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MINISTRY OF HELTHCARE OF THE REPUBLIC OF UZBEKISTAN
TASKENT MEDICAL ACADEMY
APPROVED
Vice-rector for studying process
Senior Prof.
Teshaev O.R.
«_________» __________2011y
Uniform tutorial
Theme: ACUTE ABDOMEN
(Lesson 18)
Prepared by: assistent Murodov AS
Tashkent - 2011
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APPROVED
On conference in department of surgical diseases for general practitioners
Head of department___________________senior prof Teshaev O.R.
Text of lecture accepted by CMC for GP of Tashkent Medical Academy
Report №___________from____________2011 y
Moderator
senior professor Rustamova M.T.
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Exercise: number 18
Syndrome: acute abdomen
Topic 6.3.: Perforated gastric ulcer and duodenal ulcer. The clinical picture, diagnosis and
differential diagnosis. The tactics of the SPM. Rehabilitation.
1. Venue activities and equipment: Hospital, Training Room, House of the hospital, dressing
room, operating. Case patients, hospital records and outpatient hospital patients, blood and urine
tests, the results of instrumental examinations, radiographs, guidelines, training manual on
practical exercises, case studies, test questions, algorithms, performance skills, scripts,
interactive teaching methods, standard protocols, handouts materials from the Internet, slides,
EMC.
2. Length classes 327 minutes.
3. Session Purpose
3.1.Uchebnye objectives:
, Form an overall concept and idea of perforation of gastric ulcer and duodenum.
-To know clinic and a plan for perforated ulcers surveys stomach and duodenum.
-Teach students to diagnose perforated gastric ulcer and duodenal
-To develop the students' clinical myschlenie.
-Be able to provide emergency medical care at the time of doctors and GPs admitted to hospital
in patients with perforated stomach ulcer and duodenum.
- Treatment of patients with perforated ulcer.
3.2. The student should know:
-Anatomy and physiology of the stomach and duodenum.
Etiopathogenesis and clinic-perforated gastric ulcer and duodenal ulcer.
Diagnostic methods, perforated gastric ulcer and duodenal ulcer.
- Types of surgical treatment for perforation of gastric ulcer and duodenum.
3.3.Student should be able to:
- Conduct a clinical examination of patients with perforated gastric ulcer and duodenal ulcer.
-Be able to palpate the abdomen
- Identify the range and volume of surgical treatment of perforated gastric and duodenal ulcers
depending on the length of hospital stay of patients in the hospital.
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-Formulate and justify the clinical diagnosis.
-Maintain regular check-up cards of patients.
4. Motivation
Perforated ulcer - a formation of a defect in the wall of the stomach or duodenum 12, to exposure
of gastric contents into the free peritoneal cavity, resulting in her infection. In the absence of a
history of ulcer ulcer called a "dumb". Perforated gastroduodenal ulcers often in men with a short
history of peptic ulcer (3 years) is usually in the fall or spring, which appar ¬ ently connected
with the seasonal exacerbation of peptic ulcer. During the wars and economic crises increased
the frequency of perforation in 2 times, connected with the deterioration shown ¬ power and
negative psycho-emotional background. In order to reduce mortality and improve outcomes of
surgical treatment to diagnose and hospitalize patients with perforated gastric ulcer and duodenal
ulcer.
5. Interdisciplinary communication and vnutripredmetnye:
biochemistry, pathological anatomy, patfiziologiya, therapy, anesthesiology and resuscitation,
clinical pharmacology, gynecology, urology, internal medicine.
The stomach is located in the upper abdomen. Much of it is in the left upper quadrant, a smaller in the epigastric oblasti.Pri average degree of stomach fullness greater curvature of the projected
midway between the umbilicus and xiphoid process (Fig. 1, 2).
1. Skeletopy and the projection of the stomach to the anterior abdominal wall.
2. The position of stomach in the abdomen.
1 - lig. hepatogastricum; 2 - lien; 3 - ventriculus; 4 - lig. gastrocolicum; 5 - duodenum; 6-lig.
hepatorenale; 7 - foramen epiploicum (Winslovi); 8 - lig. hepatoduodenale; 9 - vesica fellea; 10 hepar; 11 - lig. teres hepatis.
In the stomach distinguish the front and rear walls, into each other in the small and large
curvature. Place of junction of esophagus and the stomach is called input, ostium cardiacum, and
the initial part of the stomach, adjacent to the entrance - Cardio or cardiac part, pars cardiaca. To
the left of the entrance is a vault or the gastric fundus, fundus ventriculi, delimited from the
cardiac part of the cardiac sulcus, incisura cardiaca. In some cases the bottom of the stomach acts
up, so that between the esophagus and the bottom is clearly indicated by cardiac furrow. In other
cases, the esophagus and gradually expands, becomes part of the cardiac, cardiac groove with
poorly expressed the right of the entrance is part of the body and pyloric stomach, the latter
being subdivided into the entrance vestibule, antrum pyloricum, and the pyloric canal, canalis
pyloricus, rolling into the duodenum ( Fig. 3). Between the body and gastric pyloric part in most
cases there is a well-defined intermediate groove. Exit the stomach, pylorus, duodenum isolated
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from the circular groove, which corresponds to the ostium pyloricum. On the lesser curvature of
stomach, close to the pyloric region of a corner notch, incisura angularis; areas of small
curvature is formed angle stomach.
3. The anatomical nomenclature departments zheludka.1 - fundus ventriculi; 2 - pars cardiaca; 3
- curvatura ventriculi major; 4 - corpus ventriculi; 5 - pars pylorica; 6 - antrum pylori; 7 - ostium
pyloricum; 8 - curvatura ventriculi minor; 9 - ostium cardiacum.
In radiological practice, the division of the stomach to the department is somewhat different. The
lowest lying part of the stomach, situated against incisurae angularis, referred to as sinus
ventriculi. Several distally from sinus ventriculi is a physiological sphincter, sphincter antri,
which separates the body from the stomach antrum pylori. Vault, the body and sinus are the
digestive sac, saccus digestorius, a pylorus and antrum pyloricum evacuation channel form,
canalis egestorius. Fig. 4 shows the scheme of division into sections of stomach, used for
radiographic studies.
4. Rentgenoanatomicheskaya nomenclature of the stomach. 1 - polus cranialis; 2 - formix; 3 pars cardiaca; 4 - corpus; 5 - sinus; 6 - polus caudalis; 7 - antrum pylori; 8 - pylorus: 9 - bulbus
duodeni; 10 - angulus; 11 - cardia; 12 - oesophagus.
Position, the projection and skeletopy. Most often the stomach for a considerable distance (about
3 / 4 of the surface) is located in the left upper quadrant, and only part of the pyloric serves the
epigastrium.
In more rare cases, the entire stomach is located in the left upper quadrant. This situation is more
common in the stomach or crescent shape retortoobraznoy. Sometimes, when distended stomach
or abdominal organs omitting only the cardia and gastric fundus are located in the left
hypochondrium, while most stomach (body and pyloric part) lies in the epigastric region.
Log in stomach, ostium cardiacum, is located on the left of the spine at the level of X thoracic
vertebra, about 1-2 cm down from hiatus oesophagei, at a depth of 9-15 cm from the anterior
abdominal wall. The front of the chest wall, respectively, are projected ostium cardiacum
cartilage VI-VII rib 2-4 cm from the midline to the left. Cardia is at 3 cm below the entry-level
XI thoracic vertebra. It is the most constant in its position and firmly fixed to the upper
abdominal wall by ligaments, as well as abdominal esophagus, which has a short length (1.5-2
cm) and connected to the diaphragm. The bottom of the stomach carries left dome of the
diaphragm and is located at the X-XI thoracic vertebra.
Small curvature of the pylorus can be located at different levels in relation to the xiphoid
process. According to our data, it is most often located at the xiphoid process, at least - at a
distance of 5-7 cm below it. The distance between xiphoid process and the large curvature in the
range of 0 to 15 cm, on average - 7 cm
Place transition stomach into the duodenum is at the level I lumbar vertebra, which corresponds
to midway between the xiphoid process and umbilicus.
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When filling the stomach pylorus is displaced by 3-5 cm to the right of the midline of the body.
The relatively large portion of the stomach pyloric displaceability due to the fact that it is less
fixed to the surrounding organs, as part of the cardiac.
Ligamentous apparatus. Ligaments surround the stomach by continuous circle and play an
important role in its fixation. In the ligaments between the peritoneum enclosed adipose tissue,
blood and lymph vessels, lymph nodes and nerve branches. There are following gastric ligament
(Fig. 5).
5. Bundles of the stomach. A - anterior surface, B - posterior surface.
1 - gastro-pancreatic ligament, 2 - gatekeeper-pancreatic ligament, 3 - gastro-diaphragmatic
ligament, 4 - gastro-splenic ligament, 5 - gastrocolic ligament, 6 - hepatoduodenal ligament, 7 hepatogastric ligament.
Hepatogastric ligament, lig. hepatogastricum, a dublikaturu peritoneum stretched between the
gate of the liver and small curvature of stomach, it goes to the left of the abdominal esophagus,
the right continues in the hepatoduodenal ligament. Both of these ligaments are small gland,
omentum minus.
In conjunction hepatogastric distinguish the hard part, which lies closer to the cardiac portion of
the stomach, and the unstressed portion located to the right of the previous one. Bunch has a
trapezoid shape, its width at the base (near the small curvature) is 10-19 cm, at the gates of the
liver - 5.10 cm, the length of the gate of the liver to the stomach angle between 6-14 cm in the
peritoneum hepatogastric bond is adipose tissue, which layer in the direction of the liver is
reduced.
Sometimes the fatty tissue between the sheets hepatogastric ligament near the gate of the liver is
almost completely absent. In such cases, through the transparent sheets of it is visible tailed share
a liver and part of the body of the pancreas.
In the upper part of the ligaments pass hepatic branch of the anterior vagus trunk. At the bottom
of this link, in some cases is the left gastric artery, accompanied by the same name veins, most
often, these vessels lie on the stomach wall along the lesser curvature. In addition, often (16.5%)
in a tense part of the ligament is extra hepatic artery coming from the left gastric artery. In rare
cases, there is the main trunk, left gastric vein or tributaries of it.
In the mobilization of the stomach along the lesser curvature, especially if a bunch of cut through
the gate near the liver (stomach cancer), consider the possibility of passing this additional left
hepatic artery, as its intersection may lead to necrosis of the left lobe of the liver or part of it.
Right at the base of hepatocellular gastric ligament is the right gastric artery, accompanied by the
same name veins.
7. Acute inflammation of the uterus, ectopic pregnancy, ovarian apoplexy, twisting legs cysts or
ovarian tumors, necrosis of the uterus or myoma node tumor of ovary.
The main clinical signs of acute abdomen: abdominal pain, anemia, and shock.
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Vistserosomaticheskaya pain with inflammation of the organ.
Vistserosomaticheskaya pain, sepsis, peritonitis.
Acute spasmodic pain in the obstruction of a hollow organ (intestine, bile ducts).
Anemia of bleeding in the gastrointestinal tract or abdominal cavity.
In the primary research methods include the following patient.
History: time and the start of pain (sudden, gradual), the localization of pain and dyspeptic
dizuricheskie conditions, temperature, transferred in the past, diseases of the abdominal cavity
and abdominal organs surgery.
Inspection: the forced position of the patient, patient anxiety, changes posture, weakness,
lethargy, signs of dehydration (pointed facial features, dry mucous membranes of the mouth),
pallor, jaundice, discharge (vomiting, stool, blood).
Temperature: axillary and rectal.
Hemodynamics: heart rate, blood pressure, auscultation of the heart.
Research stomach: inspection, palpation, percussion, auscultation, the volume of the stomach,
rectum examination (tenderness, overhanging walls).
To determine the indications for urgent admission is sufficient to establish whether there was
peritonitis, an inflammation or blockage of the body, bleeding.
In any case not to introduce drugs and analgesics, as under their influence may change the
clinical picture of the disease, which greatly complicates diagnosis and may delay surgery.
The diagnosis at the direction of the hospital or acute abdomen during the diagnosis of acute
abdomen indicate nosological form of the disease. By direction of hospitalization make an
extract from the history of the disease (clinical history and carried out the treatment).
If you need to shock during transportation in a specially equipped vehicle an antishock treatment.
In the methods of investigation include the patient in a hospital general clinical research: history,
physical examination data on systems.
In the study of the cardiovascular system, along with percussion and auscultation of the heart,
determination of heart rate, blood pressure in cases of suspected myocardial infarction make
ECG.
Perforated ulcer - a severe complication of gastric ulcer and duodenal ulcer, leading to the
development of peritonitis. Perforated gastroduodenal ulcers often in men with a short history of
peptic ulcer (3 years) is usually in the fall or spring, which appar ¬ ently connected with the
seasonal exacerbation of peptic ulcer. During the wars and economic crises increased the
frequency of perforation in 2 times, connected with the deterioration shown ¬ power and
negative psycho-emotional background. Perforated ulcers can occur at any age, as a child - up to
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10 years, and in old - after 80, but mainly occurs in patients 20 to 40 years. For young people,
characterized by perforation of ulcers, are localized ¬ yuschihsya in the duodenum (85%), for the
elderly - in the stomach.
In 10% of patients with perforation of gastroduodenal ulcer bleeding accompanied ¬ tion in the
gastrointestinal tract. In these cases the source of hemorrhage is not itself Perforated ulcer (she
punches in connection with obliteration of the vessels and the development of necrotic area of
intestinal or gastric wall), and the mirror ("kissing"), sore back wall of the duodenum, often
penetrating into the head of the pancreas, or the gap mucosal and submucosal layers of gastric
cardia (Mallory-Weiss syndrome).
Classification
1. On the etiology of perforation distinguish chronic and acute symptoms ¬ matic ulcers
(hormonal, stress, etc.);
2. Localization: a) gastric ulcer (small or large curvature, ne ¬ anterior or posterior wall of
antrum, prepiloricheskom, pyloric, cardiac department or in the stomach;
b) duodenal ulcer (bulbar, postbulbarnye).
3. Clinical forms: a) rupture into the free abdominal cavity (typically, covered);
b) atypical perforations (in the omental bursa, small or large gland - between the sheets of the
peritoneum, in retroperitoneal fat, isolated in the induced spikes ¬ cavity);
c) a combination of perforation with bleeding in the gastrointestinal tract.
4. Phase of peritonitis (clinical period): a phase of chemical peritonitis (during the initial shock)
phase of the development of bacterial ¬ ne ritonita and systemic inflammatory response
syndrome (pseudo period of prosperity ¬) phase of diffuse purulent peritonitis (the period of
severe abdominal sepsis).
Pathology and pathogenesis
Morphological differences between the perforated stomach ulcers and two ulcers ¬
nadtsatiperstnoy very little. Visually determined through de ¬ fect in the wall of the organ. In
most cases the perforation is localized to the anterior wall of the duodenum (in bulbs) and you ¬
RF Input of the stomach. On the part of visceral peritoneum marked redness, swelling of tissues
and fibrin overlay around perforated ¬ radios, long-term ulcer history - the phenomenon
expressed by chronic ¬ REFLECTION perigastrita, periduodenita with deformation and scar
change ¬ niyami organs and surrounding tissues.
On the part of the mucous seen rounded or oval defect in the heart of ulcers. Edge of chronic
ulcers of the dense to the touch as opposed to acute, which has the form ¬ paradise "cookie"
holes without scarring her dye ¬ s. For the microscopic picture is characterized by destruction of
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the layers of ventricular ¬ dochnoy or intestinal walls, excessive development of scar tissue, the
presence of degenerative lesions and obliterating arterial ulcers in a circle with an abundant
leukocyte infiltration.
Perforated ulcer leads to a flow of gastroduodenal derzhimogo with ¬ in the free abdominal
cavity, affecting the peritoneum ¬ ny cover the chemical, physical, and then the bacterial stimuli
¬ resident. Initial reaction to the perforation is very similar to the patho ¬ genesis of shock
(which gave grounds to call this phase the initial stage of shock). This is due to burn abdominal
acidic gastric juice, spout ¬ shimsya the abdominal cavity. Subsequently develops seroplastic
and then purulent peritonitis. The rate of development of peritonitis is higher, the lower the
acidity of gastric juice. That is why the phenomena races ¬ lence (diffuse) purulent peritonitis
can not be over 6 or even 12 hours after perforation of a duodenal ulcer. At the same time, these
terms are usually expressed in gastric ulcer perforation (very fast ro ¬ - 2-3 hours there is diffuse
purulent peritonitis in the quire ¬ struction and perforation of gastric tumors).
A number of patients (approximately 10% of cases), perforation, especially if it is of small
diameter, concealed by a film of fibrin, a lock of Sal ¬ nick the bottom surface of the liver or
colon - the so-called masked ¬ emaya Perforated ulcer. After this flow of gastroduodenal
contents into the abdominal cavity stops the pain subsides, the disease process is localized
peritonitis and limited sub-hepatic space and / or the right iliac fossa. In what follows, ¬ what
follows, the following options of the disease. First, the defect is covered wall may reopen that
accompanied the emergence of re ¬ etsya characteristic clinical symptomatic ¬ ki and
progressive development of peritonitis. Secondly, with a good delimitation of the free abdominal
cavity izlivshegosya infected ¬ vannogo content may be formed podpechenochnogo or
subdiaphragmatic abscess or abscess in the right iliac fossa. And finally, thirdly, in extremely
rare cases, perforation of a fast cover for final closure of the defect option due to the surrounding
tissue, scarring, ulceration and get better gradually ¬ of the patient.
In anecdotal rupture occurs in atypical vari ¬ ante: the cavity of the omental bursa, a small or
large gland bundle ¬ ivaya peritoneal leaflets in the retroperitoneal space in the cavity bounded
otgra ¬ spikes. In such cases, clinical disease is atypical ¬ Bani, and diagnosis is extremely
difficult. In re ¬ a result of perforation of ulcers of the small curvature of stomach to the small
thickness of the sebaceous ¬ ka arises inflammatory infiltrate (sometimes mistaken for FLEG ¬
Monna stomach), and then his abscess. Prolonged existence of an abscess like ¬ leads to the
formation of cavities of considerable size, and the "erosion of" gastric wall over a large area. He
can punch himself in the abdomen, which causes the rapid development of widespread purulent
peritonitis and infectious-toxic shock. Perforated ulcers, localized on the greater curvature of
stomach, into the space between the sheets of the greater omentum leads to the appearance of
purulent ¬ veniyu omentita. Perforation of ulcers of the stomach wall leads back ¬ leads to
ingress of gastric contents in the first packing a bag and then through Winslow's foramen into the
right lateral canal and stomach under ¬ vzdoshnuyu hole.
Of the factors causing the perforation of ulcers include: overflow ¬ ludka same food, errors in
diet and alcohol intake, physical exertion, accompanied by increased resistance ¬ intragastric
pressure.
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The clinical course and symptomatology
In a typical course of perforated gastric ulcer and duodenal ulcer conventionally divided into
three periods, in general, the corresponding phases of the development of peritonitis, but having
some of its features: 1) "Abdo ¬ minalnogo shock" (phase chemical peritonitis), lasting an
average of 6 hours, 2) " imaginary being "(development phase seroplastic of peritonitis and
systemic inflammatory reactions ¬ tion) - usually 6 to 12 hours, and 3) diffuse purulent
peritonitis (hard ¬ of abdominal sepsis) occurring usually after 12 hours of the mo ¬ ment of
perforation.
The first period is characterized by sudden onset through ¬ tremely severe epigastric pain that
patients com ¬ Niva with a knife ("dagger-like pain") or a whip. Strength and appearance bys ¬
trot it can match any other pain in Ms. ¬ vote. H. Mondor figuratively wrote: "The sad state of
adult and pose a courageous man of eloquent epithets talk about ispy ¬ Pipeline them suffering."
The pain initially localized in the upper abdomen separated ¬ crystals, more to the right of the
midline at the duodeno ¬ tional burst ulcer. Pretty soon it spreads to the right polo ¬ fault
abdomen, including the right iliac region, and then grabbing ¬ em all its departments. There is a
characteristic irradiation of pain in his right shoulder, supraclavicular region and right shoulder
blade, depending on the stimuli ¬ zheniya izlivshimsya phrenic nerve endings of the content.
Vomiting during this period is not typical (it can be observed at radio ¬ perforated ulcers
stenosing piloroduodenalnyh against the stretched and fullness. In such cases, vomiting may
precede perforation). Typically, it occurs much later - in developing TII ¬ peritonitis.
On examination, attention is drawn to the appearance of the patient: he lies motionless on his
back or right side, with those given to the stomach lower limbs, hands covering his stomach,
avoid changes in body position.
Face sunken, pale, with a frightened expression, and sunken eyes. Maybe a cold sweat.
Respiration is rapid and shallow. Ha ¬ teristic initial bradycardia: pulse rate often drops to 50-60
beats per minute (so-called vagal heart rate) due to burn tires and Bru ¬ nerves acid. Blood
pressure can be reduced.
Language in the first hours after the perforation remains clean and moist. Abdomen in breathing
is not involved. Attention is drawn to stress the abdominal muscles, which reasonably
characterizes the literature as doskoobraznoe ¬ Xia. Muscle tension is tonic, with ¬ than lean
young men, both rectus abdominis loom prominently in the form of longitudinal rolls, split
tendon jumpers in the transverse direction (scaphoid abdomen).
It should be borne in mind that sometimes the anterior abdominal muscle tension ¬ Noah wall
has such a pronounced character. This is possible in patients with old age, when expected
rhenium and malnourished people due to the sagging tissues.
Initially, the muscle tension lo ¬ kalizuetsya as pain in the upper abdomen of ¬ affairs.
Gradually, it dos ¬ Tiga right iliac oblas ¬ T, following the spread of livshegosya into the
peritoneal cavity of gastroduodenal contents. But even if the muscle stress ¬ mapping covers the
entire anterior abdominal wall, it is almost always the highest in the first place ¬ initially
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occurrence of pain, ie, epigastric or right upper quadrant ¬ PTO. Along with the on ¬
conjugation of the muscles in these fields of about constantly defined and other symptoms of
irritation of the peritoneum.
Characteristic symptom of perforation of the ulcer is the appearance of free gas in ¬ peritoneal
cavity, which manifests itself a symptom of the disappearance of hepatic dullness ¬. In the
patient on his back on the usual place but ¬ determined blunt percussion (two fingers above the
transverse edge of the costal arch liners and okologrudinnoy lines to the right) are distinct
tympanitis. More precisely, this symptom can be detected by percussion on the right middle
axillary line with the patient lying on left side (it should be remembered that the shortening or
disappearance of research ¬ hepatic dullness may be caused by interposition of the colon).
However, in some cases because of the small honors if ¬ a gas emitted into the abdominal cavity,
the characteristic symp-that can not be detected in the early hours of the disease. In the case of
massive ¬ adhesions it may not appear. During this period the ne ¬ ristaltika stomach, intestines,
usually does not listen.
Even in the early hours of the disease in most cases can be detected ¬ live a sharp pain in the
pelvic peritoneum and vaginal digital rectal examination.
The second period. The patient's face becomes normal color. Pulse, blood pressure and
temperature are equalized. Breath ¬ bo Lee freely, it ceases to be superficial. Language becomes
dry and furred. Anterior abdominal wall less rigid, yet persists with palpation tenderness in the
epigastrium and right side of the abdomen. In the case of concealed perforated ulcer pain in the
upper Mrs. Vaught ¬ gradually subside. In connection with wicking or gastric contents duodeno
¬ tional on the right side channel and the accumulation of peritoneal exudate in the right iliac
fossa, pain, lo ¬ locally muscle tension and symptoms of irritation of the peritoneum in the right
iliac region. If a doctor sees a patient for the first time, during this period, he was not appreciated
sufficiently in history, can make a mistake and a diagnosis of acute appendicitis.
Given the large amount of free fluid in the abdominal cavity, its sloping ground on the right and
left side channels define ¬ mined by blunt percussion sound. Peristalsis is weakened or non ¬
exists. At rectal examination can detect the overhang of re ¬ days of the rectal wall and its pain.
Patients in this period of apparent prosperity are reluctant to make themselves look, say that it is
useful to bo ¬ already almost gone, or soon will be, if only to be left alone, have been slow to
consent to surgery.
The third period. After 12 hours of perforation of the state ¬ tion of patients began to deteriorate
progressively. The first symptom is pro ¬ gressiruyuschego peritonitis is vomiting. She repeated
dehydrating and obessilivaya patient. The patient is restless. Skin and mucous membranes
become dry. There is a detailed Sindh ¬ rum systemic inflammatory response. The body
temperature rises, the pulse quickens to 100-120 beats per minute, blood pressure decreases to
the stand ¬. Again, there is shortness of breath. Tongue dry, thickly overlaid with a touch of
having the form crusts dirty-brown color. The appearance ¬ etsya bloating, peristaltic noises are
heard not in the deposits gih ¬ determined locations stomach plenty of fluids. As noted, not
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without reason, NN Samarin (1952), "... and diagnosis, and surgical care in this period are
usually already too late. "
Atypical perforation occurs not more than 5% of its cases. In tissue retroperitoneal perforated
ulcer, located in nye ¬ fore-stomach and the back wall of the duodenum (rarely, usually
penetrating into the head of the pancreas, which is complicated by profuse bleeding). In the first
case, the air from the stomach can enter the mediastinum, the left fiber nadklyu ¬ chichnoy area
or the left side wall of the chest, causing subcutaneous em ¬ fizemu. In the second case it
appears in the umbilicus (the gas propagates from the retroperitoneal space on the round
ligament of the liver) and in the right lumbar curve ¬.
As a result of perforation of ulcers of the small curvature of the stomach to the small thickness of
the seal may be an inflammatory infiltrate, and then its ab ¬ stsess.
Atypical perforation (posterior wall of the stomach, small in thickness or greater omentum) is
clinically manifested differently from the perforation into the free abdominal cavity. Abdominal
pain is moderate, with no clear localization. Muscle tension anterior abdominal wall is not as
pronounced. In case of delayed diagnosis of perforated ulcers develop severe septic
complications of abdominal and retroperitoneal space (omental abscess, small and large glands,
retroperitoneal abscess, etc.), cus ¬ technically be highly systemic inflammatory response to it
and erased ¬ local symptoms.
Diagnosis
D iagnosis of perforated ulcers is based primarily on careful questioning ¬ rated the patient,
physical examination data, laboratory and radiological investigations, if necessary ¬ STI using
endoscopic techniques.
Information that can be collected during the survey of patients have different diagnostic value.
For this reason, all patients can be divided into several groups. The first group includes patients
who have suffered in the past, peptic ulcer disease and the diagnosis was previously confirmed
by under ¬ they radiologically or endoscopically. In such cases, the diagnosis presents no great
difficulties. The second group consists ¬ Ute people who have not previously been examined,
but a careful distribution of demand can identify typical symptoms of gastric ulcer or duodenal
ulcer (acid regurgitation, pain soon after eating or fasting, night pain, regular consumption of
drink ¬ Eve soda, periodic tarry stools, etc.). The third group includes those who, due to an
uncritical attitude to the available manifestations of the disease have denied any gastric disease
in history. Wrote H. Mondor, many patients have "something dispepsiches ¬ past," but they
think that what happened to them at the mo ¬ ment disaster has nothing to do with some old
insignificant ¬ tive digestive disorders and are therefore negative ¬ Indeed answer the question
the doctor about the presence of disease in the past. And finally, the fourth group includes
patients who have the most careful questioning can not be identified in the past, any violation of
the solutions ¬ gastrointestinal tract. Approximately 10% of cases ¬ s perforation occurs against
a background of well-being with no prior symptoms ¬ yuschih peptic ulcer disease.
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Just before the ulcer perforation often arise prodro ¬ mal symptoms, reflected in increasing pain
in the epigastric region of ¬, chills, subfebrile temperature, nausea, vomiting occasionally. ¬
torye some surgeons evaluate these signs as a condition threatening perforations ¬ radio.
Unfortunately, this conclusion is only a "hindsight", in retrospect.
For the diagnosis is important characteristic pose the patient, his outside appearance ¬ shny and
especially, the detection of pronounced muscular stress of ¬ determined by superficial palpation.
In assessing this symptom should be taken into account the time elapsed from the mo ¬ ment of
perforation, since the development and progression of peritonitis to replace a pronounced strain
of the abdominal wall comes on gradually increasing ¬ bloating, which is largely wt ¬ kiruet
protective muscle tension. Furthermore, if the rupture pro ¬ emanated from a patient with flabby
muscles and obesity, muscle voltage in ¬ it is difficult to detect. In such cases, to identify rigid ¬
sion and continuous tonic muscle tension anterior abdominal wall is possible with careful
methodical palpation (should try to avoid causing the patient severe pain), during which the
voltage is amplified by a swarm of ¬.
The presence of free gas in the abdominal cavity can be detected by percussion of the liver in
about 60% of cases of perforation of gastroduodenal ulcers. The absence of liver dullness is
crucial in cases where the zone of bloat found on the liver moves with change of position by
turning the patient and with the spin ¬ HN on the left side.
Perforated ulcers radiodiagnosis reduced mainly to reveal ¬ leniyu free gas in the abdomen,
which is found in 80% of cases. The establishment of this symptom points to the right lane ¬
perforation of a hollow organ, even in the absence of clear clinical symptoms (the surgeon must
be aware that the air in the subdiaphragmatic space in older women can sometimes get in atony
of the fallopian tubes).
The accuracy of radiological diagnosis is directly dependent on the number of STI ¬ a gas
emitted into the peritoneal cavity: the large numbers it is easy to detect, at a minimum sometimes not at all possible.
Gas bolus is in the highest parts of the abdominal cavity. With the patient on his back the highest
point of its location is top ¬ Nij anterior abdominal wall. On turning the patient on his side, he
shifted to the appropriate hypochondrium, to the point of attachment to the diaphragm and the bo
¬ kovoy wall of the abdomen, and upright gas occupies the highest position under the dome of
the diaphragm. The presence of adhesions in the abdominal cavity distorts the above laws, and
accumulation of gas can be localized in the neti ¬ pichnom place.
Radiographic differential diagnosis between pneumoperitoneum and interposition of the colon
pnevmatizirovannoy, located between the liver and the diaphragm is based on the fact that a strip
of free gas, localized in the abdominal cavity is shifted depending on the position the patient, but
inflated ha ¬ Zami portion of the colon of his position usually does not change .
In unclear cases, patients offered intensive drink soda water ("the effervescent mixture")
releasing the gas exits through the perforated hole and can easily be detected by X-ray again. For
14
the same reason you can use any water-soluble contrast material (20-40 ml). Stepping beyond the
contours of his stomach and duodenal ulcer perforation is an absolute sign of ulcers.
In diagnostically difficult cases, you can use the integrated X-ray endoscopic study. It lies in the
fact that after the negative results of the survey ¬ x-ray of the abdomen produce
fibrogastroskopiyu patient.
During it reveals the location of ulcers and for indirect signs of presence in ¬ perforation. Often
during the injection of air into the stomach in pain ¬ GOVERNMENTAL dramatically
intensified the pain, which directly indicates the presence of ¬ probode ulcers. The diagnosis is
confirmed during the survey re-imaging, in which show the appearance of a large number of free
gas under the dome of the diaphragm.
These laboratory studies of blood do not reveal any specific changes in the early stages of the
disease. The number of leuko ¬ tsitov remains normal or slightly elevated, with no changes in
the formula. Only with the development of peritonitis appears high leuko ¬ cytosis with a shift to
the left of the formula.
Specific diagnostic aid in emergency situations ¬ s has an ultrasound. Detect free gas in the
abdomen with it is not easy, but to identify encysted or delimited bodies of liquid content is
usually successful.
In cases where the above instrumental methods of study do not allow to recognize the disguised
or atypical percolation perforated gastroduodenal ¬ yuschuyu ulcer, a diagnosis of peritonitis is
not ruled out resorting to laparoscopy.
Differential Diagnosis
Perforated gastric and duodenal ulcers primarily have to differentiate from acute diseases of the
upper abdomen, which is also characterized by pain in the epigastric region.
Perforation of stomach cancer - a rare complica ¬ tion of cancer process. The age of patients,
usually older than 50 years. During Zabo ¬ Levani has much in common with perforation of
gastroduodenal ulcers, although the initial segment ¬ no such stormy, as ulcer, with the
characteristic rapid development of diffuse purulent peritonitis. A history may reveal a loss of
body mass, reduced an ¬ Petit, weakness, occurred as the last few months before entering the chi
¬ rurgichesky hospital.
An objective examination of the assumption that a perforation of the tumor confirmed by
palpation finding dense hummocky education in the epigastrium. In other clinical manifestations
of the same as that of a perforation of the gastro-duodenal ulcers.
If you are a laparoscopy, it reveals a tumor with perforation and do unto ¬ leniem stomach
contents into the abdominal cavity. You can also see the metastases in the liver and other organs.
15
Clinical differences between acute cholecystitis, biliary colic, acute pankrea ¬ titanium, acute
appendicitis and renal colic from perforated gastric ulcer and duodenum are well-known medical
practitioner. These are set out in Chapters I and II. We therefore consider a more rare disease of
concern in the aspect of parsed pathology.
Phlegmon stomach. The disease is difficult to differentiate from perforated ulcer. The clinical
picture is characterized by sudden-onset phlegmon epigastric pain radiating to the back, nausea,
vomiting rarely. In history there are dyspepsia. The patient is restless, has forced supine position.
Tongue coated, dry. Abdomen retracted, partially involved in breathing, tense in the epigastric
region. Liver dullness preserved, sometimes determined by the blunting of sloping ground belly.
Peristalsis listen. The disease is accompanied by a rapid pulse, fever, and the high ¬ kim
leukocytosis.
In carrying out fibrogastroskopii are pronounced inflammation ¬ tion of the gastric mucosa
throughout. The control X-ray of the abdomen, made after endoscopy confirmed the absence of
¬ gives free gas in the abdomen.
Acute impairment of mesenteric blood flow. Manifests itself suddenly emerging severe
abdominal pain without specific localization. ¬ need be taken into account the presence of atrial
fibrillation, dyspeptic complaints and anamnesti ¬ České information regarding deferred earlier
embolism and available at the present time infusion ¬ chronic occlusions in the systemic
circulation. Pain ¬ Noah restless, tossing in bed, can collapse. Characterized by rapid
development
intoxication with indistinct clinical picture of the abdominal cavity. Vomiting is rare, more often
- loose stools mixed with blood. Belly swollen, soft, ne-no noise ristalticheskie from the very
beginning of the disease. Pulse frequent, not rare ¬ arrhythmic.
No increase in body temperature. White blood cell count dramatically but taller ¬. In the case of
myocardial intestine appears symptomatic peritoneal ¬ ka. The final diagnosis in the early stages
of onset, ie, the stage of intestinal ischemia is carried out by laparoscopy and radiopaque aortomezenterikografii.
Retroperitoneal rupture of abdominal aortic aneurysm. Begins abruptly with severe pain in upper
abdomen. Typically, this disease occurs ¬ tion in elderly people with severe cardiovascular
disease. Of history can often get information about the presence of an aortic aneurysm in a
patient.
An objective examination of the abdominal cavity is defined by a painful, immobile, pulsating
tumor formation, which can be over ¬ h Lusha rough systolic murmur. Stomach in the early
hours of the disease is not swollen, h ¬ determined that muscle tension by getting the blood into
the abdominal cavity of for ¬. Pulse may be rapid, reduced blood pressure, body temperature is
normal or reduced. Ripple iliac and femoral arteries abruptly oc ¬ Laboe, the lower extremities
are cold. Patients who quickly comes anuria, phe ¬ of renal failure. The majority of patients are
determined by signs of acute anemia.
Perforated ulcer may simulate and therapeutic disease.
16
Myocardial infarction. In the case of the forms may gastralgicheskoy sudden appearance of acute
pain in the epigastric area radiating to the CERD ¬ tsa and interscapular area. Increasingly ill
elderly people who have previously been angina.
On palpation may reveal pain and tension of the abdominal wall in the epigastric region. Liver
dullness preserved, the peristaltic sounds normal. Fresh on the electrocardiogram detect
violations of focal coronary circulation.
Pneumonia and pleurisy. Perhaps an acute onset of pain in the upper abdomen without a definite
location. Anterior abdominal wall may be moderately voltage ¬ wife in the epigastric region.
Liver dullness saved. Clinical and X-ray studies confirm the presence genologicheskoe
pneumonia.
In conclusion, it should focus on surgeons that accurate differential diagnosis is possible only in
the first hours after the perforation of gastroduodenal ulcer. During perforation of purulent
peritonitis picture is smoothed and becomes similar to the clinical picture of inflammation of the
peritoneum of any other prois ¬ walking. Emergency median laparotomy finally determines the
cause.
Treatment
The volume of medical diagnostic aid in pre-hospital:
1. The most important task a doctor, suspected perforation of ulcers gastric ¬ ka or duodenum, is
the organization of the fastest hospitalization in a surgical ward.
2. Reasons for the diagnosis of perforated ulcer in a typical clinical picture of Ceska ¬:
a) acute onset, b) "a dagger-like pain" in his stomach, and c) expressed in ¬ signs irritation of the
peritoneum during the initial period due to aggressive chemical agents, and d) the disappearance
of hepatic dullness.
3. If severe the patient's condition and symptoms of shock, fluid therapy is carried out,
administered vasopressors, carry oxygen inhalation.
4. We do not recommend the introduction of narcotic analgesics, which may "blur" the clinical
manifestations of the disease and dezorienti ¬ strated surgeon hospital.
Minutes of diagnosis in the surgical patient:
1. In the emergency department patient with a perforated ulcer suspected to be examined by a
doctor in the first place.
2. Thermometry produce the body, determine the number of leukocytes in the blood and the
necessary laboratory tests (blood group, Rh-factor, blood glucose, etc.).
3. In all cases, record the ECG for exclusion of abdominal form of myocardial infarction.
17
4. Perform a survey radiographs of the abdomen to detect free gas. If you allow the patient's
condition, ¬ gation study carried out in a vertical position - if not in lateroposition.
5. In addition to patients with a confirmed diagnosis of perforated gastroduodenal ulcer,
hospitalization in the surgical department near ¬ tain patients with suspicious clinical symptoms.
6. In the surgical department of diagnostics must be completed and a diagnosis of perforated
ulcer is confirmed or rejected. This can be used laparoscopy. If you can not run it for whatever
reasons, have to resort to a diagnostic medium median laparotomy.
I n the surgical ward the patient should explain the severity of illness, the need for immediate
surgical intervention, to cheer, to quiet, to get his consent for the operation. It is not rare to ¬ tact
and at the same time hard to convince the patient in the absence of another way out of this
situation.
Indications for surgical intervention. The diagnosis of perforated gastroduodenal ulcer is an
absolute indication for urgent surgery. This applies to covert perforation.
Conservative treatment must be carried out in the extremely red ¬ FIR when the patient
categorically refused the operation. Thera ¬ anisotropy by the method of Taylor is the following.
Under local anesthesia
1% solution injected into the stomach dikaina thick tube, through which it is freed from the
content. After removal of the large hall-probe transnational ¬ conducting thin gastric tube and
connect it to the apparatus for continuous aspiration, which is carried out over several days is not
¬. The patient is attached to the position of Fowler. Put ice pack on his stomach. Correction of
fluid and electrolyte balance, gender ¬ notsennoe parenteral nutrition, detoxication therapy and ¬
denotes massive doses of antibiotics for 7-10 days. Before Uda ¬ leniem probe on it and
introduce water-soluble contrast radiology ¬ cally convinced of the absence of its wicking the
contours of the stomach or two ¬ nadtsatiperstnoy intestine. Meanwhile, even in the case of
distinguishing the perforations of gastroduodenal ulcers, the probability of the formation of lo ¬
locally abdominal abscesses is very high. Therefore, this method can be recommended in
extreme cases, since it is inef ¬ ciency is lost time, suitable for rapid BME ¬ shatelstva, and the
patient is doomed, despite its belated agreement on these things ¬ operation.
The choice of method operations. The type and amount of benefits is determined strictly Institute
¬ vidual, depending on the type of ulcer, the time elapsed from the moment of perforation,
degree of peritonitis, the patient's age, the nature and severity of comorbidity, employing the
technical capabilities ¬ ing teams. Distinguish palliative surgery (suturing of perforated ulcers)
and radical (resection of gastric ulcer excision with vagotomy and others). Choosing a method of
surgery, you should keep in mind that the main purpose of the operation is to save patient's life.
For most patients this ¬ closure of perforated ulcer is shown. This operation is the power of any
surgeon, in extreme cases it can be satisfied ¬ filament under local anesthesia.
Suturing perforated ulcers is shown in the presence of diffuse ne ¬ ritonita (usually with
perforation of the old more than 6 hours), a high degree of operational risk neither ¬ (severe
18
comorbidity, starches cue ¬ age), younger patients with "fresh" ulcer without visual signs of a
chronic process and ulcer history, in the case of symptomatic perforation of stress ulcers.
"Youth" ulcer after suturing and antiulcer medic ¬ mentoznogo treatment tend to heal and
bezretsedivnomu flow in 90% of cases. In determining the amount of surgery for perforated
ulcers of the same ¬ ludka, be aware that they are, especially in elderly patients ¬ Comrade, can
be malignant. Therefore, if possible, desirable to carry out resection of the stomach. If this is not
feasible, you need to take a biopsy.
Perforations in the stomach wall, "close" two rows uzlo ¬ O sero-muscular sutures. Each of them
¬ Dyj impose a longitudinal axis ¬ rated to the stomach (ulcers) ¬ lenii direction. A number of
joints located ¬ assumed in the transverse direction, thus avoiding the narrowing of the lumen of
the organ.
Perforated ulcer piloroduodenalnoy zone preferably single-row suture synthetic suture ¬ cally,
without seizure slizis ¬ one in the transverse direction, so as not to cause a narrowing of
Enlightenment ¬ ta. If the walls of the ulcers in circles ¬ T ¬ perforated holes immobile Vision,
loose seams and imposed by tying begin to erupt, they can reinforce podshivaniem strand
packing or gastro-colic ligament on the stem (Fig. 9.3).
Sometimes when you have to take advantage of seams erupting by Polikarpov, who suggested
not pull the edge of the ulcer suture ¬ E, and a free strand of backfill hole perforated seal on the
stem. This strand with a long string into the lumen of the stomach carried through perforated
holes ¬ stie, and then record the same thread, drawn through the stomach wall at the back of
serous ¬ surface. When tying con ¬ ples thread seal tightly pack ¬ induces a hole. After that, the
app ¬ ruzhnosti ulcers, and some lag ¬ fifth of it, packing extra fix from outside the individual
joints (Fig. 9.4).
Retroperitoneal perforation ¬ you are by the presence of air and tissue paraduodenal pro ¬
pityvaniya bile. For closure of such ulcers requires pre ¬ relatively mobilization of the duodenum
by Kocher. After suturing perforated ulcers of the tissue drained lyumbotomicheskogo access.
If perforation of ulcers in debilitated patients in addition IME ¬ etsya pyloric stenosis, closure of
perforated holes must complement forced back gastrojejunostomy. As the experience of
surgeons at the same time also need to make vagotomy (from this it is evident that such
intervention should not be considered optimal in such situations is better to perform resection of
ulcers piloroplasti Coy (see below).
The final stage of surgery for perforated gastric ulcer or duodenal ulcers should be careful toilet
abdominal cavity ¬ Noah. The more carefully removing the remnants were produced gastroduodenal contents and fluid, the easier it occurs after an operating period of ¬ and fewer
opportunities for education pyo ¬ Cove in the abdomen.
If at the time of surgery in the abdominal cavity there were large number ¬ stvo content, despite
a careful toilet, the abdominal cavity to drain advisable.
19
Endovideohirurgicheskoe intervention. At the appropriate operating system ¬ naschenii and
training of doctors may laparoscopic suturing of perforated ulcers. Detection of diffuse
peritonitis, the inflammatory infiltrate or signs of intra-abdominal abscess is a testimony ¬ eat to
go to laparotomy.
Stump of the duodenum sutured purse-string suture. Superimposed anastomosis between the
stump of stomach and a loop of jejunum, held behind the transverse colon through the "window"
in mezokolon.
Fig. 9.6. Vydi pyloroplasty.
Resection of the stomach is shown in cases of chronic, kalleznyh gastric ulcers (especially if they
suspect a ¬ malignancy), as well as in ¬ dekompensirovanom pylori-duodenal stenosis. This
opera ¬ tion is possible under the following conditions ¬ tions: 1) the absence of diffuse
peritonitis fibrinopurulent, ¬ tory to develop after 6-12 hours after perforation, and 2) age less
pain ¬ Nogo 60-65 years and the absence of severe concomitant diseases ¬ Nij and 3) a sufficient
qualification surgeon and the availability of conditions for this technically complex operations ¬
Noah.
Resection of the produce, as a rule ¬ rule, by the method of Billroth II, a modification ¬ fication
Finsterera Hofmeister, and in particularly favorable conditions ¬ s - the method of Billroth I. At
the bottom of the FIR ¬ duodenal ulcers, technical difficulties FIR ¬ ¬ tional processing of the
duodeno-Ups, it is advisable you complement ¬ anastomosis by Roux. Demon ¬ unhindered
evacuation con ¬ ¬ zhimogo duodenal quiche ki avoiding insolvency ¬ sequence of the stump.
Technique re-zektsii stomach described in detail in special manuals and monographs ¬ mo. It
wants only to mention that it is preferable to impose gastrojejunostomy single layer seromuscular suture vnutriuzelkovym (Figure 9.5), for a good comparison, and tissue regeneration.
This avoids the development anastomozita.
Perforated ulcer excision with vagotomy and pyloroplasty. As shown in ¬ perforated ulcer front
wall of the bulb twelve ¬ duodenal ulcer with no significant inflammatory infiltrate. Radio
operator ¬ is performed under the same conditions as the resection of the stomach.
The operation is as follows. On the edge of the ulcer dvenadtsatiper ¬ stnoy intestine impose two
racks so that they could stretch the gut in the transverse direction. Ulcer excised within healthy
tissue along with the gatekeeper in the form of a rhombus, which dlinnik directed along the axis
of stomach and duodenum (Fig. 9.6-a). By ¬ tyagivaya for racks, a defect in the duodenum
sutured in transverse direction to ¬ one-or two-story joint, thus producing a pyloroplasty on
Geyneke-Mikulicz (Figure 9.6-6). When soche ¬ Britain perforation with stenosis of the outlet of
the stomach the most adequate drainage will be provided by Finneyu pyloroplasty (see Chapter
XV, fig. 15.1).
After the reorganization of the abdomen performed vagotomy. In an emergency operation should
be preferred the most technically simple method - stem vagotomy (Fig. 9.7).
Fig. 9.7. Stem vagotomy:
20
When combined with perforations and bleeding is a more reliable means of excision of bleeding
ulcer (or resection of the stomach).
Piloroantrumektomiya with stem vagotomy. Shown pain ¬ nym duodenostasis (dramatically
expanded and atonic duodenum) or in the case of combined forms of peptic ulcer disease when
they detect perforation of duodenal ulcer and chronic ulcer.
Selective proximal vagotomy with ulcer perforated suturing performed in patients younger and
middle-aged in presence of ¬ peritonitis and rough scar deformation and two pyloric ¬
nadtsatiperstnoy intestine. This operation is used in a limited extr ¬ rennoy surgery.
Outcomes. The main causes of mortality in perforated duodenal ulcers gastroesophageal are
peritonitis, postoperative pneumonia, and severe concomitant diseases. An unfavorable outcome
is often a consequence of delays in seeking medical patient for ¬ assistance and delayed
diagnosis. In recent years, the pain in most hospitals ¬ mortality in surgical treatment of
perforated gastric and duodenal ulcers decreased and the composition ¬ lyaet 5-7%. Long-term
results depend not only on the type of surgery, but also on the correctness of the chosen
operational tactics.
Used in this lesson, the new educational technology: A method of "round table" method of
"questioning" the ball.
Using the "round table":
Embarks on a circle with a piece of paper assignments. Each student writes his answer sheet and
passes the other. Responses should not be repeated. All write down their answers, followed by
discussion: crossed out the wrong answers on the number of right - assessing students'
knowledge.
Examples:
-Specify the reasons for the etiopathogenesis and clinic of perforated gastric ulcer and duodenal
ulcer
- Provide a diagnostic algorithm of perforated gastric ulcer and duodenal ulcer
- Call instrumental methods of diagnosing perforated gastric ulcer and duodenal ulcer
-Define the tactics of GPs in gastric ulcer and perforated duodenal ulcer
Interactive game "question" the ball.
Write questions about the little pieces of paper and stick the ball modeling ribbon so that it is
possible to read the questions completely and remove the following response.
21
Throws the ball to one of the students. A student who receives the ball, pulls one of the questions
and answers the question written on a piece of paper. If the answer is correct the game continues
and the student answered the question throws the ball to another student. Thus, the game
continues until you have answers to all questions.
Questions and answers:
1.Vysokoinformativny instrumental method for diagnosis of perforated gastroduodenal ulcers.
- A highly informative tool method of diagnosis of perforation of gastroduodenal ulcers is a
panoramic radiograph of the abdomen.
2.What is the triad Mondor?
Triada Mondor - sharp dagger-like abdominal pain, wooden belly; ulcerative history.
3.Taktika GPs in identifying patients with perforated gastric ulcer and duodenal ulcer?
-Detection of patients with perforated gastric ulcer and duodenal ulcer tactic is to organize the
fastest GP admissions to a surgical hospital.
4.Kakoy diagnostic method can be applied with a negative result of the survey radiography of
the abdomen?
With a negative result, the survey radiography of the abdomen can be used pnevmogastrografii
method - introduction of air into the lumen of the stomach through a tube, gastroscopy, or
effervescent mixtures reception, gastroscopy, laparoscopy.
5.Vidy used surgeries in perforation of gastroduodenal ulcers.
- With perforation of gastroduodenal ulcers perforated holes run closure, excision of the
perforated ulcer with pyloroplasty and vagotomy, gastric resection.
6.Pokazanie to perform resection in perforated gastroduodenal ulcers.
-Indications for resection of gastric perforation in gastroduodenal ulcers are:
-Lack of diffuse fibrinous purulent peritonitis that developed after 6-12 hours after perforation;
-The patient's age less than 60-65 years and the absence of severe concomitant diseases;
Is a sufficient qualification surgeon and the availability of conditions for this technically
challenging operation.
7. What is the essence of the method of Taylor?
-Taylor method is rarely used in the categorical refusal of the patient's surgery. The technique
Taylor is as follows: under local anesthesia, a 1% solution injected into the stomach dikaina
thick tube through which the stomach is freed from the content. After removal of the large probe
transnasal a delicate stomach tube and connect it to the machine for continuous aspiration, which
22
is carried out over several days. At the same time carry out correction fluid and electrolyte
balance, a full parenteral nutrition and massive antibiotic therapy for 7-10 days.
Teacher offers to disassemble management of patients with perforated gastric ulcer and duodenal
ulcer. The teacher divides the group into 3 subgroups calculation 1,2,3, 1,2,3, 1,2,3 etc. All
rooms are a subgroup of one and transplanted into the left half of the audience, all 2 - 2 subgroup
- to the right, all 3 numbers in the middle of the audience.
By lot drawn out task:
1.Diagnostika perforated gastric ulcer and duodenal ulcer.
2. The differential diagnosis of perforated gastric ulcer and duodenal ulcer.
3.Lechenie perforated gastric ulcer and duodenal ulcer.
Then given time to prepare for writing answers in workbooks. Then one of the members of each
group in turn read the answer. At this time, the rival group, together with the teacher are expert.
Briefing - 3 min. Divide the group - 2 min., Preparation time - 10 minutes. Speech groups to 10
minutes (30 minutes). Properly respond to a group winner.
Card number 1. Diagnosis of perforated gastric ulcer and duodenal ulcer.
A. Non-invasive diagnosis of perforated gastric ulcer and duodenal ulcer.
1.Rasspros patient identification and history of ulcer, the collection of complaints.
2.Osmotr patients - Clinical examination of patients with perforated gastric ulcer and duodenal
ulcer - palpation (identification of muscle tension in the abdominal wall), percussion (the
absence of hepatic dullness, stupidity, revealing a side of the abdomen).
B. Non-invasive instrumental methods of investigation:
X-ray radiography 1.Obzornaya or abdomen (the identification of free gas under the dome of the
diaphragm, the disappearance of gastric bubble).
2.Pnevmogastrografii with no signs of perforation on plain film of the abdomen.
3.Kontrastnoe X-ray examination of stomach and duodenum - the output of contrast material
beyond the stomach.
4.Fibrogastroduodenoskopiya - revealing holes perforated ulcer. When concealed perforation of
gastroduodenal ulcers can be detected
W. Invasive diagnostic methods perforated gastric ulcer and duodenal ulcer.
1.Diagnosticheskaya laparoscopy - detection of fluid in the peritoneal cavity with bile and gastric
contents.
2.Laparotsentez.
23
3.Diagnosticheskaya laparotomy.
Card number 2. The differential diagnosis of perforated gastric ulcer and duodenal ulcer.
A perforated differential diagnosis of gastric ulcer and duodenal ulcer with other acute surgical
diseases of the abdominal cavity.
1. The differential diagnosis of perforated gastric ulcer and duodenal ulcer with acute
appendicitis.
2. The differential diagnosis of perforated gastric ulcer and duodenal ulcer: with acute
cholecystitis.
3. The differential diagnosis of perforated gastric ulcer and duodenal ulcer: with acute
pancreatitis.
4. The differential diagnosis of perforated gastric ulcer and duodenal ulcer with acute intestinal
obstruction.
5. The differential diagnosis of perforated gastric ulcer and duodenal ulcer with acute mesenteric
thrombosis.
B. Differential diagnosis of perforated gastric ulcer and duodenal ulcer with complicated forms
of acute infectious and parasitic diseases of the abdominal cavity:
Perforated ulcer 1.Differentsialny diagnosis of gastric and duodenal ulcer perforation festering
cyst.
Perforated ulcer 2.Differentsialny diagnosis of gastric and duodenal ulcers with perforation of
the colon dysentery.
3. The differential diagnosis of perforated gastric ulcer and duodenal ulcer perforation typhoid
ulcers of the small intestine.
B. Differential diagnosis of perforated gastric ulcer and duodenal ulcer with other acute illnesses:
Perforated ulcer 1.Differentsialny diagnosis of gastric and duodenal ulcers with abdominal form
of myocardial infarction.
Perforated ulcer 2.Differentsialny diagnosis of gastric and duodenal ulcers in diabetic
psevdoperitonitom.
Perforated ulcer 3.Differentsialny diagnosis of gastric and duodenal ulcer with acute pneumonia
and pleurisy basement.
Card number 3. Treatment of perforated gastric ulcer and duodenal ulcer.
A. Prehospital emergency care.
24
1.Vazhneyschey challenge a doctor, suspected perforation of gastric ulcer or duodenal ulcer, is
the organization of the fastest hospitalization in a surgical ward.
2.In the prehospital period of severe state of a patient he can be helped by injection
cardiovascular drugs, give oxygen.
3.Kategoricheski contraindicated administration of drugs. 4.Psihicheski retarded and juveniles
should be operated after obtaining the consent of relatives, and in their absence - after the
decision in consultation with at least three doctors.
B. Surgical treatment of perforated gastroduodenal ulcers.
1.Predoperatsionnaya training. Before the operation should start Antishock and detoxication
therapy - blood transfusion and blood electrolyte solutions. 2.Provedenie probe into the stomach
to empty his best done under general anesthesia, since the introduction of the probe before the
operation can cause the urge to vomit, leading to increased expiration of gastric contents into the
free abdominal cavity.
3.Obscheprinyatym access is verhnesredinnaya laparotomy.
4.Operativnaya tactics.
, The following surgical procedures: suturing of perforated holes (one of the options for closure
is the method consists in the Oppel Polikarpov tamponing perforated holes seal on the stem),
perforated ulcer excision with vagotomy and pyloroplasty, gastric resection.
Appendix № 3.
7. Forms of control knowledge, skills and abilities.
- Oral answer
- Written reply
-Implementation of practical skills (for OSKI)
8. Criteria for evaluating the current control:
№
1
%
96-100
evaluation
Criteria
Excellent "5"
The full presentation is on the edematous limb
pain syndrome, classification, diagnosis, and
treatment methods dif.diagnostike. The
questions gives a correct and comprehensive
answer. To think independently and draw
conclusions. Self-supervised patients and
skillfully applies the practical skills. Interprets
25
the data of clinical and instrumental studies.
Independently, with knowledge of the facts
involved in the choice of treatment. Actively
involved in conducting intraktivnyh games. In
solving the situational problems applies
unconventional approaches grounded in the
responses.
2
91-95
Excellent "5"
In full view of a syndrome of limb ischemia,
classification, diagnosis, and treatment methods
dif.diagnostike. The questions gives a correct
and comprehensive answer. To think
independently and draw conclusions. Selfsupervised patients and skillfully applies the
practical skills. Interprets the data of clinical
and instrumental studies. Independently, with
knowledge of the facts involved in the choice of
treatment. Actively involved in conducting
intraktivnyh games. In solving the situational
problems applies unconventional approaches
grounded in the responses. When interpreting
the data biochemistry made one mistake
3
86-94
Excellent "5"
The full presentation is on the edematous limb
pain syndrome, classification, diagnosis, and
treatment methods dif.diagnostike. The
questions gives a correct and comprehensive
answer. To think independently and draw
conclusions. Self-supervised patients and
skillfully applies the practical skills. Interprets
the data of clinical and instrumental studies.
Independently, with knowledge of the facts
involved in the choice of treatment. Actively
involved in conducting intraktivnyh games. In
solving the situational tasks made some errors
4
81-85%
"Good"
A student has full understanding of edematous
limb pain syndrome, classification, diagnosis,
and treatment methods dif.diagnostike. The
questions gives the correct answer. Selfsupervised patients and skillfully applies the
practical skills. Interprets the data of clinical
and instrumental studies, but not fully aware of
the value of individual data. Knowingly
26
involved in the choice of treatment. Actively
involved in conducting intraktivnyh games. In
solving the situational tasks made some errors
5
6
7
76-80%
"Good"
A student has full understanding of edematous
limb pain syndrome, classification, diagnosis,
and treatment methods dif.diagnostike. The
questions gives the correct answer. To think
independently. Self-supervised patients and
skillfully applies the practical skills. Interprets
the data of clinical and instrumental studies, but
not fully aware of the value of individual data.
Knowingly involved in the choice of treatment.
Actively involved in conducting intraktivnyh
games. In solving the situational tasks and skills
made a few inaccuracies
Good "4"
A student has full understanding of edematous
limb pain syndrome, classification, diagnosis,
and treatment methods dif.diagnostike. The
questions gives the correct answer. To think
independently and draw conclusions. Selfsupervised patients and skillfully applies the
practical skills. Independently, with knowledge
of the facts involved in the choice of treatment
tactics, but admits mistakes. In carrying out the
practical skills makes a grave error. Situational
problems decides not to complete.
Satisfactory "3"
The student is aware of the edematous limb pain
syndrome, classification, diagnosis, and
treatment methods dif.diagnostike. The
questions do not give a complete answer. Make
mistakes in presenting the classification and
dif.diagnostike. The answers are not confident.
Practical skills and case studies serves correctly.
71-75%
66-70%
8
61-65%
9
55-60%
Satisfactory "3"
At half the questions gives the correct answer.
Answers are not confident. Poor knowledge of
the classification of ischemia. To individual
questions knows the answers, but to present
their idea can not.
Satisfactory "3"
Half the questions asked gave the correct
answer. In presenting the essence of the
66-
27
syndrome, diagnosis, diff. Diagnostic algorithm
for the interpretation of medical mistakes.
Uncertain poses a problem. Practical skills are
difficult to perform. Situational tasks executes
correctly.
Unsatisfactory "2"
10
under
54%
The student has no idea about the syndrome,
classification, diagnosis of the disease, does not
know diff.diagnostike treatment policy and is
not able to perform practical skills.
Chronological map
stages of training
form class
№
Duration
of activity
(327min)
1
Introductory speech teacher, study subjects
5
2
Discussion of homework. Interactive game "lottery"
The survey, discussion
(Annex № 1)
30
3
Admission of patients in the clinic, dispensary
work. Study dispensary cards.
Reception questioning,
examination of patients.
Primary surgical treatment
of wounds.
60
4
Improvement of practical skills, interpretation of
laboratory data, radiographs.
The algorithm of
60
break
30
5
Discussion of the practical lessons with the teacher.
A poll debate
35
6
Hearing the abstract of the report the student,
followed by discussion as a group
Abstract messages,
discussion threads
32
7
Group discussion as interactive games. The solution Working in small groups,
of case problems on the wound, securing the
interactive game
students' knowledge
8
Conclusion lecturer on the topic. Evaluation of each
student on a 100 ballnoy system and announces it.
Distributes tasks for self-training.
(Annex № 2,3)
9
Independent work in the library
Magazine, the work
65
10
28
program, questions for
self-training.
10. Control questions:
1. The concept of perforated gastric and duodenal ulcers.
2. Clinic perforated gastric ulcer and duodenal ulcer.
3. The diagnosis of perforated gastric ulcer and duodenal ulcer.
4. Methods of investigation of patients with perforated gastric ulcer and duodenal ulcer.
5. Principles of surgical treatment of perforated gastric ulcer and duodenal ulcer.
11. References:
1. Chazov EI Emergency Conditions and emergency medical care. M. 1990.
2. Saveliev VS Guide to Emergency Surgery of the abdominal cavity. M. 2004.
3. Situational problems.
4. Test questions.
5. Algorithms for diagnosis and treatment of major syndromes for training GPs. Edited by
Usmanov RI T. 2003.
6. Algorithms for diagnosis and treatment of surgical. Edited by Acad. Karimov SH.I. T. 2003.
- Optional:
Family Medicine. Edited by prof. Krasnov AF Samara, 19