Perforated stomach ulcer symptoms emergency care. Emergency care for gastric ulcer perforation - an algorithm for pre-medical manipulations

A perforated ulcer is a serious complication that occurs when peptic ulcer when a through defect of the muscular wall of the organ is formed. The contents of the stomach, being in abdominal cavity, provokes irritation leading to the development of peritonitis. As a result of the fact that female sex hormones are able to inhibit the secretory activity of the stomach, most widespread perforated ulcer is noted among the male population.

Reasons for education

The main reason for the development of pathology is the presence of peptic ulcer. When exposed to hydrochloric acid on the affected area of ​​the wall of the duodenum or stomach, all its layers are destroyed. The factors that provoke the disease are:

• Infection with the bacterium Helicobacter pylori.
• Overflowing of the stomach with food, which causes stretching of the walls.
• The use of products that irritate the mucous.
• Frequent and prolonged stress. People who constantly live in a state nervous tension, are much more likely to experience what a perforated ulcer is.
• Smoking.
• Physical overexertion, as a result of which the pressure in the stomach rises.
• Uncontrolled intake of some medicines. If necessary, their use by patients with peptic ulcer is simultaneously prescribed drugs that reduce the production of hydrochloric acid.
• Frequent use of alcohol. Strong alcoholic drinks damage the gastric mucosa.
• Smoking stimulates the production of hydrochloric acid.
• Violation of the diet, the predominance of fried, spicy, smoked foods in the diet are common causes of the disease.

Another factor in the perforation of a stomach ulcer can be hereditary predisposition when the mucosal defect is genetically determined.

Signs of a perforated ulcer depend on the stage of the disease.

The initial period is called chemical peritonitis. Its duration is about 5 hours. Signs of a perforated ulcer include:

• Sharp pain, which is localized near the navel, gradually spreading throughout the abdomen.
• Paleness of the skin, cold perspiration.
• The patient's breathing becomes rapid, the pressure decreases.
• The muscles of the anterior wall of the abdomen are very tense. Even soft palpation causes increased pain. The condition is relieved by lying on the side (usually on the right) with legs bent and pressed to the stomach.

The second period is characterized by a decrease in the intensity of the pain syndrome, when the symptoms of a perforated ulcer disappear, and an imaginary improvement occurs. Muscle tension weakens, even with palpation, pain may be absent. However, the body temperature rushes up, in the blood it is found high content leukocytes. The absence of peristaltic noise indicates toxic intestinal paresis. Percussion of the abdomen determines the presence of free fluid in it. There is a gray coating on the surface of the patient's tongue. If medical care is not provided at this stage of a perforated stomach ulcer, the condition begins to deteriorate rapidly.

The third period of the disease occurs approximately 12 hours after the perforation has occurred. At this stage, with a perforated gastric ulcer, the symptoms are expressed in the form of intoxication, accompanied by severe vomiting, which leads to dehydration. Body temperature drops sharply from 39–40⁰С to 36.6⁰С. The abdomen enlarges as a result of the accumulation of free gas and fluids in it. The volume of excreted urine decreases, then stops altogether. Irreversible changes occur when treatment in rare cases ends with a positive outcome.

Varieties of perforated ulcer

Perforated ulcer is divided depending on:

• Etiology. Distinguish between perforation in the chronic or acute form of the disease, which has arisen from exposure to pathogenic bacteria, impaired blood circulation, and an existing malignant formation.
• The place of localization - perforation of the ulcer can form on the back or front wall of the stomach, in the area of ​​curvature, on the duodenum.
• clinical manifestations. Classic variant when a breakthrough is made inside the abdominal cavity, atypical - the contents of the stomach enter the retroperitoneal region, as well as perforation with gastric bleeding.

In addition to these types, gastric ulcer perforation is divided into 3 stages - chemical, bacterial, diffuse purulent.

Diagnostic methods

Detection of the first symptoms of a perforated gastric ulcer requires urgent appeal V medical institution, where after diagnostic measures and clinical examination will be selected the most efficient scheme treatment.

In addition to a direct examination, the doctor prescribes research:

1. Radiography. Thanks to this technique, it is possible to determine the amount of air in the abdominal cavity.
2. Endoscopic examination. The study is carried out if perforation was not detected on x-ray, however, the existing symptoms indicate the opposite.
3. ultrasound. The method allows you to determine the localization of abscesses, the volume of fluid in the abdominal cavity.
4. ECG. Helps to evaluate the work of the heart, identify existing heart rhythm disturbances, eliminate abdominal shape myocardial infarction, which is of great importance in preparation for surgical intervention when it is necessary to choose the right methods of anesthesia.
5. Laboratory study of blood. General analysis provides information about the presence inflammatory process. Biochemical research establishes the degree of intoxication, allows you to differentiate acute pancreatitis.
6. Diagnostic laparoscopy. Used for bright severe symptoms when it is required to clarify the source of irritation of the abdominal cavity. The method has contraindications - obesity, hemophilia, severe condition of the patient, damage to the diaphragm, the presence of adhesions in the abdominal cavity, hernia.

When diagnosing a perforated ulcer, the period of time that has passed since the moment of perforation is taken into account. This will help determine the degree of development of peritonitis.

Treatment

In case of perforation of a gastric ulcer, in order to save the patient's life, it is necessary to urgently eliminate the underlying disease. Emergency care provided conservative method or through surgery. Great importance is given to proper nutrition recommended for this disease.

Conservative treatment

Therapy is performed when there are contraindications for the operation or the patient refuses it. Drug treatment can be prescribed only if 12 hours have not passed since the moment of perforation. The age of the patient should not exceed seventy years. The basis of therapy is antibiotics, antispasmodics, drugs that reduce secretory function. With the help of a special probe, the stomach is freed from the contents, an ice pack is placed on the stomach. Antibacterial therapy lasts 7 days.

Surgery

The surgical method is the main one. In this case, several types of operations are performed - suturing of a perforated ulcer, excision of an ulcer, resection of the stomach.

Young patients who do not have a long history of ulcers, the elderly, those in serious condition, and also if no more than 6 hours have passed since the moment of perforation, the method of suturing the perforated ulcer is used. The operation is performed under general anesthesia. After excision of the ulcer, the muscular and serous membranes are sutured in the longitudinal direction. Then visual control of the abdominal cavity is carried out, temporary drainages are installed. If the hospital has the technical capabilities, with a perforated gastric ulcer, the operation is performed using laparoscopic equipment.

Resection of the stomach is prescribed:

• With a long history of ulcers.
• When there are no results after drug therapy
• With perforation of several ulcers at once.
• Suspicion of oncology.
• When a perforated ulcer of an old form cannot be sutured due to cicatricial formations.

The operation, performed under general anesthesia, removes two-thirds of the stomach. The disease, as a rule, requires urgent surgical intervention, which is usually performed urgently when data on acidity and other indicators of the work of the stomach are not enough. Therefore, the decision to perform the operation by suturing the perforated ulcer or by resection is made by the doctor during the operation.

When a localization of a neoplasm without a pronounced inflammatory process is found on the anterior wall of the stomach, excision is used using endoscopy and laparoscopy. Moreover, in addition to removing the stomach ulcer, treatment includes ligation of the vagus nerve.

Possible Complications

It is important that with a perforated stomach ulcer urgent Care was provided on time. Otherwise, serious complications are possible. Delay in taking measures to treat a perforated ulcer or delayed diagnosis pose a danger to the health and life of the patient. With a perforated stomach ulcer, surgery cannot be postponed. Complications can occur regardless of how the operation was performed - by suturing a perforated ulcer or by gastric resection.

The most common consequences:

• Damage to the sutures, as a result of which the contents of the stomach enter the abdominal cavity.
• Formation of local abscesses.
• The lying position, which the patient has to take for a long time, leads to a weakening defensive forces organism, resulting in a high risk of developing bronchopneumonia.

More often complications occur in elderly patients and those who have a weakened immune system.

After surgery for perforation of a stomach ulcer, the patient is advised to take maximum care of his health - walk more in the fresh air, relax, avoid emotional and physical overload, adhere to the rules of a healthy diet.

Diet

Proper nutrition occupies a particularly important place in the postoperative period. Immediately after the operation, the patient is recommended a strict diet. The first 2 days you can not eat, it is allowed to drink a little water. Then the patient is offered mashed soups, cereals on the water, kissels. 10 days after the operation, lean meats, fish, vegetable stew, omelettes, low-fat dairy products.

Prohibited foods during the first few months after surgery:

1. Chocolate.
2. Carbonated drinks, alcohol.
3. Too hot, as well as spicy, salty dishes.
4. Muffin.
5. Garlic, radish, onion.
6. Chips, fast food.
7. Citrus.

People who have had suturing of a perforated ulcer or other types of surgical intervention, such a diet must be followed for the rest of your life.

Urgent Care

Take anamnesis and establish accurate diagnosis only a specialist can do it, so emergency care for a perforated stomach ulcer consists in urgent delivery of the patient to the hospital. The sooner this is done, the greater the chance of coping with the disease. Before a medical examination, the patient should not take narcotic analgesics, otherwise, with a perforated stomach ulcer, the symptoms will be blurred, which can disorient the doctor and interfere with the correct treatment process. Emergency care includes fluid therapy, oxygen inhalation, the introduction of vasopressors.

Forecast

If within 12 hours from the moment of perforation of the ulcer, first aid is not provided, and there is no surgical treatment, death most often occurs. Timely emergency care for a perforated stomach ulcer increases the chances of a favorable outcome. When a perforated ulcer is sutured on time, it may re-perforate in less than 2% of cases.

The number of deaths after surgical operation ranges from 5 to 8 percent and depends on the age of the patient, his general condition and concomitant diseases.

Peptic ulcer disease occurs when destructive changes in the mucous membrane of the organ, when its protective function is reduced. This leads to an increase in the pathological focus and, without therapy, completely destroys the gastric wall. When, under the influence of a physical, bacterial or chemical stimulus, a gap appears in the wall of the stomach, a perforated ulcer develops, which can be fatal.

Causes of a perforated ulcer and risk factors

Perforation of a gastric or duodenal ulcer is a chronic disease that occurs when a complication chronic disease these organs. The following points can be a provoking factor:

1. Filling the stomach with an increased volume of food.
2. Exacerbation of a chronic ulcer.
3. Alcohol intake, fatty or spicy foods.
4. Increased acidity of the stomach.

All these causes of perforated gastric ulcer are valid in the presence of peptic ulcer, the causative agent of which is the bacterium Helicobacter pylori. Although 50% of the world's population is infected with this microorganism, not everyone gets sick. Activates the pathogenic effect of bacteria any violation protective functions our body. Risk factors for peptic ulcer disease include:

• violation of the quality of sleep;
• prolonged stress;
• lowered immunity;
• uncontrolled intake of NSAIDs;
• smoking;
• alcohol consumption;
• violation of the quality of nutrition;
• the presence of gastritis or other pathologies of the gastrointestinal tract;
• heredity.

Symptoms and signs of the disease

Treatment of perforated gastric ulcer (MBK code 10) depends on the stage of the inflammatory process. The disease is provoked from getting into the abdominal region of the contents of the stomach. Then the first period of development of a perforated ulcer begins - chemical peritonitis. It lasts from 3 to 6 hours, accompanied by acute pain in the right hypochondrium or paraumbilical segment, later covering the entire abdomen. The patient's sweating increases, the skin turns pale, arterial pressure decreases, breathing becomes rapid, sometimes vomiting occurs, gastrointestinal bleeding.

If left untreated, bacterial peritonitis develops after 6 hours when sharp pains disappear. In this phase, the temperature rises, the pulse quickens, and intoxication of the body increases. The patient begins to feel relief, becomes uncritical to his condition. If no help is provided during this period, the patient proceeds to the most severe stage of the perforated ulcer.

Period acute intoxication begins after 12 hours from the onset of the disease and is characterized by constant vomiting, which quickly leads the body to dehydration. Typical symptoms of perforated ulcer stage 3: skin become dry fever body drops to 36 degrees, blood pressure drops below normal, the process of urination stops, the patient's response to external stimuli. It is no longer possible to save a patient who has reached this phase.

Classification of perforated ulcer

perforated ulcer duodenum and stomach is classified according to the clinical course of the disease, according to the localization of the focus (stomach or 12 duodenum) and pathological and anatomical features. The disease occurs in two forms: typical, when the contents of the stomach enter the abdominal region and atypical, when the contents enter the stuffing bag or flow into the retroperitoneal tissue.

Diagnosis begins with a thorough questioning of the patient's complaints, a study of the medical history, physical and laboratory studies, the use of X-ray and endoscopic methods. Perforated (perforated) ulcer is characterized by pain attack, therefore, the first thing the doctor resorts to is an examination using palpation on the left side and an x-ray. With the help of the main X-ray method the presence of a through defect, air in the abdominal cavity under the diaphragm and intestinal airiness, characteristic of a perforated ulcer, are determined.

Additional research methods to clarify the diagnosis:

1. Endoscopy. Carried out if there is a suspicion of a perforated ulcer, and x-ray examination gave a negative result.
2. Electrocardiogram. It is done to assess cardiac activity, the presence of scars on the heart, to determine rhythm disturbances. ECG excludes myocardial infarction.
3. ultrasound. The presence of gases in the intestine is confirmed, the focus of damage to the walls of the stomach and the size of the circumference of the perforation are revealed.
4. Blood test (general). Shows availability high content leukocytes.
5. Laparoscopy. Helps quantify and qualitative analysis accumulation of effusion in the abdominal cavity.

Treatment of perforated ulcers of the stomach and duodenum

Perforated ulcers are treated only with surgery. Preoperative preparation for resection of the stomach is to restore blood pressure and remove gastric contents. Specialists take into account the onset of the attack in time, the size and location of the ulcer, the age of the patient, the presence of other pathologies, and then the operation technique is determined.

There are two types of surgery for a perforated ulcer: suturing, in which the organ is preserved during the operation, and resection - a radical excision of the ulcer, which leads to the loss of a large part of the stomach, and after that the patient becomes disabled. Suturing is indicated for widespread peritonitis, and the technique consists in excising the edge of the ulcer and then suturing part of the stomach. Resection is done in the presence of large chronic ulcers, suspicion of oncology, purulent peritonitis.

Emergency care for sudden acute pain

With any suspicion of an attack of a perforated ulcer, the patient should be given first aid, which consists in his urgent delivery to the hospital. An accurate history of the disease can only be compiled by a qualified doctor, and the sooner this happens, the better. Do not think that emergency care for a perforated stomach ulcer is a technique narcotic analgesics, since these drugs will only alleviate the symptoms, which will disorient the doctor and interfere with proper organization nursing process.

Diet after perforated ulcer surgery

Nutrition during the recovery period after excision of a perforated ulcer plays a very important role. The diet is aimed at restoring peristaltic and secretory functions, so the diet should be complete and balanced. It must consist of daily carbohydrates(420 g), fats (100 g), proteins (100 g). You can eat salt no more than 12 g / day, and drink at least 1.5 liters of water / day. The calorie content of the daily menu should not exceed 3000 kcal.

Nutrition after the operation should be divided into 5-6 times / day and in small portions. The break between meals should not be more than 4 hours. As for prohibited foods, you should not include rich pastries, coarsely ground bread and any freshly baked products in your diet. Will have to give up mushrooms and meat broths, fatty meat, fried foods, smoked meats, canned food and fermented milk products.

Prohibited foods after perforated ulcer surgery: hard-boiled eggs, corn, beans, millet, pearl barley, cabbage, radish, spinach, cucumbers, mushrooms, spices, spicy snacks, kvass, coffee, sparkling water, alcohol.

What you can eat: a sample menu for the day

Despite multiple prohibitions, the menu after removal of a perforated ulcer can be very diverse. Immediately after surgery for 1-2 days give only water, weak tea. Gradually introduce pureed soups, cereals, vegetable purees.

If on the 10th day after the operation there is no nausea, no pain, belching and other unpleasant symptoms, then it is allowed to use unmashed food. Approximate menu on the day after rehabilitation:

• Breakfast - soft-boiled egg, non-acidic cottage cheese, a sandwich with butter, cocoa.
• Lunch - pumpkin baked with honey.
• Snack - crackers, yogurt.
• Lunch - vegetable soup, chicken fillet steamed.
• Snack - boiled rice, steam cutlet, milk and berry jelly.
• Dinner - baked fish, carrot puree.

Possible complications of the disease and prognosis

The most important consequence of a perforated ulcer is peritonitis. In the abdominal cavity, the contents of the stomach accumulate, which has leaked out, which provokes the appearance of pus. If the operation is not carried out on time, then the person will live 2-3 days. Absence surgical treatment perforated ulcer - 100% death in all cases. Postoperative mortality accounts for 5-8% of the occurrence of complications, age and presence comorbidities sick.

III. Perforated ulcer of the stomach and 12 duodenal ulcer.

Perforation or perforation - the formation of a hole in the wall of the stomach or duodenum, and the flow of gastrointestinal contents into the abdominal cavity.

Complicates peptic ulcer in 10-12% of patients.

It occurs 10 times more often in men. It occurs more often in people with a long history of ulcers.

Factors that provoke perforation:

Plentiful food;

physical stress(weight lifting, abdominal trauma);

Alcohol consumption.

Clinic:

There are three periods during a perforated ulcer :

1 period - the period of pain "shock" - the first 6 hours,

2 period - imaginary improvement -6-12 hours after perforation,

3 period - the period of peritonitis, after 12 hours.

First period (shock:) manifested by sudden sharp pain (dagger pain) in the epigastrium on the right (95%) or right hypochondrium (symptom of Dvelyafua) and all the symptoms of shock.

Patients are agitated, screaming in pain. The facial expression is pained.

Forced position on the back or on the side with legs pulled up to the stomach, avoid changing it.

On palpation, the abdomen is sharply painful, the tension of the abdominal muscles is plank belly(defense), sharply "+" - a symptom of Shchetkin - Blumberg, the disappearance of hepatic dullness.

The pulse is slow at first (Grekov's symptom).

It should be remembered that in patients over 70 years of age, in 50% of cases with perforation of a gastric and duodenal ulcer, the pain is not intense, there is no acute onset, the abdomen is accessible to palpation (there is no tension in the muscles of the anterior abdominal wall).

The second period (imaginary well-being).

The general condition and appearance of the patient improves somewhat.

The symptoms of shock disappear, pain in the abdomen and tension of the muscles of the abdominal wall decrease, the pulse, blood pressure, and respiration level out.

This period can be misleading for both the patient and the healthcare worker.

Due to the improvement in the patient's condition, the patient may refuse to be hospitalized, and as a result of a diagnostic error, doctors will miss the most appropriate time for surgical intervention.

Third period progressive diffuse peritonitis occurs 12 hours after perforation.

As a result of intoxication, the general condition worsens, all the clinical symptoms of peritonitis appear.

Algorithm for emergency first aid and first aid.

Before transportation:

1. lay the patient on his back;

3. do not inject drugs and analgesics;

4. it is forbidden to take laxatives and enemas, which, by increasing intestinal motility, contribute to a more rapid spread of infection;

5. to relieve pain, put an ice pack on the stomach;

6. with vomiting, nausea: metoclopramide solution 5% - 2 ml (cerucal) in/in or/m;

7. insert a probe into the stomach to evacuate the contents, but do not rinse, with flatulence, you can enter a gas outlet tube;

8. according to indications infusion therapy intravenous drip solution of sodium chloride 0.9% - 400 ml, glucose 5%, reopoliglyukin with prednisolone 60-120 mg.

Tactics: emergency transportation of the victim to the surgical hospital lying on a stretcher under the control of the condition and hemodynamics.

Delayed hospitalization leads to the development of peritonitis with an unfavorable outcome and makes the prognosis hopeless!

Diagnosis and treatment in the hospital.

Instrumental research:

1. Plain radiography of the organs of the fighting cavity - a symptom of a "sickle" - the presence of air under the diaphragm.

2. Ultrasound - fluid in the abdominal cavity.

3. Emergency laparoscopy.

Lab tests:

1. KLA - signs of inflammation.

2. Determine the blood type and Rh factor.

Treatment:

emergency operation under anesthesia:

Laparotomy with ulcer closure

Laparotomy with excision of the ulcer,

Laparotomy with resection of the stomach, in rare cases.

The operation ends with drainage of the abdominal cavity.

IV. Ulcer penetration - penetration of an ulcer into one of the neighboring organs (pancreas, liver, omentum).

Clinic:

Intensive constant pain in the epigastric region with irradiation to the back, the pain is especially severe at night.

On the x-ray deepening of the "niche".

Paramedic Tactics

v. Pyloric stenosis.

This is a narrowing of the outlet of the stomach as a result of scarring of the ulcer.

Allocate three phases of cicatricial pyloric stenosis:

Compensation;

subcompensation;

Decompensation.

Clinical symptoms:

Feeling of fullness and heaviness in the epigastrium;

Vomiting of food eaten the day before;

Belching rotten;

Weight loss, dryness and flaking of the skin,

Splashing noise and visible peristalsis in the stomach area,

In the stage of decompensation, dehydration and convulsions due to repeated vomiting and loss of fluid, electrolytes.

On the radiograph:

Delayed emptying of the stomach (in the stage of decompensation, a delay in evacuation for more than 24 hours),

Expansion of the stomach.

Paramedic Tactics : Refer for consultation with a surgeon.

Principles of treatment.

In the stage of compensation, conservative antiulcer therapy. In the stage of subcompensation and decompensation - surgical treatment.

VI. Ulcer malignancy - degeneration into cancer.

Stomach cancer ranks second after lung cancer.

Age criterion 45-65 years, rarely in young, childhood.

Precancerous diseases and risk factors:

Chronic callous ulcers,

More often, ulcers of the greater curvature and subcardial region are malignant,

The size of the ulcer matters: more than 1 cm - 8% malignancy, ulcer 1.5-2 cm - 25%, ulcer - long-term non-scarring ulcers,

hereditary predisposition,

The nature of nutrition (the predominance of smoked meats, spices, fresh bread, cheese, rice, very hot fatty foods, frequent use strong alcoholic beverages)

Clinical picture: allocate the early period, the period of obvious clinical manifestations, terminal.

In the early period: weakness, fatigue, loss of appetite, bad taste in the mouth, frequent belching rotten, feeling of heaviness in the epigastric region, causeless weight loss.

During the period of obvious clinical manifestations;

1. Pain in the epigastric region is constant regardless of food intake.

2. Aversion to meat food and the smell of fried onions.

3. Anorexia - lack of appetite.

4. Progressive weight loss.

5. Dysphagia - with cancer of the cardiac region.

6. Nausea and vomiting with blood.

7. Feelings of rapid satiety and fullness of the stomach, due to stenosis of the pylorus.

8. Causeless prolonged fever.

A cancerous tumor, having arisen, gradually infiltrates the entire wall of the stomach, growing into neighboring organs.

Metastasis:

1. Virchow's metastasis - an enlarged lymph node in the left supraclavicular region.

2. Liver metastases, manifested by jaundice and ascites, sometimes this is the first clinical manifestation with which the patient comes.

3. Metastases in the ovaries in women.

4. Metastases on the abdominal wall - peritoneal carcinomatosis.

5. Possible metastases in the head and spinal cord, bones, lungs.

A terrible complication that requires emergency care is bleeding.

Paramedic tactics:

2. send to Oncology Center(office) at the place of residence of the patient emergency notice about a newly diagnosed oncological disease (or suspicion of a disease).

Laboratory diagnostics:

1. KLA: Anemia is often the first symptom of the disease.

2. Analysis gastric juice: persistent deacidification and detection of lactic acid.

3. Analysis of feces for occult blood - a constantly positive Gregersen reaction.

4. ELISA is the detection of special tumor antibodies.

Instrumental diagnostics:

1. FGDS - the type of tumor is detected + biopsy, histological examination.

2. Radiography of the stomach - a filling defect, an atypical relief of the mucous membrane around the ulcerative niche.

3. Ultrasound of the liver, ovaries, lymph nodes.

4. Computer tmtgraphy.

5. Radioisotope scanning.

6. Diagnostic laparoscopy.

Treatment:

Radical surgery - extensive resection of the stomach with removal of the tumor, regional lymph nodes, omentums in combination with chemotherapy and radiation therapy;

If radical treatment is impossible, then a palleative operation is performed - gastrostomy, jejunostomy or gastroenteroanastomosis (anastomosis between the body of the stomach and small intestine) for the possibility of feeding the patient and symptomatic treatment is carried out.

Forecast.

After radical operation about small tumor patients live 5 years or more. With advanced cancer after 5 years, no more than 30% of those operated on remain alive.

III. Conclusion.

To be able to provide first aid and first aid for a perforated ulcer, stomach bleeding, to be able to make a diagnosis and determine the correct tactics for complications of peptic ulcer disease is the responsibility of a paramedical worker, from the correctness and timeliness of whose actions the patient's life and the prognosis for recovery directly envy.

Control questions:

1. Name the complications of peptic ulcer.

2. Which of them can be attributed to acute abdomen?

3. Describe the basic principles of emergency care and treatment of peritonitis.

4. What is the first aid for a patient with suspected gastrointestinal bleeding?

5. Define "penetration".

6. Define "stenosis" of the pylorus and name its symptoms.

7. Define "malignancy" and name the symptoms of the disease.

8. Paramedic tactics in case of suspected oncological disease.

Topic: "Surgical diseases and injuries of the abdominal wall and abdominal organs: diseases of the large intestine."

Form of organization educational process: lecture.

Lecture type: current.

Type of lecture: informational.

lecture time: 2 hours.

Goals:

educational: know

q methods of examination of patients with surgical diseases large intestine;

q paramedic tactics in providing emergency care to patients with suspected intestinal bleeding, transportation rules;

q main symptoms of bowel diseases;

q the volume of preoperative preparation of the patient for emergency and scheduled operations on the intestines;

q principles surgical treatment, features of the postoperative period.

educational: understand the importance of correct and timely provision help.

developing: develop logical clinical thinking, the ability to analyze, compare, draw conclusions.

Location: Medical College.

Intersubject communications Keywords: traumatology, fundamentals of nursing, propaedeutics of clinical disciplines, disaster medicine, therapy.

Internal connections:

1. Stages of development and formation of surgery. Organization surgical care population.

2. Pain relief.

3. Fundamentals of transfusiology.

4. Operative surgical technique.

6. Bleeding.

7. Prevention of surgical nosocomial infections.

8. Desmurgy.

9. Perioperative period.

10. Surgical infection.

Equipment: lecture notes, thematic tables.

Literature for the teacher used in the development

lectures:

1. Zhukov B. N., Bystrov S. A., Moscow, 2007.

2. Ruban E. D. "Surgery", Rostov-on-Don, 2006.

3. Dmitrieva Z. V., Koshelev A. A., Teplova A. I. “Surgery with the basics

4. Kolb L. I., Leonovich S. I., Jaromich I. V. " general surgery", Minsk, 2003.

5. Maximenya G. V., Leonovich S. I., Maksimenya G. G. “Fundamentals of practical

surgery”, Minsk, 1998.

6. Avanesyants E. M., Tsepunov B. V., Frantsuzov M. M. “A guide to

surgery”, Moscow, 2002.

7. Guidelines for ambulance, (national project "Health"), a team of authors, made in accordance with the terms of reference of the Ministry of Health and Social Development of the Russian Federation "On issues of information support for medical and secondary medical workers providing primary health care” No. 1287-VS dated March 16, 2006, GEOTAR-Media, 2007.

Literature for students:

Main literature:

1. Zhukov B. N., Bystrov S. A., Moscow, 2007, pp. 330-334.

additional literature:

1. Dmitrieva Z. V., Koshelev A. A., Teplova A. I. “Surgery with the basics

resuscitation", St. Petersburg, 2001.

2. Ruban E. D. "Surgery", Rostov-on-Don, 2006.

3. Kolb L. I., Leonovich S. I., Yaromich I. V. “General Surgery”, Minsk, 2003.

4. Maksimenya G. V., Leonovich S. I., Maksimenya G. G. Fundamentals of Practical Surgery, Minsk, 1998.

5. Morozova A. D., Konova T. A. "Surgery", Rostov-on-Don, 2002.

6. Avanesyants E. M., Tsepunov B. V., Frantsuzov M. M. “Surgery manual”, Moscow, 2002.

Homework: study of lecture notes, study of basic and additional literature.

Stages of the lecture:

1. Organizational moment - 1 min: the teacher checks the readiness

students to class, notes the absent.

2. Motivation of the lesson: the topic, learning goals, name are stated

key questions - 4 min.

3. Communication of new knowledge - 85 min.

Lecture structure:

1. Introduction: topic, learning goal, name of the main questions,

this topic for practice.

2. Main part: presentation of theoretical material.

3. Conclusion: conclusions and generalizations on the topic, significance for practical activities.

On prehospital stage:

2. Cold on the stomach.

3. Oxygen therapy through nasal cannulas, mask.

4. Introduce antispasmodics: drotaverine 2% solution 0.1 ml/kg IM, papaverine 2% solution 0.1 ml/kg IM, no-shpa 0.1 ml/kg IM.

5. The fight against hyperthermic syndrome: physical methods, medications(papaverine 2% solution 0.1 ml/kg IV or IM, Diphenhydramine 1% solution 0.1 ml/kg IV or IM).

6. Maintenance of cardiovascular activity by the introduction of cardiac glycosides: corglicon 0.06% solution of 0.1-0.15 ml / year of life (no more than 0.5-0.8 ml) in 10% glucose solution intravenously as a bolus.

7. Transport to a medical facility.

At the hospital stage:

1. Emergency radiography of the abdominal cavity in vertical position("sickle" of gas under the right dome of the diaphragm).

2. Insert a permanent probe into the stomach for decompression, removal of contents.

3. Determine the group and Rh factor of the patient's blood, clinical, biochemical analyzes blood, blood gases, CBS, general analysis urine.

6. Assess the parameters of blood pressure, CVP, heart rate, respiratory rate, toC.

7. Insert the catheter into bladder to account for hourly diuresis.

8. Catheterization of the main vein.

9. Conduct a short preoperative preparation: infusion detoxification and rehydration therapy.

10. Operation: intubation anesthesia, median laparotomy, revision of the abdominal organs, with a perforated stomach ulcer - suturing the perforated hole after refreshing its edges or an economical atypical resection of the stomach (typical resections of the stomach according to Billroth are not performed in children), with a perforated duodenal ulcer- also economical resection, with intestinal perforation - the imposition of an intestinal stoma, depending on the level of the location of the perforated hole - jejuno-, ileo, colostomy.

EXAMINATION TICKET No. 39

Task number 1.

Patient K., 57 years old, noted an increase in blood pressure for a long time with a maximum of up to 220/125 mm Hg. Art., habitual blood pressure - 180/95 mm Hg. Art. Not treated. For the last 2 days, burning retrosternal pain radiating to left shoulder without a clear connection with physical activity, lasting from 5 to 20 minutes. 2 hours ago there was an intense growing retrosternal pain, weakness, cold sweat. On physical examination: the skin is cold, moist. Vesicular breathing in the lungs. Heart sounds are muffled, rhythmic with a heart rate of 106 per minute, blood pressure 90/60. Stopped urination.

1. Formulate a diagnosis.

2. Indicate complications and their manifestations.

3. Provide emergency assistance.

4. Methods of surgical care.

5. Specify the types of rehabilitation of patients with this disease.

Task № 2.

A 34-year-old patient came to the ambulance station with complaints of repeated seizures. acute pain in the right lumbar region with irradiation along the ureter down the abdomen and into the external genitalia. Attacks of pain are accompanied by nausea, vomiting.

1. What is your preliminary diagnosis?

2. Tactics of an ambulance doctor

3. What needs to be done additional research?

4. Principles of emergency care.

5. Rehabilitation.

Task number 3.

A primipara, 22 years old, was admitted with a full-term pregnancy. The contractions started the night before, the waters broke 4 hours ago. The temperature at admission was 36.5°C, contractions of medium strength, after 2-3 minutes. Height - 140 cm, pelvis dimensions: 20-23-26-16. Diagonal conjugate 8 cm, abdominal circumference 98 cm. The head is located above the entrance to the small pelvis. The fetal heart rate is 130 per minute. Light waters flow.

2. What is the shape of the pelvis and the degree of its narrowing?

3. What is the true conjugate?

4. What to do?

5. What the doctor should have done antenatal clinic taking into account the interests of the mother and fetus from the standpoint of primary prevention of an unfavorable course of childbirth?

Decipher the ECG.

Algorithm for emergency care in the primary reaction to radiation.

Sample answers to ticket number 39

Sample answer to problem number 1.

1.IHD. Acute myocardial infarction. Hypertonic disease III Art. Risk IV Art.

2. Cardiogenic shock, acute renal failure anuric stage.

3 Sol. Morphini hydrochloridi 1% -1.0 i.v. Heparini IV drip 1000 IU per hour under the control of APTT. Sol. Dopamini IV drip 5-20 mcg/kg/min., Sol. Noradrenalini hydrochloridi 0.2% solution 1-2 ml. With an increase in blood pressure, the appearance of urine - Sol. Isoceti 10 mcg/kg/min. When the ST segment is elevated on the ECG, thrombolytic therapy (tissue plasminogen activator 100 mg IV for 30-60 minutes, streptokinase 1500,000 IU IV for 1.5 hours).

4. Carrying out angioplasty against the background of balloon counterpulsation.

5. Physical, psychological, medical, social.

Sample answer to problem number 2.

1. An attack of renal colic on the right, which is caused by the migration of a stone along the ureter.

2. Hospitalize in a surgical hospital, preferably in the urology department.

3. Ultrasound, survey and excretory urography, blood and urine tests.

4. Warm bath, antispasmodics, painkillers.

5. In case of spontaneous passage of the stone, it is recommended to follow a diet, water regime.

Sample answer to problem number 3.

1. The condition of the woman in labor is satisfactory. Childbirth was complicated by early rupture of amniotic fluid.

2. General uniformly narrowed pelvis III-IV st. (absolute contraction)

4. Given the degree of narrowing of the pelvis, the satisfactory condition of the fetus is absolute reading for delivery by caesarean section.

5. The doctor of the antenatal clinic had to refer the pregnant woman for antenatal hospitalization in a planned manner to the maternity hospital at the gestational age of 38 weeks.

ECG response template.

Ventricular tachycardia, HR 150/min.

Pathological perforated ulcer is regarded by medicine as an inevitable complication of gastric ulcer. Similar phenomenon also observed in the duodenum. The accompanying name for this medical phenomenon is perforation or a severe violation of the integrity of the wall of a certain section of the gastrointestinal tract, followed by secretion into the abdominal cavity. Perforation of the wall occurs due to the long absence of treatment of the underlying disease.

Causes

The formation of a hole in the walls of the stomach is associated mainly with a complication of a previously existing problem - an ulcer of a chronic or acute type. Perforation occurs when the layers of tissue that make up the wall of the stomach are completely separated. Sometimes the cause of the development of this pathological condition is the actions of the patient himself. This is ignoring the doctor's prescriptions and violating the established diet.

The causes of the neglected state of the stomach and the exacerbation of an existing ulcer are:

1. Strengthening the aggressive effect on the already damaged part of the organ wall. The increase in acidity directly proportionally affects the rate of hole formation.
2. sudden jump intra-abdominal pressure, can occur under high voltage.
3. Ignoring dietary prescriptions: drinking alcohol, forbidden foods, salty foods.
4. State of chemical poisoning.
5. Because of negative impact non-steroidal anti-inflammatory drugs.
6. A state of intense emotional tension.
7. Heredity, cases similar disease in family history.
8. Additional infection with the bacterial microorganism Helicobacter pylori.
9. state of overeating.
10. Completion of complex exercise with phases of high voltage.

Impact of the above negative factors is a prerequisite initial damage walls of the digestive tract, which later turns into more severe forms.

Problems with complications of peptic ulcer are stated in 10% of cases with any diseases of the gastrointestinal tract. The most common age of those suffering from this disease is 20-50 years. In addition, men are more prone to this complication, since the presence of estrogens in women acts as a powerful limiter of the level of acidity of the gastric secretion.

In case of violation of the integrity of the wall of the stomach or the lower gastrointestinal tract, secretion enters the abdominal cavity. Particles seep through the hole products used, microorganisms, large quantities gastric juice and some bile. The diameter of the breakthrough can reach 5 mm, but does not exceed it.

The consequences of exposure to acidic juice - chemical burns important organs peritoneum. The ingress of even a small amount of juice onto the surface of any other organ is accompanied by strong pain sensations, which easily put the patient into a state of pain shock.

Contamination of the body with stomach secretions can cause serious spread infectious microorganisms. Delaying first aid can lead to serious complications and even death of the patient.

Symptoms

If there are prerequisites for a breakthrough of the stomach wall, minor signals may indicate an upcoming perforated ulcer. The symptoms of perforation of the secret into the peritoneum are conditionally divided into 3 groups, characteristic of certain periods of the course of this complication.

1. Stage of pain shock. The different diameter and location of the hole determines the approximate time of this stage - 3-6 hours. The initial sign is a sharp dagger pain in the upper abdomen. Patients talk about the intolerance of this symptom, which is caused by the ingress of hydrochloric acid on other organs. Gradually, the pain goes down, appears strong tension muscle fibers in this area.

Symptoms of the initial form of a trial ulcer are as follows:

There is an almost immediate slowdown in heart rate.

Breathing changes to shallow with intermittent intervals, later becomes more frequent.

There is a constant tension of the facial muscles, sunken eye syndrome.

Pale shade of the skin of the face, cold sweat appears, limbs begin to get cold.

BP is slightly lower.

2. Second stage ulcer exacerbation called imaginary well-being . It is expressed in the weakening of the acute initial symptoms and the temporary subsidence of discomfort. May last up to 12 hours. Many patients talk about a complete recovery and retreat of the disease, but with a decrease in vigilance, the current state can change dramatically.

For stage 2 perforated gastric ulcer, the characteristic symptoms are:

Partial or complete weakening of early pain sensations;

There is a restoration of breathing using the abdomen, the tension of the muscles of the upper press and the peritoneum disappears;

There is a state of complete euphoria, patients behave quite naturally, sometimes relaxed.

3. Third stage. There is a sharp pathological deterioration of the current condition, which can last up to fatality. Signs of this stage of a perforated ulcer are:

The appearance of gag reflexes, systematic nausea;

The state is stated severe dehydration, mucous membranes and skin are dried;

Diuresis develops - a strong restriction of urine production, may be accompanied by a complete restriction of this process - anuria;

A sharp jump in temperature up to 40 degrees, followed by an inexplicable drop below normal;

Decreased blood pressure, a sharp increase in heart rate, sometimes up to 130 beats;

There is lethargy, lethargy, a strong state of anxiety.

Classification

There are several classifications of perforated ulcers, the treatment of which is based on certain distinctive features. If we consider the forms of the disease with respect to origin, there are:

Perforation of the chronic form of peptic ulcer;

Perforation of an ulcer of an acute type (there are symptomatic, hormonal or stressful forms);

The appearance of a hole can occur as a result of a violation of the integrity of the tumor formation of the wall;

The cause of perforation can be a state of thrombosis caused by an advanced form of atherosclerosis.

There is a classification of this disease according to location. There are gastric ulcers: relative to curvature (large or small), relative to the sections of the stomach, anterior wall or posterior. The second variety is duodenal ulcers: bulbar forms and postbulbar variety are distinguished.

There is a classification according to the clinical manifestations of the pathological condition:

1. The outpouring of the secret of the stomach directly into the abdominal cavity. It is subdivided into typical and covered forms.
2. Atypical distribution of acid juice; into the inter-adhesive cavity (the area limited from other organs), into the stuffing box, into the large or small omentum.
3. The intake of juice accompanied by bleeding: can occur in any part of the gastrointestinal tract, directly in the abdominal region.

According to the stages of development, the classification is given in the section of symptoms.

ICD code 10

Regarding the main classification of microbial 10, peptic ulcer disease has several codings, the base of which is "K 25". Varieties of forms are classified by adding an additional number to this value, indicating a certain complication or type of perforation:

K25.0 - an acute variety of the disease with concomitant bleeding;

K25.1 - acute type ulcers with perforation;

K25.2 - a combination of the first 2 forms: perforation acute form, supplemented by bleeding;

K25.3 - the usual course of the disease without complications;

K25.4 - unspecified form with additional bleeding;

K25.5 - similar type, but with perforation;

K25.6 - unidentified form with all sorts of complications;

K25.7 - chronic course ulcers without bleeding and perforation;

K25.8 - unidentified type with no bleeding and perforation.

Diagnostics

When analyzing likely development perforated gastric ulcer, timely and correct diagnosis of this disease is the main criterion for the success of the subsequent operation. To clarify suspicions, experts conduct the following studies:

Inspection by palpation.

X-ray diagnosis.

An endoscopic procedure is scheduled.

A more modern non-invasive diagnostic method is an ultrasound procedure.

With residual suspicion, laparoscopy may be indicated.

The level of inflammatory reactions can be monitored by laboratory research blood composition.

Ambulance emergency

A severe form of a perforated gastric ulcer must be accompanied by an ambulance. medical care qualified specialists already in the first hours of exacerbation. Even a moment's delay can be fatal, because the overflowing gastric juice of high acidity corrodes the main organs of the abdominal cavity, causing more and more irreparable damage to them every minute.

At the slightest suspicion of a complicated ulcer, you should get rid of the idea of ​​self-treatment. 99% of all patients survive solely due to the timely surgical intervention of physicians, in home environment implement a complex necessary activities impossible.

The sequence of first aid is as follows:

1. It is necessary to provide the patient horizontal position with slightly raised head. The knees should be slightly bent.
2. Specialists, using a medical probe, perform the procedure of suctioning gastric juice through the oral cavity.
3. Cardiac medications are administered to relieve shock.
4. The stomach is filled saline solution with the addition of glucose, which allows you to create optimal conditions for the subsequent surgical intervention.

The timeliness of emergency care for a perforated stomach ulcer is the key to saving the patient's life!

Treatment

After a correct diagnosis, the specialists proceed to the treatment stage. Eliminations negative consequences from the penetration of the secret of the stomach into the peritoneal cavity is carried out through two types of operations: suturing the through hole while maintaining the stomach, as well as excision of the ulcer by resection (removal of a certain part of the organ).

Suturing is performed in the initial forms of perforation in young patients, in the elderly with severe forms. The patient is given general anesthesia, the operating time of the surgeons reaches 12 hours.

The second type of operations is used in the case of chronic forms, in the presence of a peptic ulcer that does not respond to drug treatment. If old scar tissue from old sores is found, suturing cannot be used, therefore resection is resorted to.

After the end of the work of surgeons, it is mandatory to appoint rehabilitation therapy, which is replaced by a preventive set of measures.

Operation and prognosis

For the successful completion of any operation, it is important to diagnose the disease in time, identify all complications and prepare data for surgeons. When ulcerative perforation stomach, there is little information about the current state of the patient, doctors have to make well-considered important decisions in the process of work. But, even taking into account such informative complexity, the outcome of the operation is 92-98% positive. Re-development a perforated ulcer in this area due to poor-quality performance of work occurs only in 2% of cases.

There is a sad pattern: if the operation time exceeds the set 12 hours, then the probability lethal outcome increases up to 40%.

Treatment after surgery, drugs

seen next feature: at maximum activity in this period, the speed of recovery reaches very rapid results.

After recovering from anesthesia, the patient can move his legs in different directions, it is allowed to rise from the pastel for 2-3 days of rehabilitation. great attention should be given breathing exercises and small in power physical activity. Such restorative therapy becomes a powerful limiting factor for postoperative complications.

Due to the absence of complications, it is necessary to be on outpatient treatment for 2 weeks. Sometimes this time is slightly reduced. For patients, several drugs are prescribed, designed specifically for the postoperative recovery period:

1. Ranitidine and Vikalin tablets.
2. Innovative remedy Omeprazole and familiar to many Almagel.
3. Phosphalugen or Rebaprazole.

Each medicine is a powerful antibacterial drug that supports the body's defense against recurrence of the disease.

Particular attention in postoperative period given to dietary nutrition. A special diet minimizes the destructive effect of acid on the restored stomach wall.

Postoperative therapy is based on the following basic steps:

1. The systematic or actual implementation of the gastric drainage procedure improves the peristalsis of the organ, it can be performed for several days.
2. Holding antibiotic therapy based on the elimination of the bacterium Helicobacter.
3. The secretory function of the organ can be artificially suppressed by medications.
4. In severe cases, patients are given special formulations into the bloodstream - infusion therapy.
5. May be assigned earlier diet food for a speedy recovery.

If in the postoperative period it is possible to limit possible complications, That further treatment based on a strict diet.

Video of laparoscopic suturing of a perforated ulcer