. It is forbidden also to leave
the patient with suspicion on perforation of a gastroduodenal ulcer for dynamic observation
in home conditions or ambulatory, including with the purpose of specification of the
diagnosis.
In a surgical hospital the diagnosis of a perforated ulcer of a stomach or duodenal
intestine is the absolute indication to operation. In doubtful cases, when this diagnosis
confidently cannot be rejected, the urgent diagnostic laparotomy is carried out, which
at confirmation of the diagnosis is translated in medical. Any delay with an operative
measure concerning a perforated ulcer considerably worsens the prognosis.
In the preoperative period the stomach should be emptied with the help of a thick
gastric probe.
The most wide-spread operation concerning a perforated ulcer of a stomach and
duodenal intestine is ulcerorrhathy or plastic closing of a perforative aperture (for
example, by lock of the large omentum) with obligatory inspection of an abdominal
cavity and its washing up by plenty of a sterile isotonic solution of sodium chloridum
or solution of furacin. At localization of an ulcer in a duodenal intestine, anamnestic
data, showing about increased acidproducting function of a stomach and at the
appropriate qualification of the surgeon usually truncal vagotomy and one of variants
of draining operation (pyloroplasty, gastroduodenostomy, gastroenterostomy) is carried
out. In series of cases under the appropriate indications the typical resection of a
stomach or antrumectomy in a combination to a vagotomy can be made. At presence of
a purulent peritonitis the operative measure is usually limited by ulcerorrhaphy, the
abdominal cavity is sanated and all complex of measures on treatment of a peritonitis is
carried out.
The conservative treatment concerning a perforated ulcer of a stomach or duodenal
intestine is carried out extremely seldom, mainly owing to categorical refusal of the
patient of operation. In its basis the following principles are fixed, which keeping is
necessary:
— Bed regimen;
— Under a local anaesthesia with 1 % solution of dicainum a thick probe for
complete erasion of gastric contents is entered in a stomach, and then more thin gastric
probe for a constant active aspiration during 5 — 6 day is entered;
— During all this time the patient should be stacked in bed so that the prospective
place of localization of perforated ulcer occupied the highest position in relation to other
part of a stomach (duodenal intestine);
— Correction of a water-electrolyte condition and high-grade parenteral feed
during 7 —10 days;
— Massive therapy by antibiotics of a wide spectrum of action during infusion
therapy (7 — 10 days).
The aspiration stops after the end of the mentioned above term and disappearance
of a seen impurity of a bile in aspirated gastric contents. Before erasion of a probe it is
necessary to inject a water-soluble radiopaque solution, to carry out X-ray inspection
and to be convinced of absence of getting of a radiopaque solution for contours of a
stomach or duodenal intestine.
The outcomes of operative treatment in many respects depend on terms of
performance of the operative treatment: so, on the data of clinics of academy, among
operated in the first 6 hours from a beginning of disease the lethality makes about 2 %,
at operations in terms from 6 till 12 hours this parameter raises up to 9 %, and at
operations in terms from 12 till 24 hours after perforation it makes 14 %, if the
operation is carried out in later terms, from 30 up to 45 % of the patients die.
Acute gastrointestinal bleedings. The efflux of a blood in a cavity of a
gastrointestinal tract is united in a syndrome of gastrointestinal bleedings, which can be
acute, arising suddenly, and chronic, beginning imperceptibly and quite often
proceeding for long time. Besides the gastrointestinal bleedings can be obvious and
concealed. At concealed hemorrhages the impurity of a blood in contents of a
gastrointestinal tract (vomitive masses, stools) can be found out only with the help of
laboratory methods of
research (for example, reaction of Gregerson), and such bleedings are not included into
group of acute gastrointestinal bleedings. At obvious bleedings the blood is found out in
not changed kind together with contents of a gastrointestinal tract and its presence is
found out at usual survey of vomitive masses or stools. In clinical current of a peptic
ulcer of a stomach and duodenal intestine the gastrointestinal bleedings can arise in any
of the listedabove variants.
At an ulcer of a stomach and duodenal intestine the gastrointestinal bleeding arises
at each fourth - fifth patient with these diseases. Approximately at half of persons, died
from a peptic ulcer of a stomach and duodenal intestine a gastrointestinal bleeding was
an immediate cause of death.
Etiology. More than 100 diseases of the man are known now, during which there
can be an acute gastrointestinal bleeding. In frame of the reasons of such bleedings
about 60 % are made by an ulcer of a stomach and duodenal intestine; others 40 % —
other diseases: tumours of a stomach (15—17 %), errosive and hemorrhagic gastritis
(10 — 15 %), syndrome of Mellory - Vase (8 — 10 %), syndrome of a portal
hypertension (7 — 8 %), tumours of an intestine, ulcerative colitis, divertuculosis and
other diseases (7 — 10 %).
Pathogenesisof acute gastrointestinal bleedings at various diseases is various: at
malignant neoplasms the reason of bleedings usually is the disintegration and
ulceration of a tumour; at a syndrome of a portal hypertension — trophic changes of
mucosa, ulcerationand breaks of walls of the extended veins of a stomach and
esophagus owing to a portal crisis; at a syndrome of Mellory - Vase — destruction of
walls of blood vessels owing tobreak mainly of mucous and submucous layers of a
cardial department of a stomach; at an angiostaxis, leukoses, illness of Verlgoff, general
diseases of a blood and hemorrhagic diathesises the pathogeny of bleedings is
connected to change of coagulative properties of a blood, disorders of a capillary
permeability and quantitative or (and) qualitative failure thrombocytes.
of
The pathogeny of acute gastrointestinal bleedings at an ulcer of a stomach and
duodenal intestine is rather complex, as in one cases the bleeding occurs from arrosived
large vessels in the field of an ulcer, in others — from small arteries both veins of walls
and fundus of an ulcer, in third — there aisparenchymatous bleeding from a mucous
coat of stomach outside of an ulcer, where alongside with a hyperpermeability of a
vascular wall multiple small arrosions, being a source of a profuse bleeding, quite often
are found out. Plentiful meal of rasping nutrition, especially under conditions of
difficulty of its evacuation from a stomach, physical strain, the blunt trauma of a
stomach, especially at the filledstomach provoke gastrointestinal bleedings at a peptic
ulcer.
At a bleeding owing to an arrosion of a wall of a large blood vessel in the field of
an ulcer, arising as a result of a necrosis and the subsequent influence of a gastric chyme
on a wall of a naked blood vessel (more often of an artery), destruction of a vascular
wall and the occurrence of a bleeding usually occurs in a phase of an exacerbation of a
peptic ulcer and the lumen of an arrosived vessel frequently remains open, as the
destruction of tissue frames prevails above proliferative processes in a zone of a
bleeding point. The localfactors of a hemostasis, including a retraction of a vessel
(rather circumscribed owing to degenerative changes of a vascular wall and fibrosis of
environmental tissues), aggregation of elements of a blood, the formation of a
thrombus, are insufficient for spontaneous stopping of a bleeding and it quite often
accepts profuse character.
At a slowly progressing ulcer outside of a phase of an exacerbation the productive
inflammation of a vascular wall can handicap to a massive bleeding even at an arrosion
of a large vessel, which lumen frequently appears narrowed owing to a proliferation of
an intima and subendothelial frames, therefore clottage of such vessel can be sufficient
for a spontaneous stopping of a bleeding. However in a wall of chronic ulcers there can be
focal degenerative changes of blood vessels with formation of arterial aneurysms in the fiel
of edges and fundus of an ulcer. The destruction of thin walls of these aneurysmal expansio
is accompanied by serious profuse bleedings.
The pathogeny of bleedings is less investigated at microscopical defects in walls of
small blood vessels of a fundus and edges of an ulcer, but in these cases, apparently, a
progressing necrosis in a crater of an ulcer, inherent to a phase of an exacerbation of diseas
has the decisive meaning in a pathogeny of a bleeding. A pathogeny of bleedings from a
mucosa of a stomach outside of an ulcer also is unsufficiently found out. On the data of
series of researches, the basic pathogenetic mechanisms of such bleedings be: can
— A permanent plethora of all vascular system of a stomach, especially superficial
capillaries and veins causing a hypoxia and disorder of a vascular-tissue permeability, that
results to massive erythropedesis and hemorrhage;
— Expressed dystrophia of superficial layers of a mucosa and decrease of an exchange
of nucleic acids promoting to formation of microerosion;
— Accumulation of neutral mucopolysaccharides as a consequence of disintegration o
tissue peptic-carbohydrate bonds and increase of a vascular permeability;
— Disorder of rhythms of polymerization and depolymerization of acidic
mucopolysaccharides in a wall of blood vessels, change of a permeability of
hematoparenchymatous frames;
— Hyperplastic and dystrophic processes, reorganization and pathological neogenesis
of Glands of all gastric systems, breaking secretory activity of a stomach, bolstering a
vasodilatation and tissue hypoxia (V.D. Bratus)
The appreciable role in a pathogeny of acute gastroduodenal bleedings at a peptic ulcer
is played also by disorders in system of a hemostasis. They are reduced to decrease and
complete loss by an arrosived vessel of ability to a retraction, which posesses a rather
essential role in mechanisms of a local spontaneous hemostasis. In acidic medium there is
an inactivation of Thrombinum, that results in decrease of coagulant ability of a blood, and
than above acidity of a gastric juice, especially is oppressed coagulant system of a blood in
the intragastric center of a bleeding. Simultaneously with dropping of a coagulability of a
blood immediately in the field of a locating of a bleeding point, under influence of acidic
medium of a gastric chyme and chemically active proteolytic enzymes, contained in it, the
fibrinolytic activity raises. This is promoted also by trypsinums, discharged with a tissue of
a pancreas, if the bleeding ulcer penetrates in this organ.
In process of increase of gravity of a hemorrhage there are attributes of a
hypercoagulation of a blood, its fibrinolytic activity even more amplifies and reologic
property are worsened owing to progressing aggregation of elements of blood (V.V.
Rumantsev).
The deficiency of vitamins P, C, K, especially in the winter-spring period, when the
exacerbations of a peptic ulcer arise most frequently, also breaks mechanisms of a
hemostasis. For these reasons, despite of decrease of bloody pressure in bleeding vessels,
owing to an oligemia and collapse the independent spontaneous stopping of a
gastroduodenal bleeding at an ulcer of a stomach and duodenal intestine is always
problematic. As well as at any acute hemorrhage, the condition of the patient is
characterized by the following changes: decrease of mass of a circulating blood,
centralization of a circulation and disorder of cardiac activity, that at the end results in an
oxygen starvation first of all of cardiac muscle, parenchymatous organs and brain.
 Pathological anatomy. Most frequently morphological changes at acute
gastroduodenal bleeding specify the roughly progressing necrosis reaching deeplocated
blood vessels with a necrosis of their walls aatkept lumen. In other cases on a surface
of an ulcer there is a thin layer of necrosed tissue consisting of unstructured basis, in
which parts of nuclear disintegration are non-uniformly posed. Quite often in
unstructured basis there are strings of a fibrin more concentrated in the field of a fundus
of an ulcer, than its edges. Less often zone of a necrosis is absent and surface of an ulcer
is covered only with strings of a fibrin containing in a plenty the rests of breaking up
nucleuses of leucocytes and lymphocytes. More often zone of a necrosis penetrates in
deeper located connectivetissue, which at a chronic ulcer is usually covered with
granulations, is plentiful infiltrated by leucocytes, hystiocytes, plasma cells. The fundus
of an ulcer, as a rule, consists of a fibrous connective tissue, poor for cellular elements,
and the infiltration with lymphoplasmocytes is expressed mainly on a course of blood
vessels and in its superficiallayers.
Classification.The acute gastroduodenal bleedings are differed basically to two
classification attributes: bleedings owing to a peptic ulcer of a stomach both duodenal
intestine and bleeding of a not ulcerative etiology. Bleedings also are distinguished on
localization of its source (stomach, duodenal intestine and their anatomic departments).
The rather large practical importance there is a classification of gastroduodenal
bleedings by gravity of a hemorrhage. Thus, the application of these simple
classification attributes provides an establishment of the etiological and topical
diagnoses in aggregate with definition and degree of gravity of a hemorrhage, that is
necessary for definition of medical tactics and contents of transfusion therapy.
Clinic. The acute gastroduodenal bleedings usually arise suddenly on a background
of habitual for the patient an exacerbation of a peptic ulcer or other of the listed above
diseases. Quite often after the begun gastrointestinal bleeding at peptic ulcers pains in
epigastric area, available up to it, disappear (sign of Bergmann). Simultaneously with it
or earlier common signs of an acute hemorrhage occur — paleness of seen mucous and
dermal integuments, giddiness, hum in a head, ears, quite often syncopal condition, and
then in 15 — 20 minutes and later occur a hematemesis and melena. The vomitive
masses at acute gastroduodenal bleedings can be as «coffee», that usually specifies a
slow bleeding, and the given vent blood has time in a lumen of a stomach to react with
acidic gastric contents, therefore the haemoglobin turns to a hydrochloride hematin
having dark brown colour. At a plentiful bleeding, especially if its source is posed in a
stomach the given vent blood has not time to react with a gastric chyme, it is coagulated
and forms blood clots which are filling lumen of a stomach. These clots on appearance
sometimes remind a crude liver and the patients quite often mark a vomiting «with
pieces of a liver*. At a very intensive bleeding the overflow of a stomach and the
vomitive act arises earlier, than blood clots have time to be formed and there is a
vomiting by a scarlet blood, that is. as well as vomiting with blood clots, attribute of a
serious bleeding from the top departments of a gastrointestinal tract. The vomiting
replicating in short intervals of time, specifies continuation of a bleeding, and the
occurrence of a vomiting in a long interval testifies torelapse
a of a bleeding.
At a slow and not intensive bleeding, especially if the source located in a duodenal
intestine, on a background of the moderately expressed signs of an acute hemorrhage
the dark stools can appear, the impurity of a blood in which is easily found out by the
expressed positive reaction of Gregerson. In case of an anamnestic bleeding shown by a
melena, at inspection of the patient it is necessary to carry out digital research of a
rectum, that allows to determine character of its contents and presence of an impurity,
undergone to decomposing with formation of sulfurous Ferri lactas of a blood, that
gives dark colour tosuch clots. At more intensive bleeding owing to exaltation by the given
vent blood of peristaltic activity of an intestine occurs a liquid tarry stools, and at a very
intensive bleeding stools, sometimes consensual, can look like «cherry jam» or consist from
small-transformed blood.
The acute gastrointestinal bleedings, shown only by a melena, have more favorable
prognosis in comparison with bleedings, shown by a hematemesis. There is the most
adverse prognosis at bleedings, shown by a hematemesis and a melena.
At a mild degree of a hemorrhage its common attributes are unstable, as they are
caused not by an oligemia, but reflex reactions and pathological deposition of a blood. The
creation of conditions of physical and mental rest results in series ofdisappearance
cases in of
these attributes. The appreciable disorders of a hemodynamics caused by bleedings, usually
occur at a hemorrhage more than 0,5 I, as the rate of a bleedingateven an arrosion of a large
vessel in an ulcer does not exceed rate of a hemorrhage at exfusion of a blood at the donor.
Besides approximately in 15 min after a hemorrhage the compensatoric hydremia develops
and quite often on a background short-term reflex arterial hypertension, therefore in early
terms from a beginning of a bleeding the hemodinamic changes can be less expressed in
comparison with due at this degree of hemorrhage.
a In subsequent, at an appreciable
hemorrhage, there is a thirst, dryness of mucosas of an oral cavity, the diuresis is reduced,
that specifies a dehydration owing to a hemorrhage. These signs usually arise already on a
background of hemodinamic changes — tachycardia, decrease of arterial pressure,
compensatoric tachypnea etc.
Diagnosticsof acute gastroduodenal bleedings is carried out on the basis of the clinical
and laboratory data. An anamnesis has the essential importance in an establishment of the
reason and location of a bleeding point, which can be found out from the overwhelming
majority of the patients rather in details, however approximately at one third of patients the
arisen bleeding is the first clinical sign of disease. It is necessary also to find out, whether
the patient uses medicines which can cause a bleeding (aspirinum, steroid preparations,
derivative of pyrosolon etc.).
The bleedings with a hemorrhage up to 0,5 I essentially are not reflected in a common
condition of the patient and only sometimes are shown by short-term common delicacy,
giddiness, and then the occurrence of a black stools is found out. At a plentiful hemorrhage
there are expressed signs of an acute anemia with the subsequent occurrence of a
hematemesis and tar-like stools. The duration of the period between occurrence common
of
signs of an acute hemorrhage and hematemesis or melena changes from several minutes up
to day and more, that depends on intensity of a bleeding. At bleedings owing to a peptic ulc
decrease of intensity of pains is marked (sign of Bergmann). At a blood analysis in early
terms decrease of quantity of erythrocytes and the decrease of a haemoglobin content can b
absent or to be considerably less expressed in comparison with size of a hemorrhage, the
repeated blood analysises with simultaneously definition of a pulse rate and level of arterial
pressure are necessary for judgement about its sizes, quite often after a hemorrhage there is
leukocytosis, rising of ESR. These changes, as well as fervescence, apparently, are caused b
toxic action of products of disintegration of a blood, absorptived from an intestine. The
changes in a muscle of heart are expressed by decrease of wave T and segment ST, that mo
probable is connected to a hypoxia of myocardium
a (F.I. Komarov). At serious bleedings
there can be psychic disfunction as exaltation and hallucinations. The occurrence of the
listed changes depends on intensity of a bleeding and size of a hemorrhage, which can be
determined under the formula: V = 37x( 1,064 — d), where V — size of a hemorrhage in
litres, d — densities of a blood, determined on a method of G.A. Barashkov.
The character
of vomitive masses and stools also matters at scoping of hemorrhage volume and bleeding
point, but this importance is rather. Last years the establishment of the etiological and topic
diagnosis at acute gastroduodenal bleedings became perfectmore due to more and more
wide application of gastroduodenoscopy with the help of fibrogastroscopes.
Gastroduodenoscopy at acute gastroduodenal bleedings is carried out as urgent research an
at an individualization of a premedication there are practically no contraindications to its.
The application of an endoscopy allows to establish the correct etiological and topical
diagnosis of a gastrointestinal bleeding more than at 90 % surveyed
of the patients.
At impossibility of endoscopic research the radiopaque research of a stomach in a
horizontal position of the patient can be applied for an establishment of localization and
character of a bleeding point, but this research is considered counterindicative (before
steady stabilization of hemodinamic parameters) at serious bleedings, accompanied by
syncope or collaptiod condition. Other additional methods of diagnostics of acute
gastroduodenal bleedings (hepatolienography, celiacography, external radiometry etc.) are
applied seldom.
At differential diagnosticswith pulmonary bleedings it is necessary to have in view,
that at bleedings from the top respiratory ways the hematomesis has foamy character, is
accompanied by tussis, and variegrated moist rale caused by hit of a blood in
tracheobronchial tree quite often are auscultated in lungs.
Treatment.At a prehospital stage the first medical assistance at acute gastroduodenal
bleedings consists in the following:
— Strict bed regimen;
— Antacids inside (almagelum, phospholugelum etc.), thrombostatic preparations
(250 units of thrombinum in 50 ml of water on one spoon 15 mines within 2 hours);
— Bubble with ice (heater filled by cold water) on area of an epigastrium;
— At a serious hemorrhage: inhibitors of a fibrinolysis inside (solution of epsilon-
aminocapronicum acidum 5 % — 60,0 on one spoon in 15 mines within 2 hours; to raise th
foot end of a bed or to give a position of Trendelenburg, 10 ml of 10 % solution of calcium
chloridum intravenously, Vicasolum 5 ml or Dicynonum 2 ml intramuscularly. Change
(with registration in a list of observation) of arterial pressure and pulseeveryone
rate in 15
— 30 min.
The delay of the patient at a prehospital stage is inadmissible, and even the proved
suspicion on an acute esophageal or gastroduodenal bleeding is the absolute indication for
urgent hospitalization of the patient in the nearest surgical hospital. The evacuation of the
patient should be made in a laying position in support of the medical personnel.
At entering of such patient in a surgical hospital the group of a blood first of all should
be determined at him and the conservative treatment based on keeping following
of the
principles has to be continued:
— replenishment of deficiency of volume of a circulating blood by transfusion of an
integral blood of small terms of a storage and hemocorrectors (plasma, solution of
Albuminum, erythrosuspension etc.);
— Suppression of a gastric secretion and neutralization of a hydrochloric acid of a
gastric juice by application of antacids, cholinolytics, H-blockers (Cimetidinum, hystodil.
Tagametum, cinaet on 0,4 gr 3 — 4 times per day, famotidin — on one tablet once per day
etc.), local hypothermia;
— Local and common hemostatic therapy;
— nasogastral intubation for erasion of gastric contents, control of a hemostasis and
stopping of a bleeding by use of 4 ml of Noradrenalinum in 150 ml of an isotonic solution o
Sodium chloridum, then the probe is blocked on 2 h, if this introduction is noneffective —
the operative treatment (O.S. Kochnev) is shown to the patient;
— Maintenance therapy (cardiovascular preparations, use of Oxygenium, warming of
extremities etc.), cleansing enema for erasion of the given vent and breaking from
up blood
an intestine.
In a special card of observation or the case history basic parameters of a
hemodynamics, peripheric blood and diuresis are recorded (better graphic way).
The importance of purposeful both intensive hemostatic and maintenance therapy
considerably grows with application of a medical endoscopy, at which the stopping of a
bleeding is made by application of an electrocoagulation, laser and other ways of an
artificial hemostasis.
The indications to urgent operative measure concerning acute bleedings at an ulcer of a
stomach or duodenal intestine are:
— The serious bleeding, when the intensive care during 6 — 8 hours appears
unsuccessful;
— A serious bleeding stopped at conservative treatment, but when the occurrence of a
relapse even with a small hemorrhage represents real danger to life of the patient;
— The relapse or proceeding bleeding irrespective of its intensity, especially at
penetrating ulcers of a stomach and duodenal intestine confirmed by an endoscopy;
— Endoscopic attributes of instability of a hemostasis.
The first operations concerning a bleeding ulcer of a stomach were made in Russia by
prof. S.P. Fedorov in 1903. Now concerning acute gastroduodenal bleedings at an ulcer of
stomach and duodenal intestine the vagotomy (usually truncal) with a ligation or
underrunning of a bleeding vessel (ulcer) and one of variants of draining operations or
resection of a stomach together with erasion of an ulcer are even more often carried out.