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Under penetration understand the spread of ulcers beyond the wall of the stomach or duodenum into the surrounding tissues and organs. Distinguish the stage of ulcer penetration through all layers of the stomach wall or duodenum (intramural penetration); the stage of fibrous fusion with adjacent organs and the stage of complete penetration into the tissues of adjacent organs. Most often, ulcers penetrate into the lesser omentum, into the head of the pancreas, into the hepatoduodenal ligament. Penetration into the liver, gallbladder, transverse OC and its mesentery is possible (R.V. Senyutovich, 1988).

Ulcers of the posterior and lateral walls of the bulb and postbulbar ulcers of the duodenum more often penetrate into the head of the pancreas, biliary tract, liver, hepato-gastric or duodenal ligament, large intestine and its mesentery; stomach ulcers - in the lesser omentum and the body of the pancreas. Penetration is accompanied by the development of the inflammatory process and the formation of fibrous adhesions, sometimes quite extensive. Clinical manifestations depend on the stage of penetration into the organ into which the ulcer has penetrated. The course of ulcer becomes more severe, the clinical picture is polymorphic, symptoms appear characteristic of diseases of adjacent organs involved in penetration (clinic of pancreatitis, cholecystitis, perigastritis, periduodenitis).

When the ulcer penetrates, the rhythm of epigastric pain is lost. It becomes almost constant, more intense, loses its natural connection with food intake, does not decrease from taking antacids, nausea, vomiting increase, signs of inflammation appear - low-grade fever, leukocytosis, ESR increases. The appearance of back pain, pain of a girdle nature is observed with the penetration of the ulcer into the pancreas. For the penetration of the gastric body ulcer, pain radiates to the left half. chest, in the region of the heart, the development of jaundice occurs when the ulcer penetrates into the head of the pancreas, into the hepatoduodenal ligament.

In the area of \u200b\u200bthe pathological focus, pronounced muscle tension is often determined. abdominal wall, palpation pain and it is possible to palpate the inflammatory infiltrate. Penetration of the ulcer is indicated by persistent and persistent back pain, aggravated after eating and at night, not relieved by antispasmodics. At the same time, pain from the epigastrium radiates to the back to the spinous processes of the vertebrae, which often become sensitive to palpation, sometimes also spreads to the left, less often to the right, and even becomes encircling.

With the penetration of the ulcer into the lesser omentum (more often with an ulcer of the lesser curvature of the stomach), pain from the epigastrium more often spreads under the right costal arch; when the ulcer penetrates in the direction of the diaphragm (ulcers of the upper stomach), the pain radiates from the epigastrium to the retrosternal space, neck, shoulder region, often imitating coronary heart disease; when the ulcer spreads into the mesentery of a thick or small intestine (more often with postbulbar ulcers and ulcers of the anastomosis) pain spreads down to the navel or even to hypogastrium; upon penetration into a hollow organ, it leads to the formation of a fistula between the stomach (duodenum) and the organ into which the ulcer penetrated. The formation of a fistula is more often preceded by a period of severe pain syndrome, accompanied by subfebrile body temperature, leukocytosis with a neutrophilic shift of the white blood count to the left.

In the presence of an anastomosis with a gallbladder or gallbladder, pain radiates from the epigastric region under the right scapula, to the right supraclavicular region, vomiting with an admixture of bile, belching of a bitter taste. Ingestion of the contents of the stomach and duodenum into the gallbladder, gallbladder can cause acute cholangitis, OH. With RI in the projection of the gallbladder, a horizontal level of liquid with gas above it (aerocholia), filling with a contrasting mass of gallbladder and bile ducts is detected.

With the formation of a fistula between the stomach and the transverse OC, food from the stomach enters the large intestine, and feces from the intestine penetrate into the stomach. More often, such a fistula occurs with postoperative peptic ulcer jejunum (M.I.Kuzin, 1987). With such a fistula, vomiting with an admixture of feces (fecal vomiting), belching with a fecal odor, defecation soon after taking food with unchanged food in the feces, weight loss is noted. When RI reveals the ingress of a contrast mass from the stomach through the fistula into the colon.

Sometimes the ulcer penetrates into the tissue of the retroperitoneal space, when the ulcer is localized in places not covered by the peritoneum, the cardiac part of the stomach, the posterior wall of the duodenum.With such penetration, phlegmon of the retroperitoneal space can develop with the formation of congestions in the right lumbar region, on the lateral surface of the chest, in the right groin area, there are signs of a severe purulent-septic process (high hectic temperature, chills, sweating, symptoms of intoxication).

With RI, it is usually possible to identify a deep "niche" in the stomach or duodenum, extending beyond the organ (with completed penetration), low mobility of the ulcerative zone and the absence of noticeable changes during treatment.

With EI penetrating ulcer more often round, less often polygonal, deep, the crater is steep, the edges are usually high (due to pronounced inflammatory edema) in the form of a shaft, clearly delimited from the surrounding CO. After the inflammatory process subsides, the severity of the endoscopic signs of an ulcer also weakens (a decrease in hyperemia and an inflammatory shaft around it). A penetrating ulcer leads to deformation of the CO, the formation of gross disfiguring scars, retraction, narrowing. A penetrating ulcer often recurs, and changes in the wall of the organ and surrounding tissues progress. Penetration more often occurs in patients with a long history of ulcers and a recurrent course.

Grigoryan R.A.

Penetration - frequent complication peptic ulcer, which is often combined with stenosis, bleeding or malignancy. The most common lymphadenopathy is the posterior wall of twelve duodenum, posterior wall and lesser curvature of the stomach. Duodenal ulcers most often invade the head of the pancreas, which in turn can cause pancreatitis. In addition, ulcers often penetrate into the hepatoduodenal ligament. Sometimes a fistula with a common bile duct is formed. In such cases, the disease can be complicated by cholangitis and hepatitis.

Pain syndrome is distinguished by special persistence. Often, pains lose their frequency and become permanent. When the ulcer penetrates into the pancreas, patients usually complain of intense back pain.

Patients with penetrating ulcers without the presence of other complications (stenosis, bleeding, malignancy), it is advisable to carry out 1-2 courses of intensive conservative treatment in a therapeutic hospital.

If after this ulcer healing treatment is not observed, then the patient should undergo surgery. Extra caution should be exercised with penetrating gastric ulcers because of the danger of their malignancy.

Conservative treatment of peptic ulcer should start at stationary conditions... It includes the appointment of an anti-ulcer diet, antacids and drugs that normalize gastric motility. With an ulcer duodenum it is also advisable to use drugs that accelerate the regeneration processes. Treatment of gastric ulcers is carried out under mandatory X-ray and endoscopic control. Conservative treatment is described in detail in the course of internal medicine.

Surgical treatment of ulcers

Indications for surgery - the main thing in peptic ulcer surgery. Ballroom, operated not according to strict indications, constitute the main contingent of those suffering from diseases of the operated stomach and to a large extent discredit the method of surgical treatment. Surgical treatment is indicated mainly for complications of peptic ulcer disease. The testimony to him was most clearly formulated by V. “P. Berezov (1950), who divided them into three groups: absolute, conditionally absolute and relative. The absolute indications include: perforation of the ulcer, reasonable suspicion of the transition of the ulcer to cancer, stenoses and deformities (Schmiden's) with impaired evacuation from the stomach.

Perforation of a stomach ulcer or the duodenum - one of the most dangerous complications of peptic ulcer disease. Surgical treatment should be undertaken as much as possible early dates, immediately after diagnosis.

Conservative treatment (Taylor, 1957), proposed for the treatment of perforations and consisting in active aspiration of gastric contents and massive antibiotic therapy, cannot be an alternative surgical methodbecause for him the mortality rate is incomparably greater. It can be used only involuntarily, if due to some conditions (absence of a surgeon and the inability to deliver the patient to the hospital) it is impossible to perform the operation or it is necessary to gain time before the surgeon arrives. In any case, in a critical situation, this method should be remembered.

Reasonable suspicion of the transition of an ulcer to cancer... This complication refers to gastric ulcers, which, according to various statistics, more often turn into cancer in 15-20% of cases, while any convincing cases of malignancy of duodenal ulcers have not yet been described. Even the most modern examination, including gastroscopy with biopsy and cytological examination, does not always allow to establish the onset of cancer degeneration of the ulcer. In order to avoid a fatal mistake, absolute indications should include not only those cases when the diagnosis of malignancy is established absolutely definitely, but also those when there is a reasonable suspicion of the transition of an ulcer to cancer.

Organic stenosis the outlet of the stomach and duodenal bulb are subject to surgical treatment even at the stage of compensation, because all experience in the development of surgery has proven that it is impossible to cure such patients with conservative measures, and the longer this complication of peptic ulcer disease exists, the greater pathological changes occur in the body. Organic stenoses should be distinguished from functional stenoses arising from edema, an inflammatory reaction during exacerbation of peptic ulcer disease. The latter can be relatively easily eliminated in the course of antiulcer therapy. The group of absolute indications also includes Schmiden's deformities of the stomach, accompanied by a violation of evacuation. The stomach is shaped like an hourglass or snail. Such a deformation is either a consequence of a previous peptic ulcer, when the scars wrinkle and deform the stomach, or is combined with an active ulcer. Conservative treatment of such patients is usually unsuccessful.

To conditionally absolute readings include: profuse gastroduolenal bleeding of ulcerative origin and penetrating ulcers.

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Penetration of the ulcer into the pancreas

Penetration of gastric and duodenal ulcers into the pancreas: symptoms and treatment

Peptic ulcer disease can develop in the form of complications. Ulcer penetration is one of the options for the consequences of the ulcerative process.

Description of the disease

Violation of the integrity of the wall of the duodenum or stomach opens the onset of ulcer formation. If the ulcer continues to deepen and captures more and more new layers of the organ wall by destruction, then in the future the continuation of the situation may be:

• perforation is the opening of an ulcer into a cavity
• or penetration - the opening of an ulcer into a nearby organ.

The situation when an ulcer in its development penetrates into the body of an organ that is in the neighborhood, occurs due to the tendency of the human body to adhesions. This phenomenon makes it possible for a closer and more fixed contact of the organ affected by the ulcer with the neighboring organ.

The ulcer in the main organ develops inside the wall due to the accompanying inflammatory process. When the ulcer becomes through, inflammatory process projected onto the wall of a neighboring organ at the site of the ulcer exit outside the tissues of the main organ.

Usually, the development of such a mechanism is the exit of an ulcer into another organ, possibly with a small area of \u200b\u200bthe ulcer of the main organ. If the diameter of the ulcer is more than 1.5 cm, then the amount of gastric juice escaping through it does not contribute to the gradual creation of an ulcer of a neighboring organ. In this case, the perforation of the ulcer occurs, which is often accompanied by shock.

A stomach ulcer can penetrate:

• small oil seal
• or into the pancreas.

A duodenal ulcer can penetrate into the following organs:

• colon,
• pancreas,
• liver,
• biliary tract.

Causes

The possibility of the development of the ulcerative process in the main organ in the direction of transferring the problem to a neighboring organ appears as a result of the influence of such factors:

• The presence of an ulcer in the duodenum or in the wall of the stomach.
• The area of \u200b\u200bthe ulcer is small - the diameter is within 1.5 cm.
• The patient's body has a tendency to adhesive processes.

Stages

The appearance of a penetrating ulcer goes through three stages:

• The ulcer is located in the duodenum or stomach and is in the period of spreading deep into the wall of the organ.
• Between the organ with the ulcer and the adjacent organ, their mutual proximity is fixed through the adhesion process.
• The spread of the inflammatory process to the projection of a future ulcer on the body of a neighboring organ with the development of the ulcer itself in its wall.

Symptoms of the penetration of gastric and duodenal ulcers

When an ulcer enters another adjacent organ, the following symptoms appear:

• some painful symptoms are observed, characteristic of the case in which organ the ulcerative process exits:
  • the ulcer penetrates into the lesser omentum - pain radiates to the collarbone or right shoulder;
  • into the pancreas - back pain often appears, it can be felt in the lower back: give to one side or be encircling;
  • to the area of \u200b\u200bthe large intestine - the irradiation of painful symptoms occurs in the navel area;
  • with the penetration of ulcers located in the upper part of the stomach, pain can be projected onto the region of the heart;
• the organs, where the ulcer penetrated, signal the appearance of symptoms characteristic of their defeat:
  • when the ulcer penetrates into the liver, symptoms of acute hepatitis appear,
  • the same in the intestines - signs of colitis or duodenitis,
  • the same in the biliary tract - symptoms of acute cholangitis,
  • the same in the pancreas - signs acute pancreatitis;
• appear general symptoms:
  • pain that previously appeared in the epigastric region in connection with food intake or had its own circadian rhythm, changed its character and became constant and intense in strength;
  • there is an increase in temperature without apparent reason,
  • the abdominal muscles are in tension,
  • the analysis of peripheral blood changes - shows the presence of an inflammatory process.

Diagnostics

The disease does not manifest itself very clearly, the symptoms are similar to many other diseases, so the diagnosis is complex.

The mandatory diagnostic measures include the following actions:

• The specialist makes a history of the patient according to his complaints and observations.
• Investigated clinical manifestations diseases, information is analyzed about which zones the pain is radiated to.
• The examination includes the delivery of clinical tests to the patient.
• Fluoroscopy of the stomach is performed.
• An obligatory measure for establishing an accurate diagnosis is fibrogastroscopy.

Treatment of gastric ulcer penetration

Ulcers, the condition of which is within the first and second stages, are subject to conservative treatment... The course is carried out in a hospital setting.

The patient is prescribed:

• drugs that normalize gastric motility;
• antacids,
• a diet aimed at the disappearance of provocations for ulcerative processes,
• in some cases, preparations of a regenerating action are recommended.

Due to the fact that a penetrating ulcer is a danger to human health, the results of treatment are monitored using X-ray equipment.

Penetrating ulcers, which have already reached the third stage in their pathological development, are recommended to be treated surgically. The same appointment is received by patients with ulcers of the initial stages, if conservative methods do not bring the expected positive result.

The following types of operations are used:

• vagotomy,
• resection,
• drainage operation.

On early stages diseases, the body can be maintained within normal limits with timely treatment and diet. At later stages, surgical intervention and a careful attitude to your health are required in order to prevent complications.

The negative consequences include the following phenomena:

• perforation of the ulcer,
• stenosis.

With timely treatment, 99 out of 100 patients are cured and lead a normal life.

If you do not apply for medical help or to allow the development of complications, then the prognosis is poor.

gidmed.com

Ulcer penetration - symptoms, treatment, emergency care

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Ulcer penetration is considered a rather dangerous complication of this disease. This problem is diagnosed in about 10-15% of cases of peptic ulcer disease, and men 40 years old who have a long history of pathology are more susceptible to it. As a rule, this disease is caused by the development of an inflammatory process in a chronic ulcer.

• Description of the disease
• Causes
• Stages
• Symptoms
• Diagnostics
• Treatment
• Forecast

Description of the disease

Penetration is the penetration of an ulcer into other organs. So, the defeat of the duodenal bulb usually extends to the pancreas. In more rare cases, it affects bile ducts or liver. Even less often, this problem is localized in the large intestine. Mediogastric ulcers usually involve the pancreas. Sometimes the small omentum suffers.

Causes

Penetration usually develops when the following conditions are present:

1. Ulcerative defect. The deeper the layers of the stomach are affected, the higher the risk of developing such complications.
2. Adhesions in the upper abdomen. It is this problem that leads to close contact of adjacent organs and reduces the likelihood of their distance from each other.

In this case, the development of a penetrating ulcer has the following mechanism:

1. As the gastric ulcer progresses, the defect affects all layers of the organ. Moreover, its area may not be too large - the diameter, as a rule, is 1-1.5 cm.

In this issue, the key role is assigned to the amount of gastric juice. An excess of this substance flows out through a special hole, which as a result provokes perforation, shock and even death. If the diameter is less important, the juice does not come out, and therefore the likelihood of shock is minimal.

1. As the peptic ulcer progresses, the adhesive process develops. This problem due to the ingress of gastric contents into the cavity. As a result of this process, inflammation develops, which leads to the appearance of adhesions. As a result, the stomach is attached to nearby organs. This process can be of a different nature - it all depends on the location of the ulcer.
2. After the attachment of organs to the stomach, its contents do not enter the abdominal cavity. In this case, a certain organ suffers, which leads to the appearance of a characteristic clinical picture.

Stages

On initial stage the disease progresses a chronic inflammatory process, as a result of which there is a partial destruction of the stomach wall. From the outside, adjacent organs adjoin the area of \u200b\u200blocalization of the ulcer.

The second stage is characterized by severe damage to the layers of the wall of the diseased organ. But the pathological process has not yet left its limits. In this case, there is no damage to the wall of another organ. The formation of dense adhesions occurs between it and the stomach. If they collapse, a through defect appears in the wall.

In the third stage, the layers of the stomach are completely destroyed. Ulcerative lesion affects the adjacent organs, which provokes the appearance of a minor flat defect. In this case, the structure of the penetrated organ is disrupted, which is located in the circumference of the ulcer. It becomes denser, sclerotic processes are observed. In addition, severe deformity of the stomach is characteristic.

Pancreatic penetration

The fourth stage is characterized by the formation of deep cavities in a nearby organ. In the penetration zone, a tumor formation of an inflammatory nature is formed.

Symptoms

This type of disorder is characterized by the appearance of the following symptoms:

1. Pain syndrome in the epigastrium. Discomfort becomes permanent and pronounced, loses its daily rhythm and is not associated with food.
2. Typical localization of pain. This condition depends on which organ is affected. So, when an ulcer spreads to the pancreas, the pain syndrome usually radiates to the right lumbar zone, sometimes to left side... Often, discomfort is also felt in the back or the pain becomes girdle.When the lesser omentum is affected, discomfort is felt at the top of the right side - pain can affect the right shoulder or collarbone. If the ulcer is located high enough, the pain syndrome can affect the heart. If the post-bulbar ulcer spreads to the mesentery of the large intestine, the discomfort radiates to the navel.
3. Local soreness. Intense pain syndrome often occurs in the projection of penetration. In addition, this violation is often accompanied by the appearance of an inflammatory infiltrate.
4. Signs of damage to certain organs. Clinical picture depends on which organ is affected by the ulcerative defect.
5. An increase in temperature to subfebrile values.

To diagnose the penetration of peptic ulcer disease, the doctor carefully examines the patient's history, conducts a clinical examination and prescribes additional studies - laboratory and instrumental.

When examining the anamnesis, attention is paid to the presence of gastric ulcer or risk factors for its appearance. Loss of connection between epigastric pain syndrome and food intake is of no small importance. Discomfort becomes permanent and radiates to the arms, neck, back.

To make an accurate diagnosis, the following studies are prescribed:

1. Blood test - in this case, the erythrocyte sedimentation rate increases and neutrophilic leukocytosis is observed.
2. Fibrogastroduodenoscopy - such an ulcer is characterized by round or polygonal borders that rise in the shape of a shaft. Moreover, the crater is quite deep.
3. Fluoroscopy - in the presence of a disease, you can see a significant increase in the depth of the ulcer, limitation of the mobility of the affected area.

   X-ray peneration

4. Laparoscopy - allows you to visualize the attachment of the organ into which the ulcer has spread to the stomach.
5. Ultrasound abdominal cavity - makes it possible to consider changes in the pancreas or liver in the event that the ulcer has penetrated into these organs.

Treatment

Penetrating stage 1-2 ulcerative lesions are difficult to respond drug therapy... If a person is diagnosed with a more advanced form of the disease, the ulcers do not heal at all. In such a situation, the only treatment is considered surgical intervention.

If a patient is diagnosed with a penetrating type 1-2 ulcer, he undergoes a gastric resection. At the first stage of a small ulcerative lesion, vagotomy can be performed, which must be combined with gastric drainage. A similar version of the intervention is carried out when large inflammatory infiltrates appear. They cannot be separated as there is a risk of organ damage.

Forecast

In the absence of adequate treatment, the prognosis is usually poor. This complication of peptic ulcer disease can lead to the development of shock and death. Due to timely surgical intervention, the likelihood of cure increases.

Ulcer penetration is a very dangerous condition in which various organs can be affected. If this pathology is detected, you need to immediately start treatment. In most cases, the only effective method therapy is considered to be surgery.

Judging by the fact that you are reading these lines now, victory in the fight against diseases of the gastrointestinal tract is not yet on your side ...

Surely you have already thought about surgical intervention? It is understandable, because the stomach is very important body, and its correct functioning is a guarantee of health and well-being. Frequent pain in the area, heartburn, flatulence, belching, nausea, dyspepsia ... All these signs are familiar to you firsthand.

But perhaps it is more correct to treat not the effect, but the cause? We recommend reading the experience of Galina Savina, how she cured stomach problems ... Read the article \u003e\u003e

zheludok24.ru

Ulcer penetration

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, ulcer penetration occurs in the lesser omentum, the head of the pancreas, and the hepatoduodenal ligament.

Pain with a penetrating ulcer becomes constant, intense, loses its natural connection with food intake, does not decrease from taking antacids. Increased nausea and vomiting. In some cases, signs of inflammation appear, as evidenced by low-grade fever, leukocytosis, and increased ESR. With the penetration of the ulcer into the pancreas, back pain appears, often taking a shingles in nature. 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 penetration of the ulcer into the head of the pancreas, hepato-duodenal ligament, obstructive jaundice may develop. An X-ray 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 therapy for penetrating ulcers is often ineffective, surgical treatment is indicated. In case of duodenal ulcer, selective proximal vagotomy is recommended with removal of the ulcer or leaving its bottom on the organ into which it has penetrated; for gastric ulcer, gastric resection is performed.

Pyloroduodenal stenosis

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 more often pyloric canal ulcers and prepyloric ulcers.

The formation of stenosis occurs as a result of scarring of the ulcer, in some cases - due to compression of the duodenum by an inflammatory infiltrate, obstruction of the intestinal lumen with edema in the area of \u200b\u200bthe ulcer.

The causes and degree of narrowing are determined by X-ray examination, gastroduodenoscopy and (if indicated) biopsy. In response to the difficulty of evacuation from the stomach, its muscular membrane is hypertrophied. In the future, the contractile ability of the muscles weakens, the stomach expands (dilatation, gastrectasia) and its prolapse (gastroptosis).

Clinical presentation and diagnosis.

IN clinical course stenosis is divided into 3 stages: I - stage of compensation, II - stage of subcompensation, III - stage of decompensation.

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 prolonged pain, a feeling of heaviness and fullness; heartburn, belching. Occasionally there is vomiting, bringing relief, with the release of a significant amount of gastric contents.

In the stage of subcompensation, the feeling of heaviness and fullness in the epigastric region increases, belching with an unpleasant smell of rotten eggs appears due to a long retention of food in the stomach. Colicky pains associated with increased peristalsis of the stomach, accompanied by rumbling in the abdomen, are often disturbing. Profuse vomiting occurs almost daily. Often, patients cause it artificially. Vomit contains an admixture of undigested food.

The subcompensation stage is characterized by a decrease in body weight. When examining the abdomen in thin patients, undulating peristalsis of the stomach is visible, changing the contours of the abdominal wall. On an empty stomach, the "splash noise" in the stomach is determined.

In the stage of decompensation, gastrostasis and gastric atony progress. 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. There is repeated vomiting. The feeling of fullness in the epigastric region becomes painful, forcing patients to induce vomiting artificially or flush the stomach through a tube. Vomit (several liters) contains foul-smelling, decaying food debris from many days ago.

Patients with decompensated stenosis are usually emaciated, dehydrated, adynamic, and thirsty. There is a decrease in diuresis. The skin is dry, its turgor is lowered. The tongue and mucous membranes of the mouth are dry. Through the abdominal wall in thin patients, the contours of a distended stomach can be seen. A jerky shaking of the abdominal wall by the hand causes a "splash noise" in the stomach.

The terminal stage of decompensated stenosis is characterized by a sign of three Ds: dermatitis, diarrhea, dementia.

X-ray examination in stage I reveals a slightly enlarged stomach, increased peristalsis, narrowing of the pyloroduodenal zone. Evacuation from the stomach is accelerated. In stage II, the stomach is dilated, it contains fluid on an empty stomach, and its peristalsis is weakened. The pyloroduodenal zone is narrowed. After 6 hours, residues are detected in the stomach contrast agent... In stage III, the stomach is sharply distended, on an empty stomach a large amount of contents are found in it. Peristalsis is sharply weakened. The evacuation of the contrast mass from the stomach was delayed for more than 24 hours.

The degree of narrowing of the pyloroduodenal zone is determined when endoscopic examination... In stage I, cicatricial-ulcerative deformity is noted with a narrowing of the pyloroduodenal zone to 1 - 0.5 cm; in stage II, the stomach is stretched, the pyloroduodenal zone is narrowed to 0.5 - 0.3 cm due to a sharp cicatricial deformation. Peristaltic activity is reduced. In stage III, the stomach reaches enormous size, atrophy of the mucous membrane appears.

In patients with pyloroduodenal stenosis due to the exclusion of normal nutrition through the mouth, the loss with vomit of a large amount of gastric juice containing H +, K +, Na +, Cl + ions, as well as protein, dehydration, progressive depletion, impairment electrolyte balance (hypokalemia, hypochloremia) and acid-base state (metabolic alkalosis).

Signs of water-electrolyte disturbances are dizziness and fainting with a sharp transition of the patient from horizontal to vertical position, rapid pulse, decreased blood pressure, tendency to collapse, pallor and cooling of the skin, decreased urine output. Hypokalemia (K + concentration ˂ 3.5 mmol / L) is clinically manifested by muscle weakness. A decrease in the level of K + in plasma to 1.5 mmol / L can lead to paralysis of the intercostal muscles and diaphragm, respiratory arrest and cardiac activity. With hypokalemia, there is a decrease in blood pressure (mainly diastolic), a violation of the rhythm of heart contractions, expansion of the borders of the heart, systolic murmur at its apex. Cardiac arrest may occur. The ECG reveals a lengthening of the Q – T interval, a decrease in the amplitude and flattening of the T wave, the appearance of a U wave. Against the background of hypokalemia, dynamic obstruction intestines.

As a result of dehydration of the body, renal blood flow decreases, glomerular filtration and diuresis decrease, and azotemia appears. In connection with renal failure "acidic" metabolic products are not removed from the blood. The pH of the blood decreases, hypokalemic alkalosis turns into acidosis. Hypokalemia is replaced by hyperkalemia. Along with this, patients develop severe hypochloremia. Impaired electrolyte levels in the blood affect neuromuscular excitability. In severe cases, against the background of hypochloremia, gastric tetany develops - general convulsions, trismus, flattening of the hands ("obstetrician's hand" is a symptom of Trousseau), twitching of the facial muscles when tapping in the trunk area facial nerve (Khvostek's symptom).

Hypochloremic and hypokalemic alkalosis, combined with azotemia, in the absence correct treatment can become incompatible with life.

Differential diagnostics.

Pyloroduodenal stenosis of ulcerative origin should be distinguished from stenoses caused by tumors of the gastric outlet. The severity of gastrectasia with slowly (years) progressive ulcerative stenosis is significantly greater than with rapidly developing (weeks and months) tumor narrowing of the pylorus. Endoscopic (including biopsy) and x-ray examination allow you to clarify the diagnosis. Diagnosis of sub- or decompensated pyloroduodenal stenosis is absolute indication to the operation.

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 pylorus and the initial part of the duodenum, periulcerous infiltration can decrease, and the patency of the pylorus improves. At the same time, correction of water-electrolyte and protein disorders is carried out. After such treatment, the risk of surgery is reduced.

Patients with subcompensated and decompensated stenosis, who have pronounced disorders of the water-electrolyte balance and CBS, need a more thorough complex preoperative preparation, which should include the following measures.

Normalization of water-electrolyte disturbances (administration of solutions of dextran, albumin, protein, balanced solutions containing ions K +, Na +, Cl +. Potassium preparations can be prescribed only after the restoration of diuresis. To maintain water balance, the patient is injected with an isotonic glucose solution. The effectiveness of the treatment is judged by general condition patient, hemodynamic parameters (pulse, blood pressure, CVP, shock index, hourly urine output, BCC), indicators of acid-base state, plasma electrolyte concentration (K, Na, Cl), Hb, hematocrit, creatinine, blood urea.

Parenteral or tube enteral nutrition, which provides the body's energy needs through the introduction of glucose solutions, amino acids, fat emulsion. A feeding tube is inserted endoscopically into the poststenotic section of the small intestine.

Antiulcer treatment with antisecretors.

Systematic decompression of the stomach (aspiration of gastric contents through a tube).

Surgery.

In pyloroduodenal stenosis, the operation of choice should be considered selective proximal vagotomy with various options for gastric drainage (pyloroduodenoplasty, 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.

studfiles.net

Penetrating gastric ulcer and 12 duodenal ulcer

Ulcer penetration is the penetration of an ulcerative lesion into neighboring organs. There is a penetration of gastric and duodenal ulcers. Erosion is localized mainly in the head of the pancreas, large canals of the gallbladder, liver, hepato-gastric ligament, large intestine.

What is the disease

If we talk in simple words, then a penetrating stomach ulcer is the spread of the inflammatory process to other organs, followed by the formation of erosions.

Penetration stages:

• the spread of erosion in all layers of the walls of the stomach, duodenum 12;
• connective tissue fusion with nearby organs or organ;
• penetration of erosion into organ tissue.

The first stage is characterized by progression chronic inflammation in erosion with partial destruction of the walls of the stomach or duodenum. The second stage is characterized by deep destruction the walls of the affected organs.

At the third stage, all layers of the walls of the organ or organs are completely destroyed. In doing so, they undergo deformation.

Development reasons

The main reasons for the development of pathology are the presence of progressive ulcers and a penetrating inflammatory process. That is, if gastritis and gastroduodenitis are not cured in time, then the walls of the stomach or duodenum become covered with ulcers. Later they appear in neighboring organs.

The key role in this is played by the increased production of hydrochloric acid, which is part of the gastric juice. Factors such as malnutrition, infection, non-compliance with the rules of treatment provoke excessive production of hydrochloric acid.

By acting regularly on the ulcer, the acid causes more and more inflammation. As a result, the layers of the walls of the stomach and duodenum will be affected deeper and deeper. The result is penetration.

Forecast

If there is no adequate treatment, the prognosis is poor. During the formation of ulcers, the replacement of normal healthy tissues with adhesions occurs. This process causes deformation of organs, which can cause narrowing of the lumens, obstruction of food.

These complications of ulcerative lesions lead to the development of shock, often cause death. If timely surgical intervention is performed, then the prognosis is positive. The cure occurs in 99%.

Symptoms of pathology

Symptoms of penetration depend on the stage of the pathology. If the disease has just begun to progress, then the person will feel symptoms characteristic of a peptic ulcer: pain in the stomach, navel (but distinctive feature this pathology - pains are regular, regardless of food intake). Hunger pains during penetration bother a person less often. Later, if any organ is damaged, the disease manifests itself in different ways.

If the ulcer penetrates into the pancreas (head area), then signs of acute pancreatitis appear:

• pain is very intense, cutting, dull (can cause painful shock) - the main symptom;
• heat;
• increase or decrease in blood pressure;
• hiccups, nausea, belching, vomiting (with bile);
• diarrhea or constipation;
• dyspnea;
• cyanosis of the skin.

When the bile ducts are damaged, the following symptoms appear:

• a sharp rise in body temperature up to 38-40 ° C;
• severe sweating, drowsiness;
• intense pain in the right hypochondrium, similar to biliary colic;
• intoxication, expressed by weakness, loss of appetite, headache, nausea, vomiting, diarrhea;
• yellowness of the skin;
• impairment of consciousness (in severe pathology);

Penetration into the intestinal area is manifested by symptoms of duodenitis, colitis:

• feeling of fullness of the abdomen;
• lack of appetite;
• heartburn;
• belching;
• nausea, vomiting with bile;
• false urge to defecate;
• heaviness in the abdomen;
• constipation.

If penetration occurs in the liver, then this condition is characterized by an attack of acute hepatitis:

• nausea;
• weakness;
• pain in the right hypochondrium, spreading throughout the abdomen;
• jaundice;
• darkening of urine;
• itchy skin;
• enlargement of the liver in size;
• weakness, headache.

With penetration in the peritoneal region, the following appears:

• heat;
• weakness, thirst;
• abdominal pain - strong, paroxysmal;
• swelling of the lower back.

Diagnostics and treatment

Diagnosis of penetration includes examination of the patient, identification of symptoms, laboratory and instrumental research.

To establish an accurate diagnostician, the following is assigned:

• delivery of analyzes;
• fibrogastroduodenoscopy procedure;
• fluoroscopy technique;
• laparoscopic examination;
• ultrasound examination.

Treatment of such a pathology is best done surgically... No medicines, dietary supplements and other drugs will help prevent irreversible consequences... Moreover, the earlier the pathology is diagnosed, the more successful the treatment.

Do not forget that any ulcer can cause sepsis, peritonitis after perforation.

In the early stages of the lesion, doctors can still prescribe a course complex therapy, in the event that healthy tissues are not replaced by connective tissue and organ deformation has not occurred. Medicines are also prescribed if the penetration of the ulcer did not entail stenosis, bleeding and other complications.

A medical course of therapy is carried out only in a hospital, since the patient and his standing should be monitored around the clock. When the condition worsens, cardinal methods of treatment are immediately taken. At advanced stages, an operation is performed, in some cases resection, vagotomy.

Pancreas treatment and prevention

Reactive pancreatitis symptoms and treatment in adults