Differential diagnosis of peptic ulcer. Differential diagnosis of gastric ulcer

Differential diagnosis, the variety of clinical manifestations of peptic ulcer disease, anatomical and topographic relationships of the digestive organs, the commonality of nervous regulation, and their functional connections create natural prerequisites for the emergence of similar clinical symptom complexes in diseases of various organs abdominal cavity and certain difficulties in differential diagnosis.

In practice, peptic ulcer disease often has to be differentiated from other diseases of the stomach and duodenum, biliary tract and pancreas.

Chronic gastritis

Chronic gastritis in contrast to peptic ulcer disease, it is characterized by a greater severity of dyspeptic symptoms. Often there is a feeling of heaviness in the upper abdomen and a feeling of rapid satiety after taking even large quantity food, heartburn, belching of sour contents, stool disorders. There is a monotonous course, short periods of exacerbation with a less pronounced pain syndrome than with peptic ulcer disease. There is a lack of seasonal frequency and an increase in pain during the course of the disease. The general condition of the patients is not particularly disturbed. However, it is impossible to exclude gastritis, guided only by the patient’s complaints. Repeated X-ray and endoscopic examinations are necessary, in which, in addition to the absence of a niche, the characteristic rigidity of the folds of the gastric mucosa and changes in its relief are revealed.

Chronic gastroenteritis

Chronic gastroenteritis, as well as peptic ulcer, may manifest as pain in the epigastric region after eating. But these pains are accompanied by intestinal rumbling, and severe pain on palpation is determined in umbilical region and below. A large amount of products of incomplete digestion of food (muscle fibers, neutral fat, starch) is detected in the feces. Among the radiological signs, changes in the gastric mucosa, rapid evacuation of contrast from the small intestine, and early filling (within 2-3 hours) of the cecum are important.

Duodenitis and pyloroduodenitis

Duodenitis and pyloroduodenitis often very reminiscent of a clinic peptic ulcer. Unlike the latter, they are characterized by:

1) the severity of constant hunger and night pain, relieved by eating, and late dyspeptic symptoms;

2) intermittent course with short periods of exacerbation, followed by short remissions. X-ray examination shows no signs of an ulcer; hypertrophied and atypically intertwined folds of the mucous membrane with a granular relief are determined. Repeated studies and gastroduodenoscopy make it possible to make the correct diagnosis.

Peptic ulcer disease often has to be differentiated from periduodenitis of non-ulcerative etiology. They are usually the result of an ulcer duodenum, manifested by pyloric syndrome with clinical peptic ulcer. After the ulcer heals with remaining periduodenitis, the intensity of the pain decreases, it becomes constant, and the seasonality of the phenomenon disappears. Non-ulcerative periduodenitis can be caused by cholecystitis, duodenal diverticulum, complicated inflammation or ulceration, and chronic appendicitis. Unlike peptic ulcers, such periduodenitis is manifested by constant pain in the epigastric region and right hypochondrium, intensifying after eating and radiating to the back. Belching, nausea, and a feeling of heaviness in the epigastrium are also observed. In their diagnosis, X-ray examination is of great help, which reveals deformation of the bulb, duodenum, its rapid emptying, and the absence of direct X-ray signs of peptic ulcer disease.

Stomach cancer

Stomach cancer, especially in initial stage, can manifest itself with a variety of clinical symptoms and resemble the clinic of a peptic ulcer. When the tumor is localized in the pyloric region, intense pain may be observed, and gastric secretion persists. Particularly difficult is the differential diagnosis of ulcerative-infiltrative and primary ulcerative forms of cancer, which may be accompanied by typical signs of peptic ulcer disease. In some cases, a gastric ulcer may resemble gastric cancer in its clinical course, for example, with a long-standing callous ulcer with constant pain, decreased gastric secretion and the formation of a large inflammatory infiltrate, determined by palpation of the abdomen. For stomach cancer, the most characteristic signs are: a short history, older age of patients, complaints of general weakness, fatigue, constant aching pain, little dependent on food intake. Many have anemia, increased ESR, and persistent hidden bleeding. Ulcerative-infiltrative forms are characterized by persistence of clinical symptoms and lack of effect from the treatment used. Fluoroscopy, in addition to the niche, reveals infiltration and rigidity of the stomach wall, breakage of mucosal folds, and lack of peristalsis in the affected area surrounding the niche. Of decisive importance in the differential diagnosis of cancer and gastric ulcers are the study of the dynamics of the disease, X-ray, cytological studies and gastroscopy with targeted biopsy.

Gallstone disease and chronic cholecystitis

Gallstone disease and chronic cholecystitis can often imitate a peptic ulcer, manifesting itself as pain in the upper abdomen and dyspeptic disorders. Distinctive features are that bile duct diseases are more common in women, in people with a hypertensive constitution and obesity. They do not have a periodicity of exacerbation and a daily rhythm of pain. The occurrence of pain after eating is mainly due to the nature of the food (fatty foods, meat, eggs, spicy dishes, marinades, mushrooms). Pain appears at different times after eating and is characterized by polymorphism - different intensity and duration. Often they are cramping in nature, like attacks (colic) and are more intense than with a peptic ulcer. Pain is localized in the right hypochondrium and radiates to right shoulder and a spatula. Jaundice may appear periodically.

At chronic cholecystitis The duration of exacerbation is shorter, usually determined by days, while with peptic ulcer disease - weeks, months, with a gradual decrease in their intensity.

Objective signs include liver enlargement, palpation and percussion pain in the right hypochondrium and the choledochal-pancreatic zone. Positive symptoms of Ortner, Murphy, and phrenicus symptom are revealed. With exacerbation of cholecystitis, fever, pathological changes in bile, a slight increase in bilirubin in the blood, and urobilin in the urine are observed. There is often a decrease in gastric secretion.

The issue of final diagnosis is resolved by X-ray and endoscopic examination of the stomach, duodenum and biliary tract, which help to identify chronic cholecystitis, which is also observed in some patients and is concomitant with peptic ulcer disease.

In such cases, the latter must be differentiated from biliary dyskinesia, which often accompanies duodenal ulcer. Unlike cholecystitis, with dyskinesia there are no changes in all portions of bile during duodenal intubation. Cholangiography reveals disturbances in the motility of the gallbladder, ducts and sphincter of Oddi. As the exacerbation of peptic ulcer subsides, the clinical manifestations of biliary dyskinesia disappear or decrease.

Chronic pancreatitis

Chronic pancreatitis its course may resemble a peptic ulcer. With it, as with peptic ulcer disease, pain is observed in the upper abdomen after eating at the height of digestion. However, they occur more often after fatty foods, are of an uncertain nature, in the case of the formation of stones in the pancreatic ducts they become cramping. The pain is usually localized to the left of the midline in the upper abdomen, often encircling, radiating to the left shoulder and scapula. When comparative or deep palpation tenderness is detected to the left of the midline. Some patients experience an increase in the amount of diastase in the urine, sometimes glucosuria. The diagnosis of chronic pancreatitis in the absence of radiological and endoscopic signs of peptic ulcer disease is confirmed by pancreatography, scanning of the pancreas, and angiography.

Chronic appendicitis

Chronic, appendicitis in some cases it may have some resemblance to peptic ulcer disease. This is due to the fact that with chronic appendicitis, pain in the epigastric region after eating is often observed, which is explained by the presence of a reflex spasm of the pylorus or periduodenitis, which developed as a result of the spread of infection along the lymphatic tract from the ileocecal region. In contrast to peptic ulcers, chronic appendicitis has a history of an attack. acute appendicitis, periodicity of exacerbation with short-term pain phenomena, their intensification when walking and physical stress. Upon palpation and percussion, an area of ​​severe pain is determined in a limited area of ​​the ileocecal region. In cases that are difficult to diagnose, X-ray examination of the gastroduodenal system and ileocecal angle helps.

Diverticula of the stomach and duodenum

Diverticula of the stomach and duodenum are often asymptomatic. When the diverticulum reaches a large size, pain and a feeling of heaviness in the epigastric region and vomiting appear. If it is complicated by inflammation or ulceration, the clinical picture can be very similar to that of a peptic ulcer. Pain is observed after eating, exacerbation periodicity. Diagnosis in these cases can be difficult and X-ray examination and gastroduodenoscopy are decisive here.

Peptic ulcer disease must be differentiated from symptomatic ulcers, the pathogenesis of which is associated with certain underlying diseases or specific etiological factors, for example, with the use of NSAIDs.

Symptomatic, especially drug-induced, ulcers most often develop acutely, sometimes manifesting as gastrointestinal bleeding or perforation. The clinical picture of exacerbation of these ulcers is erased; there is no seasonality or periodicity of the disease.

Gastroduodenal ulcers in Zollinger-Ellison syndrome are characterized by an extremely severe course, multiple localization, and persistent diarrhea. When examining such patients, a sharply increased level of gastric secretion (especially basal) is revealed; the gastrin content in the blood serum is 3-4 times higher than normal. In the diagnosis of Zollinger-Ellison syndrome, provocative tests (with secretin, glucagon) and ultrasound examination of the pancreas are important.

For gastroduodenal ulcers in patients with hyperparathyroidism, in addition to severe course with frequent relapses and a tendency to bleeding and perforation, characteristic signs increased function parathyroid glands: muscle weakness, bone pain, thirst, polyuria. The diagnosis is made based on studying the calcium and phosphorus content in the blood serum, the presence of hyperthyroid osteodystrophy, characteristic signs of kidney damage and neurological disorders.

Tuberculosis of the stomach

Tuberculosis of the stomach - one of the rare localizations of the tuberculosis process. Pathological changes can manifest themselves in the form of solitary or milliary tubercles, a diffuse hyperplastic form, and more often (up to 80%) in the form of flat superficial or small deep crater-shaped ulcers. Such ulcers are often localized in the pyloric and antral regions and often cause narrowing of the pylorus or deformation of the stomach. Clinically, the disease manifests itself as pain in the epigastric region, but less severe than with a stomach ulcer. Diarrhea and decreased gastric secretion are observed. Patients often develop tuberculous lesions of the lungs and other organs. The absence of characteristic clinical symptoms and the atypicality of the x-ray picture often cause great difficulties in diagnosing the disease, and only histological examination of biopsy specimens or surgical material allows a correct diagnosis to be made.

Lymphogranulomatosis of the stomach

Lymphogranulomatosis of the stomach refers to rare diseases. Gastric damage is more often observed with a systemic disease and rarely as an isolated form. Lymphogranulomatous formations in the wall of the stomach are characterized by the formation of tumor-like nodes protruding into the lumen of the stomach, or superficial or deep ulcerations. The clinical picture of an isolated lesion is very similar to that of cancer or callous ulcer. Ulcerative forms are manifested by epigastric pain, hidden or profuse bleeding. Common symptoms include fever, weakness, weight loss, sweating and itchy skin. Leukopenia with neutrophilia, eosinophilia and lymphopenia are detected in the blood. Due to the rarity of isolated lymphogranulomatosis of the stomach, the uniqueness of the clinic and morphological changes in the stomach wall, similar to a gastric ulcer, diagnosis is extremely difficult. The diagnosis is made by microscopic examination of biopsy specimens taken during fibrogastroscopy or from the resected stomach.

Duodenostasis

Duodenostasis - This is a violation of the motor-evacuation function of the duodenum. It can develop with diseases of the biliary tract and pancreas, periduodenitis, or be an independent disease of neurogenic origin. It manifests itself periodic attacks pain in the epigastric region, reminiscent of pain from a peptic ulcer. Its distinctive features are: the occurrence of isolated swelling in the right hypochondrium during an attack of pain, vomiting of gastric contents mixed with a significant amount of bile.

The diagnosis is established by X-ray examination, which reveals stagnation in the duodenum and its expansion, stenotic peristalsis and antiperistalsis, retrograde stagnation of barium in the stomach and delayed emptying.

Diaphragmatic hernia

At diaphragmatic hernias, as with peptic ulcers, patients complain of pain in the epigastric region during or after meals, night pain, a feeling of heaviness in the epigastrium and dyspeptic disorders. In some cases, obvious or hidden esophageal-gastric bleeding is observed. These complaints are associated with the development of ulcerative esophagitis and localized gastritis.

Unlike peptic ulcers, with diaphragmatic hernias, pain is localized high in the epigastrium, in the area of ​​the xiphoid process and behind the sternum. There is no strict periodicity; their intensity and duration vary. The pain often radiates upward and backward - to the back, to the left shoulder. A burning sensation behind the sternum or along the esophagus during or after eating is typical. A targeted X-ray examination of the chest and gastroduodenal system is of decisive importance in the differential diagnosis of these diseases.

Hernia of the white line of the abdomen

Hernia of the white line of the abdomen in some cases, it can cause sharp pain in the epigastric region and dyspeptic disorders, like a peptic ulcer. In other patients, an epigastric hernia may accompany a peptic ulcer and the underlying disease is not diagnosed. Differential diagnosis of these two diseases with a careful examination of the patient does not cause difficulties, however, the presence of an epigastric hernia obliges the doctor to conduct an X-ray examination of the stomach and duodenum in order to prevent diagnostic and tactical errors when deciding on surgery.

Intestinal dyskinesia

At intestinal dyskinesias clinical manifestations may be similar to those of peptic ulcer disease. Patients complain of pain in the epigastric region or other localization, dyspeptic disorders. Distinctive signs of dyskinesias complicated by colitis are: a history of prolonged constipation, periodic replacement of constipation with “false” diarrhea, a feeling of incomplete bowel movement. Often the pain does not depend on the nature of the food taken; relief is noted after stool and passing gas. An objective examination reveals pain along the colon, most often transverse, descending and sigmoid.

At x-ray examination there is a pronounced spasm of these parts of the colon or total colospasm. Intestinal dyskinesia and colitis may accompany peptic ulcer disease, but the absence of signs of peptic ulcer disease during fluoroscopy or fibrogastroduodenoscopy speaks in favor of dyskinesia.

>> peptic ulcer

Peptic ulcer of the stomach and duodenum is one of the most common diseases gastrointestinal tract. According to modern data, more than 10% of the total population of the planet suffers from this disease. Moreover, peptic ulcer disease is extremely dangerous disease, due to complications that may arise during the evolution of this disease. Most dangerous complications peptic ulcer disease are: internal bleeding, perforation of the ulcer, penetration of the ulcer into neighboring organs, malignancy of the ulcer (transformation of the ulcer into a malignant tumor, stomach cancer), stenosis (narrowing) of various parts of the stomach.

Ideas about the etiology and pathogenesis of gastric and duodenal ulcers have recently undergone significant changes. At the moment, Helicobacter pylori infection is considered the central link in the pathogenesis of ulcers. In this regard, the requirements for diagnostic methods and treatment of this disease.

Diagnosis of peptic ulcer begins with the collection of anamnestic data aimed at clarifying the patient’s complaints and data on the onset of the disease and its evolution from the moment of its onset.

A typical symptom of a peptic ulcer is pain in the upper abdomen (epigastric region). An ulcer of the body of the stomach or cardia is characterized by dull, aching pain projected in the epigastric region to the left of the midline. Pain usually occurs or worsens after eating (30-60 minutes). Pyloric gastric ulcers and duodenal ulcers are characterized by pain that occurs much later after eating (2-3 hours), as well as “hunger pain” that appears at night or closer to the morning. The pain usually spreads to left side epigastrium, can radiate to the chest or lower back. Characterized by a decrease in pain after taking antacids. “Hunger pains” go away after eating. Often the pain accompanying a peptic ulcer is atypical. For example, in approximately half of cases of peptic ulcer, pain can be projected in the lower part of the sternum (the area of ​​the xiphoid process) and imitate heart disease. With an ulcer of the pylorus and duodenum, pain can be located in the right hypochondrium, simulating cholecystitis. Determining the dependence of pain on the time of day and on food intake helps the doctor differentiate peptic ulcer disease from other diseases with a similar pain syndrome.

In addition to pain, peptic ulcer disease is characterized by the presence of digestive disorders. Vomiting with acidic contents often occurs, which appears at the peak of pain and brings some relief to the patient (sometimes, in the fight against pain, patients independently provoke vomiting). The presence of heartburn and belching, indicating a violation of the motor function of the stomach, is also characteristic.

In some cases (in young or elderly patients), peptic ulcer disease may be completely asymptomatic; the first manifestations of the disease in this case may be complications of the disease.

In the process of collecting an anamnesis, the doctor draws Special attention on the patient’s lifestyle, place of work, stress, diet, bad habits, chronic use of non-steroidal anti-inflammatory drugs (aspirin, indomethacin, ibuprofen, etc.). Identifying these points is important not only for a comprehensive diagnosis of peptic ulcer disease, but also for prescribing adequate treatment, the first stage of which will be the elimination of harmful factors contributing to the formation of ulcers.

An important point in collecting anamnesis is to clarify the evolution of the disease from the moment of its onset. Peptic ulcer disease is characterized by cyclical development with alternating periods of exacerbation and periods of remission. Exacerbations are usually seasonal and most often occur in spring and autumn. The remission period can last from several months to several years.

Attention is drawn to the presence of gastrointestinal diseases in the patient’s life history. In most cases, the development of peptic ulcer is preceded by gastritis or duodenitis. Finding out these details is critical to getting an accurate picture of a particular clinical case and for diagnosing peptic ulcer disease at the most early stages examinations. Anamnestic data helps the doctor draw up the correct scheme for further examination of the patient and make a differential diagnosis between peptic ulcer and other diseases with similar symptoms.

The second stage of diagnosis is examination of the patient. The doctor pays attention to the constitution and weight of the patient, which can be reduced due to frequent vomiting or the patient’s deliberate abstinence from eating (to avoid pain or heartburn). Palpation of the abdomen reveals pain in the epigastric region. Chronic ulcer may be detected as a painful lump.

The next stage of diagnosis is paraclinical examination methods.

Previously important role had a definition of acidity gastric juice and rhythms of gastric secretion. Currently, this research method has lost its former significance, as it has become clear that increased acidity is by no means a primary factor in the development of peptic ulcer disease. In some cases, however, acidity determination helps determine rare causes ulcers, for example Zollinger-Ellison syndrome (caused by the presence of a tumor that secretes gastrin, a hormone that stimulates acid secretion).

The simplest method for diagnosing gastric and duodenal ulcers and its complications is an X-ray examination using contrast. In the presence of ulcerative destruction of the organ wall, a specific picture of a “niche” filled with a contrast mass is revealed. The size and location of the niche allow us to judge the characteristics of the ulcer. X-ray examination can also determine some complications of peptic ulcer disease. For example, with perforation, air is detected in the peritoneal cavity; with stenosis, there is a slowdown in gastric emptying or its deformation, and with penetration, there is an accumulation of a contrast mass in the communication channel between the stomach and the organ into which the penetration took place.

Often, the first visit to a doctor by a patient suffering from a peptic ulcer is associated with the development of one of the complications of this disease. In such cases it is required urgent diagnostics acute condition and acceptance emergency measures to save the patient's life.

If perforation is suspected, emergency radiography without contrast is performed. If there are symptoms of internal bleeding, fibrogastroduodenoscopy is performed. The essence of the method is the introduction of a fiber-optic imaging system into the gastric cavity. Modern fibroscopy devices are equipped with additional parts that allow additional manipulations: thermocoagulation of bleeding vessels, collection of materials for biopsy, etc. Fibroscopy allows for an accurate diagnosis of an ulcer and determines its size and location. To differentiate gastric cancer, histological analysis of materials taken for biopsy is carried out. The detection of atypical cells indicates malignant degeneration of the ulcer.

If upon admission to the hospital the patient has an “acute abdomen” (consequence of ulcer perforation), diagnostic laparoscopy, which, if necessary, turns into laparotomy (opening the abdominal cavity) and surgery to eliminate the cause of the “acute abdomen”.

Currently, a comprehensive diagnosis of peptic ulcer disease requires the determination of Helicobacter pylori infection, the main factor in ulcer formation. To diagnose an infection Helicobacter pylori blood is taken and examined for the presence of anti-Helicobacter antibodies. If helicobacteriosis is detected, complex treatment is prescribed aimed at eradicating the infection (metronidazole, clarithromycin, omeprazole).

Differential diagnosis

In the process of diagnosing peptic ulcer disease, it becomes necessary to differentiate it from other diseases with a similar clinical picture.

In chronic cholecystitis, pain usually appears after eating fatty foods and is localized in the right hypochondrium and does not go away after taking antacids. At chronic pancreatitis, the pain is girdling in nature and is accompanied by digestive disorders: flatulence, diarrhea, constipation.

Gastritis and duodenitis may have a clinical picture similar to peptic ulcer. The main diagnostic criterion is the detection of an ulcerative defect on the wall of the stomach or duodenum. Symptomatic ulcers can accompany diseases such as Zollinger-Ellison syndrome, chronic use of anti-inflammatory drugs.

An important point is the differentiation of gastric ulcers from primary ulcerated gastric cancer. (duodenal ulcers rarely become malignant), which is carried out on the basis of clinical data and histological examination of the tissues forming the walls of the ulcer.

Correct diagnosis of peptic ulcer disease is the most important point for further prescription of adequate treatment and prognosis of the disease.

Bibliography:

1. Maev I.V. Diagnosis and treatment of gastric and duodenal ulcers, M, 2003
2. Mikhailov A.P. Acute ulcers and erosions digestive tract, St. Petersburg, 2004
3. Nikolaeva E.V. Gastric ulcer in St. Petersburg. : Nev.prospekt, 1999

Diagnosis of cancer It is especially difficult in case of malignant transformation of a stomach ulcer. In the figure we have already schematically represented those parts of the stomach that, according to empirical data, are especially prone to the development of cancer from ulcers. A typical x-ray picture of gastric lymphosarcoma is described as diffuse thickening of the entire stomach wall.
Majority lymphosarcoma diagnosed as stomach cancer.

Suspicious for malignant neoplasm radiological sign is also the so-called open angle of the stomach in a patient in a standing position. Normally, the angle formed by the stomach is acute; if this angle is open, i.e. there is a right angle, there is a strong suspicion of cancer, even if others have not yet been identified typical signs. This simple symptom will help in the early detection of many cases of stomach cancer.

Also gives some instructions localization. Of the 157 own observations of gastric cancer, it was distributed as follows: prepyloric region - in 70 patients, antral - in 17, lesser curvature - in 23, greater curvature - in 10, cardia - in 18, diffuse cancer - in 9 patients.
Thus, changes in the prepyloric region most suspicious.

Parietography(tomogram after pneumoperitoneum was applied and the stomach was inflated using effervescent powder) allows you to obtain an impeccable image of carcinomatous thickening of the gastric wall and primarily contributes to determining the extent of the process (Porcher, Stoessel).

Differentiation between ulcer and stomach cancer has so much important that it is advisable to summarize all the considerations that a doctor should take into account for each patient.

Anamnesis: frequency speaks in favor of an ulcer, but does not exclude the possibility of cancer (ulcer-cancer!). The primary occurrence of an ulcer in a patient over 50 years of age is suspicious for a malignant neoplasm.
Data physical research and general symptoms (anemia, weight loss, accelerated ROE) in early stages are not of decisive importance.

The most important, but not always decisive instructions gives an x-ray examination.
Localization: ulcers of the greater curvature are more likely to be suspicious of a malignant neoplasm, and on the lesser curvature there are more often benign ulcers. Multiple ulcers are usually benign.

Anacidity is highly suspicious for cancer.
Gastroscopy And cytological examination gastric contents are valuable only in the hands of an experienced researcher.

Benign ulcer after strict conservative treatment(rest, meals every 2 hours, alkalis and sedatives) radiographically reveals a tendency to reverse development, malignant neoplasm almost always remains without. changes.

When an ulcer is detected by X-ray of the duodenum, they try to obtain an image of the ulcerative niche, which is best achieved when examined in the first oblique position, since duodenal ulcers are observed almost exclusively on the anterior and posterior walls.

To identify a niche it is necessary to ensure sufficient filling of the bulb with the contrast mass. Sometimes you have to be content with identifying the residual stain. X-rays of duodenal ulcers reveal cicatricial changes better than in the stomach. They are expressed in bulb deformations, which, depending on the degree, appear better either with tighter or weaker filling. Deformations of the bulb, depending on their appearance when transilluminated in the first oblique position, are designated as trefoil or butterfly shapes.

Depending on the location of the ulcer and the degree of cicatricial wrinkling, various characteristic x-ray patterns of duodenal ulcers (Hafter) are observed. If cicatricial changes occur at the height of ulceration, before the narrowing in the recessive area, the formation of a so-called pocket occurs. Ulcers located below the bulb are rare; they clinical symptoms corresponds to the classical duodenal ulcer However, these ulcers are 2 times more likely to be complicated by bleeding (Ramsdell and co-workers).

Peptic ulcer of the stomach and duodenum.

Characteristic symptoms (BU 12pk) include hunger pain, night pain, sour belching, and if complicated by bleeding, tarry stools. In 8-10% of cases, an asymptomatic course of ulcer is possible, when perforation occurs against the background of complete well-being, without previous symptoms. One of the main symptoms of perforation of an ulcer is the absence of hepatic dullness upon percussion, indicating the presence of free gas in the abdominal cavity under the dome of the diaphragm on the right, detected during an X-ray examination of the patient on the left side or standing.

Acute cholecystitis.

Characterized by recurrent attacks acute pain in the right hypochondrium, which are accompanied by fever, repeated vomiting, and sometimes jaundice. With the development of peritonitis, differential diagnosis is difficult, but video endoscopic technology helps to recognize the cause of the disease. Objectively, it is possible to detect muscle tension only in the right iliac region, where an enlarged, tense and painful gallbladder is sometimes detected. Positive Ortner's symptom, phrenicus symptom, high leukocytosis, and tachycardia are noted.

Acute pancreatitis.

The onset of the disease is preceded by errors in diet (eating fatty, spicy, rich foods, alcohol). Characterized by sudden onset of girdle pain, accompanied by uncontrollable vomiting of gastric contents with bile. The patient screams in pain, cannot find comfortable position in bed. Objectively: the abdomen is distended, the muscles of the anterior abdominal wall are tense, peristalsis is weakened. Positive Voskresensky and Mayo-Robson symptoms are revealed. In the blood there is leukocytosis with a shift of the formula to the left, a high level of amylase, and sometimes bilirubin. Videoendolaparoscopy reveals plaques fat necrosis on the peritoneum and in the greater omentum, hemorrhagic effusion, pancreas with black hemorrhages.

Acute appendicitis.

The onset of appendicitis is characterized by pain in the epigastrium (or umbilical region - Kocher's symptom), localized in the right iliac region. The pain intensifies when walking. Symptoms of peritoneal irritation become positive and body temperature rises. In advanced cases, local and then diffuse purulent peritonitis develops, the cause of which may be perforation of the destructively altered appendix. To confirm the diagnosis, there may sometimes be a need for video endolaparoscopy or midline laparatomy.

Acute intestinal obstruction.

Abdominal pain is paroxysmal, cramping in nature. Noted cold sweat, pallor of the skin (during strangulation). The pain may subside: for example, there was a volvulus, and then the intestine straightened, which led to the disappearance of pain, but the disappearance of pain is a very insidious sign, since with strangulation CI necrosis of the intestine occurs, which leads to death nerve endings, therefore, the disappearance of pain.

Repeated vomiting appears, first with the contents of the stomach, then with the contents of 12 p.c. (vomiting bile comes from 12 p.c.). Subsequently, vomiting appears with an unpleasant (fecal) odor. The tongue is dry. Bloating and asymmetry of the abdomen, retention of stool and gas.

Bowel sounds may be heard, even from a distance, visible increased peristalsis. You can palpate a swollen loop of intestine (Val's symptom). It is imperative to examine patients per rectum: the rectal ampulla is empty (Grekov’s symptom or “Obukhov hospital symptom”).

A survey non-contrast fluoroscopy of the abdominal organs reveals Kloiber's cups.

Thrombosis of mesenteric vessels.

Characterized by sudden attack abdominal pain without specific localization. The patient is restless, tossing about in bed. Intoxication and arterial hypotension, possible appearance loose stool mixed with blood, but more often there is no stool. The abdomen is distended without tension in the muscles of the anterior abdominal wall, and there is no peristalsis. Tachycardia, often atrial fibrillation. For diagnostic purposes, video endolaparoscopy is performed, during which hemorrhagic effusion and necrotic changes intestinal loops.

Dissecting abdominal aortic aneurysm.

It is more common in old age due to atherosclerotic changes in this part of the aorta. The onset of the disease is acute, with severe pain in the epigastrium. The abdomen is not bloated, but there is some tension in the muscles of the anterior abdominal wall. When palpating the abdomen, a painful, tumor-like, pulsating formation can be determined, over which a rough sound can be heard. systolic murmur. There is also tachycardia with a decrease blood pressure. The pulsation of the iliac arteries is weakened or absent, lower limbs cold. When involved in the process of bifurcation of the aorta and mouth renal arteries signs are revealed acute ischemia kidneys, anuria with increasing signs of heart failure.

Acute myocardial infarction myocardium.

The abdominal (gastralgic) variant of the onset of myocardial infarction (MI) is observed more often with posterior diaphragmatic (lower) MI, manifested by intense pain in the epigastrium or in the area of ​​the right hypochondrium, right half belly. At the same time, there is vomiting, bloating, diarrhea, and intestinal paresis. When palpating the abdomen, tension and pain in the anterior abdominal wall are noted. It is necessary to differentiate this option from pancreatitis, perforated ulcer stomach, cholecystitis, appendicitis, intestinal obstruction, food poisoning. The diagnosis of this variant of MI is made on the basis of a dynamic ECG, resorption-necrotic syndrome, the appearance of markers of myocardial necrosis, taking into account biochemical changes characteristic of the mentioned acute diseases of the abdominal organs, identifying physical changes of cardio-vascular system(arrhythmias, drop in blood pressure, muffled heart sounds).

With a poorly defined clinical picture disease, the following tactics should be followed:

· constant (hourly) monitoring of the patient, taking into account the dynamics abdominal syndrome and cardiac manifestations of the disease;

· repeated repeated ECG recordings, including leads along the Sky;

· dynamic target control biochemical parameters;

· supervision of such patients together with the surgeon;

Subsequently, after the patient leaves the serious condition, thorough examination gastrointestinal tract.

Lower lobe pneumonia and/or pleurisy.

Characterized by an acute onset with signs of inflammation lung tissue(cough, stabbing pains in the affected half of the chest, signs of intoxication, connection of pain with the act of breathing). Helps in diagnosis x-ray examination chest organs, in doubtful cases - endovideolaparoscopy.

Treatment.

The issue of using medications for abdominal pain is quite complex. Some consider it a mistaken decision not to relieve acute abdominal pain with prehospital stage due to the risk of softening the picture of acute surgical pathology, which can make diagnosis difficult. Proponents of pain management believe that adequate early pain relief can prevent the development of painful shock.

To summarize, we can say that for abdominal pain caused by acute diseases abdominal organs, at the prehospital stage the administration of analgesics is still contraindicated. The difficulty of differentiating surgical pathology from non-surgical pathology at this stage is very relevant, therefore, for any manifestations of abdominal pain, one should, if possible, refrain from administering analgesics until the clinical situation is clarified.

For biliary colic, cholestasis, renal or ureteral colic, irritable bowel syndrome, the use of antispasmodics is possible. Infusion therapy at the prehospital stage serves only to safely transport the patient to the hospital. For this purpose, rheopolyglucin, disol, trisol, 5% glucose solution, and physiological sodium chloride solution are used.

Prevention.

For safety and prevention purposes severe complications patients with abdominal pain if an “acute abdomen” is suspected, they are subject to emergency hospitalization to the surgical hospital.

Tense ascites

Ascites(from the Greek “askos” - bag, bag) is a condition in which there is a pathological accumulation of fluid in the abdominal cavity.

Etiology ascites in 90% of cases is associated with chronic liver diseases: portal hypertension (developed as a result of liver cirrhosis), alcoholic hepatitis, obstruction of the hepatic veins (Budd-Chiari syndrome).

Other causes of ascites include heart disease (heart failure, constrictive pericarditis), malignant neoplasms (carcinomatosis, pseudomyxoma peritonei), diseases of the peritoneum ( infectious peritonitis), severe hypoalbuminemia (nephrotic syndrome), other diseases (ovarian tumors and cysts, pancreatitis, sarcoidosis, systemic lupus erythematosus, myxedema).

In the pathogenesis of ascites in liver cirrhosis, there is an increase in the activity of renin, aldosterone, angiotensin, vasopressin in the blood, as well as the activity of the sympathetic nervous system.

To explain the development of ascites in decompensated liver damage occurring with the syndrome portal hypertension, 3 main theories have been proposed.

The theory of "overfilling" vascular bed» puts forward the position that the development of ascites is based on an increase in Na + reabsorption in the renal tubules, apparently under the influence of a certain “stimulus” from the affected liver. Increased sodium reabsorption is accompanied by an increase in plasma volume.

The basic position of another theory ( theory of “insufficient filling of the vascular bed”) is that at the beginning of the formation of ascites against the background of portal hypertension and hypoalbuminemia, there is a decrease in the volume of intravascular fluid, which leads to activation of Na + -retaining mechanisms.

The theory of "peripheral vasodilation"‒ modified theory of “insufficient filling of the vascular bed” and, according to modern ideas, is the most justified. Proponents of this theory suggest that the root cause of the formation of ascites is the development of arteriolar dilatation, accompanied by an increase in vascular capacity, a decrease in the effective plasma volume and a compensatory increase in Na + reabsorption in the kidneys.

Development of ascites in malignant tumors and infections involving the peritoneum. In cancer, there are several possible mechanisms for the development of ascites:

due to hematogenous or contact metastasis with the development of peritoneal carcinomatosis and secondary inflammatory exudation; as a result of compression or germination of the lymphatic outflow tract by a tumor; in case of defeat large vessels(for example, with the development of Budd-Chiari syndrome); due to massive metastatic liver damage.

Infectious peritonitis(most often tuberculous) accompanied by exudation rich in protein fluid into the abdominal cavity and diffusion of water from the bloodstream along the oncotic pressure gradient.

Classification.

Ascites is classified according to the amount of fluid, the presence of infection of the ascitic fluid, and the response to drug therapy.

By the amount of fluid in the abdominal cavity:

· small;

· moderate;

· significant (tense, massive ascites).

By content contamination:

· sterile contents;

· infected contents;

Spontaneous bacterial peritonitis.

According to the response to drug therapy:

· amenable to drug therapy;

· refractory (torpid to treatment) ascites.

The criteria for resistant (refractory) ascites are the absence of a decrease in the patient’s body weight or a decrease of less than 200 g/day for 7 days against the background of a low-salt diet (5 g of table salt per day) and intensive diuretic therapy (spironolactone 400 mg/day and furosemide 160 mg/day). mg/day), as well as a decrease in urinary sodium excretion to less than 78 mmol/day. Resistant ascites is also spoken of in cases where it does not decrease or quickly recurs after laparocentesis, or complications of diuretic therapy do not allow diuretics to be prescribed in effective doses. In practice, criteria for resistant ascites are detected in less than 10% of patients with liver cirrhosis.

Clinic.

Ascites may occur suddenly or develop gradually over several months. A small volume of ascitic fluid may not cause symptoms.

Ascites may be accompanied by a feeling of heaviness and pain in the abdomen, and flatulence. As the volume of fluid in the abdominal cavity increases, the patient experiences the following symptoms: difficulty bending over, shortness of breath when walking, swelling of the legs, bloating, weight gain, eversion of the navel or umbilical hernias; in men - swelling of the scrotum; in women there may be swelling of the outer labia.

Physical examination in patients with ascites greater than 500 ml may reveal dullness to percussion and fluctuation (a symptom indicating the presence of free fluid in the abdominal cavity).

Percussion of the abdomen reveals dullness over the lateral areas of the abdomen, and a tympanic sound in the center. Moving the patient to the left side causes the dull sound to shift downward, above the left half of the abdomen, and a tympanic sound appears on the right.

In the presence of encysted fluid caused by adhesive peritonitis of tuberculous etiology or an ovarian cyst, the area of ​​detection of percussion tympanic sound does not shift when the patient’s position changes.

To detect a small amount of fluid, percussion is used with the patient standing: with ascites, a dull or dull sound appears in the lower abdomen, disappearing when the patient goes into horizontal position. For the same purpose, a palpation technique such as fluid fluctuation is used: doctor right hand delivers jerky shocks across the surface of the abdomen, and the palm of his left hand feels a wave transmitted to the opposite wall of the abdomen. With massive, especially intense ascites, palpation of the abdominal wall is painful, and protrusion of the navel is noted.

Patients experience peripheral edema, the severity of which may not correspond to the severity of ascites. They arise due to compression of the inferior vena cava by ascitic fluid, as well as as a result of hypoalbuminemia. In addition, symptoms such as varicose veins of the legs, hemorrhoidal veins are observed; upward displacement of the diaphragm (shortness of breath occurs), displacement of the heart and increased pressure in jugular vein; diaphragmatic hernia and esophageal reflux, which contribute to erosion of the esophagus and bleeding from varicose veins. On the stretched front abdominal wall venous collaterals (“head of Medusa”) can be seen.

Pleural effusion, usually right side, is present in approximately 10% of patients with ascites caused by cirrhosis. One of the main mechanisms for the formation of pleural effusion is the movement of peritoneal fluid upward through the diaphragmatic lymphatic vessels. Acquired diaphragmatic defects and increased portal pressure may play a certain role in this process. Elimination or reduction of ascites leads to the disappearance of pleural effusion.

When examining patients with ascites, signs of chronic liver disease can be identified: jaundice, palmar erythema, spider veins. Palpation of the liver may be difficult due to the accumulation of ascitic fluid in the abdominal cavity.

The presence of a “Sister Mary Joseph's node” (a firm lymph node in the umbilical area) may be evidence of peritoneal carcinomatosis due to tumors of the stomach, pancreas, or primary liver tumors.

Detection of Virchow's node ( supraclavicular lymph node on the left) is in favor of malignant neoplasms in area upper sections Gastrointestinal tract.

In patients with cardiovascular disease or nephrotic syndrome, anasarca may be detected.

A characteristic complication ascites may be spontaneous bacterial peritonitis.

A doctor who suspects bleeding should answer the following questions.

• Whether there is a gastrointestinal bleeding?
• What was its source?
• Is the bleeding continuing?
• What is the rate of bleeding?
• What is the severity of blood loss?

Symptoms

The clinical manifestations of acute, especially massive gastroduodenal bleeding are quite clear and consist of general symptoms characteristic of blood loss (severe weakness, dizziness, loss of consciousness) and manifestations characteristic of bleeding into the lumen of the gastrointestinal tract (hematomesis, melena or hematochezia). In a significant proportion of patients, bleeding occurs against the background of an exacerbation of peptic ulcer disease or in the anamnesis it is possible to note typical signs of this disease with a characteristic “ulcerative” pain syndrome and seasonality of exacerbations. In some patients, one can find indications of the ineffectiveness of previously performed surgical treatment when reappeared pain syndrome should be associated primarily with education peptic ulcer. Bloody vomiting and tarry stools are approximately equally common signs of bleeding of ulcerative etiology, although when the ulcer is localized in the duodenum, isolated melena is more often detected.

Physical examination findings

Physical examination data allow us to judge the severity of bleeding and presumably its source. Confused consciousness, severe pallor of the skin, rapid pulse of weak filling and tension, decreased blood pressure and pulse pressure, the presence of a large amount of blood and clots in the stomach, and when rectal examination- black liquid contents or mixed with blood - signs of acute massive bleeding. In fact, in such cases we are talking about hemorrhagic shock(deficiency of globular blood volume, usually more than 30%). With mild and middle degrees severity of gastrointestinal bleeding (decrease in the volume of circulating red blood cells by less than 30%), clinical manifestations are less pronounced. The general condition of patients, as a rule, remains satisfactory or moderate, hemodynamic parameters are within normal limits or change moderately, there is no large volume of blood in the stomach. Vomiting and melena are rarely repeated.

Instrumental methods

Today, the leading method for diagnosing the source of the type, nature of bleeding and prognosis of its recurrence, of course, remains emergency fibroesophagogastroduodenoscopy (FEGDS). It plays an extremely important role in determining treatment tactics.

The main indications for performing emergency endoscopic examination upper digestive tract - the patient has signs of acute gastrointestinal bleeding or suspicion of it and the need for hemostasis through an endoscope. The effectiveness of the study is higher the earlier it is carried out - ideally within the first hour (maximum 2 hours) from the moment of admission to the hospital. FEGDS makes it possible to detect combined complications of the disease - pyloroduodenal stenosis and ulcer penetration.

The indication for repeated (dynamic) FEGDS is the need for active monitoring of the source of bleeding due to the remaining risk of its recurrence (active control FEGDS), recurrent bleeding that developed in the hospital in a patient of extreme operational and anesthetic risk with ulcerative bleeding.

Preparation for examination of the upper digestive tract involves as much complete emptying their lumen, washing away blood and clots from the mucous membrane of the esophagus, stomach and duodenum. It is believed that in most cases this problem can be solved by washing the stomach with “ice” water through a thick gastric tube. The large internal diameter of the probe allows for the evacuation of large clots, and local hypothermia allows for a reduction in the intensity of bleeding or its complete stop.

Anesthetic support for emergency situations endoscopic interventions varies widely. A significant part of the studies can be performed under local anesthesia of the throat using premedication. If the patient's restless behavior makes it difficult to adequately examine or perform hemostasis, intravenous sedatives are used, as well as intravenous or (if the patient's condition is unstable) endotracheal anesthesia.

X-ray examination upper digestive tract as a method of emergency diagnosis of gastrointestinal bleeding has faded into the background. It is mainly used after bleeding has stopped as a method of obtaining additional information about the anatomical state and motor-evacuation function of the gastrointestinal tract. However, in the absence of conditions for performing an endoscopic examination and the doctor’s great practical skill, the x-ray method allows detecting an ulcer in 80-85% of cases.

Angiographic method diagnosis of bleeding still has enough limited use. It is used in specialized institutions that have the necessary equipment. The well-developed Seldinger vascular catheterization technique has made possible to carry out selective or even superselective visualization of the celiac trunk, superior mesenteric artery and their branches, as well as venous trunks. The limitations of the method in relation to emergency surgery conditions are explained not only by its technical complexity, but also by its relatively low information content: good contrast of extravasates from the source of bleeding is possible only with arterial bleeding quite high intensity.

Indications for selective angiography may occur in cases of repeated recurrent bleeding, when the source of hemorrhage is not established either endoscopically or X-ray method research. Of course, diagnostic angiography is performed as the first stage of therapeutic endovascular intervention aimed at selective infusion vasoconstrictor drugs, embolization of a bleeding artery or vein, or the application of a transjugular intrahepatic portosystemic anastomosis for portal hypertension and massive bleeding from esophageal varices.

The accumulated experience in the use of angiographic diagnosis of esophagogastroduodenal bleeding indicates that it can be a good help in identifying such rare diseases leading to bleeding as ruptured vascular aneurysms, vascular-intestinal fistulas, hemobilia, and portal hypertension syndrome.

Laboratory methods

An emergency blood test provides valuable diagnostic information. A drop in hemoglobin concentration, a decrease in the number of red blood cells, a decrease in hematocrit, and leukocytosis undoubtedly provide guidance regarding the severity of blood loss. Meanwhile, in the first hours from the onset of acute bleeding, all these indicators may change insignificantly and, therefore, are of relative importance. The true severity of anemia becomes clear only after a day has passed and more, when compensatory hemodilution has already developed due to extravascular fluid, necessary for the body to restore intravascular blood volume.

The study of blood volume and its components makes it possible to more accurately determine the volume of blood loss. Among the existing methods greatest distribution We obtained a colorful method with T-1824 paint (Evans blue) and an isotope method using labeled erythrocytes. Acceptable for emergency surgery conditions simple methods using nomograms, for example, determination of globular volume based on hematocrit and hemoglobin concentration. Highest value at acute bleeding has a decrease in globular volume, since the restoration of its deficiency occurs slowly, while the decrease in other indicators (volume of circulating plasma and bcc) is leveled out relatively quickly.

Differential diagnosis

In many patients, bleeding occurs against the background of an exacerbation of peptic ulcer disease or in the anamnesis it is possible to note typical signs of this disease with a characteristic “ulcerative” pain syndrome and seasonality of exacerbations. In some cases, one can find indications of the ineffectiveness of previously performed surgical treatment, when the newly appeared pain syndrome should be associated, first of all, with the formation of a peptic ulcer.

Bleeding from ruptures in the mucous membrane of the esophagogastric junction (Mallory-Weiss syndrome) should be suspected if, in young patients who abuse alcohol, repeated bouts of vomiting result in the appearance of scarlet blood in the vomit. In elderly patients, it is necessary to identify or exclude factors predisposing to ruptures of the esophagogastric junction (severe diseases of the cardiovascular system and lungs, hiatal hernia).

Presence of vague “stomach” complaints, weight loss and general condition the patient (the so-called minor symptom syndrome) is made to suspect stomach tumor as a cause of bleeding. Vomit in these cases often has the character of “coffee grounds.”

For bleeding from esophageal varices characterized by repeated vomiting dark blood. Tarry stools usually appear within 1-2 days. Among the diseases suffered, it is important to note diseases of the liver and biliary tract (primarily cirrhosis of the liver), as well as severe repeated attacks acute pancreatitis. It is known from clinical practice that these patients often suffer from alcoholism.

Anamnesis data must be carefully clarified so as not to miss very important factors that can cause acute gastrointestinal bleeding. It is necessary to determine the presence of severe therapeutic diseases with severe hemodynamic disorders (myocardial infarction, cerebrovascular accident, etc.), systemic diseases(blood diseases, uremia, etc.), possible treatment with medications that have an ulcerogenic effect.

Differential diagnosis in some cases is carried out with bleeding from the upper respiratory tract, nasopharynx and lungs when blood swallowed by a patient can simulate bleeding from the digestive tract. A carefully collected anamnesis and examination of the patient allows one to suspect pulmonary hemorrhage: characterized by the bright red color of foamy blood, usually released when coughing or spitting separately. It should also be remembered that black coloration of stool is possible after taking certain medications (iron preparations, vicalin, carbolene, etc.).

Savelyev V.S.

Surgical diseases