Treatment of Perforated Gastric Ulcers
Gastric perforation, or perforated ulcer, is a dangerous condition in which a hole forms through the organ. This condition causes stomach contents to leak into the abdominal cavity. A perforated ulcer requires immediate medical attention, as the patient experiences severe abdominal pain and, without treatment, can even lose their life.
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Causes and Risk Factors
In the vast majority of clinical cases, ulcers are caused by Helicobacter pylori bacteria, which infect the gastric mucosa and provoke inflammation by releasing harmful metabolites. However, endocrine disruptions, psycho-emotional stress, and prolonged use of certain medications can also trigger the disease.
Among the pharmaceuticals that can damage the gastric mucosa, nonsteroidal anti-inflammatory drugs (NSAIDs) occupy a special place. Uncontrolled use of these drugs promotes increased hydrochloric acid production and reduces the production of substances that protect the lining of the digestive organ.
Ulcer perforation is often caused by reasons such as:
- Constant stress, which stimulates hyperproduction of gastric juice by the cells of the organ's inner lining
- Excessive alcohol consumption and smoking, as ethanol and nicotine irritate the gastrointestinal epithelium
- A diet rich in hot spices, salt, acetic acid, and other food additives that negatively impact the gastrointestinal tract
- An unhealthy diet, characterized by irregular mealtimes, lack of a proper lunch, and a habit of satisfying hunger with sandwiches or questionable dry snacks
Diagnosis of perforated ulcer
Diagnosis of a perforated gastric ulcer is performed promptly and without delay due to the extreme urgency of the condition. The medical examination is organized directly by a gastroenterologist and includes a detailed patient interview, assessment of symptoms, and clinical presentation. Instrumental diagnostics are also performed to confirm or refute the doctor's suspected diagnosis.
Particular attention is paid to differentiating the diagnosis of a perforated gastric ulcer from other pathological conditions with similar symptoms, including cardiovascular problems and other life-threatening conditions.
Complaints and anamnesis
When a doctor suspects a perforated gastric ulcer, the first thing he does is ask the patient in detail about everything that happened before the onset of symptoms. The doctor will ask questions about your well-being, such as:
- When did the severe abdominal pain begin? Did it start immediately or gradually increase?
- Did the pain occur on its own or after an event, such as drinking strong alcohol, eating spicy food, or lifting something heavy?
- Are there any other discomforts besides the pain: weakness, dizziness, fever?
- Have you had any previous stomach problems, such as constant heaviness or discomfort after eating? Have you been previously diagnosed with an ulcer?
- What medications have you taken recently? Were they painkillers like aspirin or ibuprofen?
All these questions help the doctor determine the likelihood of an ulcer perforation. The doctor will then ask questions that help gather the patient's medical history, such as:
- How long ago did similar episodes of pain end?
- Have you seen a doctor before, and if so, what treatment did you receive?
- Have any relatives had similar cases?
Having a complete picture, the doctor can make a more accurate preliminary diagnosis and decide what further tests the patient needs.
Physical Examination
When a doctor suspects a perforated gastric ulcer, after listening to the patient's complaints and collecting a medical history, they conduct a thorough physical examination. The specialist checks the following:
- Appearance and well-being - the doctor observes the patient's appearance, paying attention to facial expression, pale skin, sweating, anxiety, or lethargy.
- Pulse and blood pressure - the doctor measures the patient's pulse rate and blood pressure because when an ulcer perforates, the body experiences severe stress, the heart beats faster, and blood pressure drops.
- Body temperature. A high temperature is rare with a perforated ulcer, but if it does rise, it signals a possible complication—infection or inflammation.
- Abdominal examination. The specialist gently palpates the patient's abdomen, determining the exact location of the pain, its severity, and duration. The doctor pays special attention to abdominal muscle tension, its firmness, and its response to finger pressure.
- Reflexes - sometimes the doctor examines the body's response to touch and analyzes limb movements to rule out neurological problems.
- Bowel sounds - the specialist uses a stethoscope to hear bowel sounds, which can change in the presence of serious stomach problems.
This examination helps doctors accurately understand the situation and confirm the suspicion of a perforated ulcer in order to prescribe the correct treatment in a timely manner.
Laboratory diagnostics
Other laboratory tests and analyses are often unnecessary given the critical time delay and the need for immediate action.
Instrumental Diagnostics
Instrumental examination methods are used immediately following the initial examination and specialist consultation.
Basic diagnostic procedures include:
- X-ray of abdominal organs
- Endoscopic examination (gastroscopy)
- Computer tomography (CT)
- Ultrasound diagnostics
Laparoscopic intervention is also practiced, providing direct visual control of the abdominal organs.
Classification of perforated ulcers
Perforated gastric ulcers are classified according to several criteria.
The first is the location of the hole. There are two most common localizations:
- Ulcer located in the lower part of the stomach
- Damage to the main part of the stomach
Determining the exact location of the perforation is only possible after specialized examinations that provide a clear picture of what is happening inside.
The second classification depends on the presence of associated problems. Ulcer perforation is almost always accompanied by a serious complication – peritonitis. This means that acid and food debris enter the abdominal cavity.
The third basis for classification is the nature of the perforation itself. Pathology may be a consequence of:
- A fresh acute ulcer
- A chronic course of the disease
Both cases are equally dangerous, but the acute form carries an increased risk of rapid massive bleeding and the rapid onset of serious complications, including death.
Treatment of perforated gastric ulcer
Sometimes doctors first try to manage the condition non-surgically by stopping the inflammation and reducing the load on the stomach, but this is the exception rather than the rule. More often than not, surgery is required.
Modern techniques allow such procedures to be performed with minimal intervention, using small incisions and specialized equipment. In addition to the surgery itself, diet and follow-up care are important.
Conservative Treatment
Sometimes, if a person refuses surgery or their condition is so severe that immediate preparation for surgery is impossible, doctors opt for a conservative approach. In this case, they prescribe:
- Correction of the balance of important minerals and salts
- Insertion of a special tube through the nose directly into the stomach to remove excess fluid and gases
- Minimally invasive procedures using gentle punctures to clear the abdominal cavity of unwanted contents
However, such measures are temporary and serve only as preparation for the inevitable surgery.
Surgical Treatment
Perforated ulcers of the stomach and duodenum are most often treated surgically. It involves several techniques:
- Laparotomy - a traditional open approach with a large incision is performed
- Minilaparotomy - the procedure involves a minimal incision
- Laparoscopy - a modern method that involves pinpoint punctures through which instruments and a camera are inserted to repair defects
There are three main approaches to performing surgeries:
- Suturing the puncture site with or without fixation of fatty tissue
- Removal of a section of damaged tissue with expansion of the outlet from the stomach
- Gastric resection - the part of the organ affected by the perforation is removed
There are also alternative surgical interventions:
- Gastroduodenostomy - creation of a new pathway for food to pass around the damaged area
- Duodenostomy - the creation of a temporary opening in the wall of the duodenum to drain its contents.
- Temporary opening of the abdominal cavity (laparostomy) in combination with one of the above approaches.
The choice of a specific technique is determined by many factors, such as the patient's health, the size of the injury, and individual characteristics.
Postoperative Treatment
Immediately after surgery, the patient is instructed to remain in bed and eat only puréed, lukewarm food without salt, sugar, spices, or any additives.
Additionally, the patient is prescribed a wide range of medications, including antibiotics and antifungals, painkillers, and IV fluids to detoxify the body. Bowel stimulation is also performed, including muscle relaxants, cleansing enemas, and medications to prevent nausea and vomiting.
General information
Symptoms of a Perforated Gastric Ulcer
The main sign of a perforated gastric ulcer is a sudden, severe ("stabbing") pain in the abdomen immediately after exposure to negative factors: overeating, eating hot, fatty, or highly irritating foods, drinking alcohol, or significant physical exertion.
The patient experiences excruciating, almost unbearable pain, forcing them to instinctively bend over and pull their knees to their chest. Simultaneously, the tension in the anterior abdominal muscles rapidly increases, becoming hard and immobile, literally freezing in a shield-like position.
A sharp deterioration in health is observed: the face turns pale, a clammy, cold sweat appears, and breathing becomes shallow and rapid due to severe pain. The heart rate increases, but blood pressure remains normal or slightly low. Later, nausea and occasional bouts of vomiting occur, caused by the development of inflammation of the peritoneum—the lining of the abdominal cavity. Thirst and occasional hiccups are also characteristic.
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Definition and general information about perforated ulcer
A hole in the stomach wall with its contents leaking into the peritoneum is accompanied by severe abdominal pain, symptoms of peritoneal irritation, and signs of toxic shock. Treatment is exclusively surgical, performed either traditionally or using minimally invasive techniques.
After surgery, patients are often prescribed long-term therapy with medications to reduce hydrochloric acid secretion, especially if vagotomy (cutting the gastric nerves) was not performed. A through hole in the stomach develops as a result of ulcer progression, exposure to stress, excessive alcohol consumption, and the use of certain medications.
This condition occurs in approximately one in five thousand adults annually. Among patients with gastric and duodenal ulcers, it occurs in approximately one in ten patients, accounting for approximately fifteen percent of the total number of possible complications.
Men suffer from this disease twenty times more often than women. This pathology typically affects young working-age individuals between the ages of twenty and forty. Particular exacerbations leading to perforation occur in the spring and fall. It is noteworthy that almost ten percent of perforation cases are not associated with preexisting ulcers and affect children and young adults.