Perforated gastric ulcer, ICD code 10. Perforated gastric ulcer. Ulcer according to the international classification of diseases

Ulcerations on the mucous membranes of the stomach are a pathological process that involves inflammation of the submucosal layer up to the muscle tissue. Typically, an acute ulcer is diagnosed if the lesion is detected for the first time. With repeated manifestations of acute attacks, it becomes chronic and begins to periodically worsen in the autumn and spring seasons.

Definition and disease code according to ICD-10

Gastric ulcer pathology is an inflammatory disease of the mucous membranes of the stomach, accompanied by the development of ulcerative formations on them. An acute ulcer forms in a short time and is more often detected in young male patients under 40 years of age.

The pathology occurs with stomach pain and dyspeptic symptoms. According to ICD-10, acute gastric ulcer has code K25.0-25.3.

Reasons for development

An acute ulcer has a fairly wide range of etiological factors, which include:

• Hereditary predisposition;
• Violation of diet and daily routine;
• Infectious pathogens;
• Including unhealthy foods in the diet;
• Excessive stomach acidity;
• Bacterial exposure to Helicobacter;
• External irritants;
• Taking non-steroidal anti-inflammatory drugs;
• Frequent psycho-emotional overload and stress;
• The presence of an inflammatory process in the gastric mucosa.

Bacterial etiology is not the least important in the development of an ulcerative process on the gastric mucosa.

It provokes the development of an inflammatory process, and then, in the absence of proper therapy, develops into an ulcer. Helicobacteria are characterized by increased vitality; they do not die in a hydrochloric acid environment, methodically destroying ever larger areas of mucous membranes.

Typically, Helicobacter pylori is activated against the background of a sharp decrease in immunity. The penetration of a bacterial pathogen is almost impossible to prevent, since Helicobacter enters the body with dirty hands, kisses or contaminated things.

Therefore, the best protection against this microorganism will be excellent immunity. Timely treatment of infectious lesions at the earliest stages of their development, while the mucous membrane has not yet undergone pronounced changes, will help prevent the formation of an ulcerative process.

Classification

Acute peptic ulcer disease has a fairly broad classification and is divided into several groups according to different principles.

1. According to the type of ulcerative process, the pathology is divided into multiple, single and combined with chronic ulcers;
2. In size, an acute ulcer can be small (up to 5 mm), medium (6-10 mm), large (11-30 mm) and giant (more than 30 mm);
3. According to etiology, the disease is divided into Cushing's ulcer, Curling's ulcer, Helicobacter and non-Helicobacter ulcers;
4. According to localization, the ulcer can be located in the antrum, in the body of the stomach, in the pyloric or cardiac region;
5. According to clinical characteristics, ulcers are divided into typical with severe symptoms or atypical without symptoms, but with severe pain (or without pain), but with signs not characteristic of an ulcerative process in the stomach.

According to the morphological features, all acute ulcers are practically no different from each other. Ulcerative formations have a wedge-shaped structure, in which the diameter of the edges of the wound is larger than the diameter of its bottom.

Symptoms

The acute form of peptic ulcer usually does not have a specific picture and is manifested by general symptoms:

• Painful symptoms in the upper part of the epigastrium, on an empty stomach the pain becomes sharper and more intense, and after eating the pain subsides;
• Heartburn and sourness, and if the acidity is low, then air is belched;
• Hyperthermic reaction, irritability and unstable sleep;
• Constipation and flatulence;
• Weight loss and...

The patient's mood changes dramatically, which often indicates increased pain. It is quite simple to distinguish from ulcerative ones - with an ulcer, pain occurs half an hour to an hour after eating and lasts for an hour or two while food is present in the stomach cavity.

After digestion, painful symptoms decrease. Also, with peptic ulcers, spasms tend to intensify at night and on an empty stomach.

Diagnostics

Often, pathology develops in patients who were previously diagnosed with hyperacid gastritis and other lesions of the gastric mucosa. When diagnosing an acute ulcer, patients are prescribed:

• , in which the stomach cavity is filled with contrast, so that thinned areas of the stomach walls can be detected through the light;
• helps detect Helicobacter pylori antigens;
• FEGDS. During this procedure, a special probe with a camera is inserted into the esophagus, which allows the specialist to visually assess the degree of ulcerative damage to the walls of the organ;
• During FEGDS, the doctor can take a tissue biopsy of the ulcerative lesion, which is necessary to assess the composition of the destroyed tissues and identify traces of Helicobacter activity;
• To detect the remains of bacterial activity, patients are also prescribed urine;
• To assess the condition of the stomach, it is carried out.

If necessary, the doctor may refer you for additional studies such as antroduodenal manometry, etc.

Treatment of acute stomach ulcers

Typically, patients are prescribed drugs from the group of antibiotics, painkillers and acid-lowering medications, and enzymatic agents to improve gastrointestinal activity.

1. The basis of therapy is proton pump inhibitors and histamine receptor blockers, which inhibit hydrochloric acid secretion. They are taken for about 3 weeks, depending on the patient’s body’s response to such treatment.
2. Regardless of the form of peptic ulcer, patients are prescribed bismuth preparations, which have a pronounced hepatoprotective and enveloping effect, which protects the stomach from the aggressive irritating influence of food and gastric secretions.
3. In case of Helicobacter activity in the stomach cavity, patients are prescribed antibiotic therapy, and a complex of 3-4 different antibiotics such as Metronidazole, Clarithromycin and Tetracycline is selected.

Prescription of drugs is carried out only by a gastroenterologist and only a doctor should cancel them. If the patient stops taking the medication on his own, he will simply suppress the disease, but will not achieve a cure, which will soon lead to a relapse.

Diet

Diet is no less important in the treatment of acute gastric ulcers. Patients with a similar pathology are prescribed dietary table No. 1.

According to this nutrition program, patients can eat neutral foods that do not contain hard-to-digest fats or coarse plant fibers.

On the first day after the onset of the acute period, patients are recommended to consume mucous decoctions of oatmeal or rice. It is recommended to eat jelly, pureed soups in chicken broth or water. Fish or meat dishes like steamed cutlets, meatballs or meatballs. Porridge or pureed vegetable purees are a great side dish for such dishes.

In the first 2-3 days of an exacerbation, you can even fast, observing the drinking regime. It is necessary to completely exclude from the diet smoked foods, salty foods, fatty foods, sweets, spicy foods and foods with coarse fibers that cause flatulence.

Complications

Acute peptic ulcer disease is dangerous due to the risk of developing massive internal bleeding.

• Acute ulcerative process, more than other varieties, is prone to penetration into the deep gastric layers penetrated by vascular canals. This usually occurs with ulcerative formations that are located in the body or antrum of the stomach. Moreover, an attack in patients can begin suddenly and rapidly gain intensity.
• Acute ulcerative formations can lead to a pathology called the suitcase handle phenomenon. In this case, the acute process rapidly spreads to the omentum, which has large arteries. When its membranes are destroyed, the arteries are drawn into the stomach, break through and bleed heavily. If the picture is unfavorable, then the bleeding becomes so intense that the patient can lose half of his blood in an hour.
• An ulcer is also dangerous due to perforation, when the affected area turns into a through hole from which food masses fall out into the peritoneal cavity. As a result of this situation, peritonitis develops, in which acute stomach pain begins, after a couple of hours there is retention of feces and urine, bloating and acute pain are bothersome.
• A complication of an ulcer can also manifest itself in the form of penetration. A similar condition also represents the formation of a through hole, but only at the point of contact of the stomach with any neighboring organ (gallbladder, pancreas, etc. The walls of the organs grow together, forming a through passage between themselves.

A timely visit to a specialist and proper treatment of a peptic ulcer will help to avoid any complications.

Forecast

Prognosis for acute ulcers depends on the timeliness of seeking qualified gastroenterological care, as well as on the effectiveness of antibacterial therapy.

In every fifth patient, ulcerative gastric pathology is complicated by bleeding, and 10-15% of ulcer patients experience ulcerative penetration or perforation. In children, peptic ulcer disease is practically not complicated. In people with ulcers, the risk of developing gastric malignancy is 3-6 times higher than in people without ulcers.

If a patient is diagnosed with a gastric ulcer, it will remain with him for life. To avoid further exacerbations, it is necessary to strictly follow the specialist’s recommendations, completely change your diet and lifestyle, eliminate alcohol and cigarettes, and protect yourself from all kinds of stressful and depressive situations that often provoke exacerbations.

It is necessary to follow a daily routine and work/rest schedule, because chronic fatigue quite often becomes the beginning of many pathologies. This is the only way to keep the ulcer under control and prevent relapse of the pathology.

Inflammatory processes in the stomach are divided into types depending on the form, location, nature, etiology and complexity. Diseases of the digestive system can be acute, chronic or in remission.

Gastric ulcer is a chronic form of the disease in which ulcers can form in the wall of the stomach; it consists of phases of periodic exacerbation and remission. The disease worsens mainly in the spring and autumn periods and can have complications in the form of internal bleeding, perforation and the development of peritonitis.

Stomach ulcer and its types according to ICD 10

According to ICD 10, gastric ulcer has code K 25, its varieties are classified according to phases and symptoms:

• By 25.0 – acute form with bleeding;
• K 25.1 – acute form with perforation;
• K 25.2 – acute form, accompanied by bleeding and perforation;
• By 25.3 – acute period without perforation and bleeding;
• K 25.4 – unspecified ulcer with bleeding;
• By 25.5 – unspecified ulcer with perforation;
• K 25.6 – unidentified with bleeding and perforation;
• By 25.7 – a chronic period without bleeding or perforation;
• By 25.8 – unidentified without bleeding and perforation.

Gastric ulcers have many different complications, but in ICD 10 only perforation is recorded, the rest have other classification codes and belong to other sections. Assigning codes to diseases greatly facilitates the work of doctors; a surgeon in any country will immediately understand that K 25.1 is an acute ulcer with perforation.

Reasons for development

A stomach ulcer with a general ICD code of 10 K 25 usually occurs against the background of gastritis and the main cause of the disease is the bacterium Helicobacter pylori. Almost 50% of the adult population is infected with Helicobacter; this occurs in family life through dishes, saliva and hygiene items.

But peptic ulcer disease can have other causes:

• violation of diet and nutrition;
• emotional and mental experiences;
• heredity;
• other diseases of the digestive system (gastritis);
• drinking alcohol in large quantities, smoking;
• long-term drug therapy;
• intoxication associated with professional activities.

The process of formation of ulcers on the walls of the stomach occurs due to the increased release of hydrochloric acid, bile and digestive enzymes.

Symptoms of the disease

The course of peptic ulcer disease and its symptoms depend on the complexity and location of the pathology:

• severe pain;
• constant heartburn;
• unpleasant belching;
• nausea with vomiting;
• bleeding;
• loss of consciousness;
• Weight loss;
• peritonitis.

Pain is most often associated with eating; heartburn always accompanies an ulcer.

Perforated ulcer

Perforated or perforated gastric ulcer code K 25.1, K 25.2, K 25.5 or K 25.6 according to ICD 10, depending on the complexity of the process and its location. This form of peptic ulcer is life-threatening; with perforation, food from the stomach can enter the abdominal cavity and cause the development of peritonitis. During an exacerbation, the pathology develops quickly and if help is not provided in time in the form of qualified treatment, the prognosis will be unfavorable.

The cause of activation of the pathology may be:

• diet violation;
• binge eating;
• physical overload;
• decreased immunity;
• exacerbation of the inflammatory process around the ulcerative focus.

Perforation of the stomach walls and accompanying complications are classified in the following order:

• severity of the disease;
• degree of development of peritonitis;
• localization of the outbreak;
• characteristic pathological features.

Based on symptoms, perforated ulcers are divided into three degrees.

First degree

The most characteristic feature of this stage of the disease is severe, intensely growing pain in the stomach area, radiating to the right, and can involve the right shoulder blade and shoulder. The pain is so severe that the patient can only be in one position - bending his knees to his stomach. At the slightest movement, the pain pierces so much that the person’s face turns pale, breathing quickens and the pulse decreases.

The abdominal muscles become toned, the stomach swells due to a large accumulation of gases. Vomiting is usually absent.

Second degree

The most dangerous stage, during which peritonitis usually develops. The acute pain subsides and you might think that relief has come and the attack of exacerbation has passed. At this point, the tongue seems dry and a coating appears on it. Often these symptoms are confused with the development of appendicitis and appropriate care is not provided.

Third degree

Development of purulent peritonitis with rapid deterioration of the patient’s condition. At this point, about 12 hours have passed since the onset of the attack of pain. At this stage, frequent vomiting occurs, contributing to dehydration. The skin and mucous membranes become dry, the coating on the tongue turns brown.

When pus spills in the abdominal cavity, the temperature rises, the pulse becomes frequent, blood pressure decreases greatly, and bloating is observed. At this stage, urgent surgical assistance is needed. It often happens that it is no longer possible to help the patient.

Diagnostics

Gastric ulcer code K 25 according to ICD 10 requires accurate diagnosis and timely treatment.

Diagnostics should be carried out in a clinical setting in a comprehensive manner:

• questioning the patient and palpation of the abdominal area;
• laboratory blood test (leukocyte level increases);
• X-ray;
• endoscopy;
• laparoscopy (not always performed, there are contraindications).

When the doctor has assessed the patient’s condition and the severity of the pathology, treatment is prescribed.

Treatment for perforated ulcers

Most often, when a perforated gastric ulcer is detected, surgery is performed, and it is very important what condition the patient is in.

If suturing is possible due to the condition of the lesion, surgeons sew together the edges of the defect in the stomach walls. Thus, the organ remains intact, its size does not change. Additionally, medications are prescribed to treat the causes of peptic ulcers.

In case of large defects, the development of purulent peritonitis, or oncology, gastric resection is performed (removal of part of the organ with the ulcer).

With timely surgery, the prognosis is usually positive; if the patient refuses surgery, as a rule, everything ends in death.

Gastric ulcer or gastric ulcer is a common pathology of the digestive system, occurring in almost 1/10 of the population. More than 70% of patients are men, mostly young – from 20 to 45 years. Although this disease is much less common than duodenal ulcer, it has a more severe course, is more difficult to treat and is fraught with the development of severe complications.

Gastric ulcer has its own general code according to ICD10 - K25, which is divided into subsections, depending on the type and stage of the ulcer:

What is a stomach ulcer?

Peptic ulcer is a defect in the gastric mucosa, which is formed under the influence of various external and internal factors. It is considered not as a disease of a single organ of the stomach, but as a disease of the whole organism for two reasons:

• The development of ulcers is promoted by a number of disorders in the body;
• the presence of an ulcer has a negative impact on other organs and systems, leading to the development of complications and deterioration of health.

For these reasons, it is more correct to speak not about an ulcer - a defect on the mucous membrane, but about a peptic ulcer - a pathology of the body as a whole.

What are the causes and risk factors for developing the disease?

The inner lining of the stomach is covered with a layer of mucus, which protects against damage from gastric juice and food. It becomes unprotected when, for any reason, the function of the mucous glands is insufficient. There are many such reasons.

1. The presence of pathogenic Helicobacter bacillus in the stomach is detected in 80% of patients with ulcers. This bacterium invades the mucous membrane and destroys its cells. The infection can enter the stomach with saliva and mucus when using shared utensils or close contact. This allows ulcers to be classified as contagious diseases.
2. Stress leading to impaired blood circulation in the stomach.
3. Systematic exposure to alcohol and tobacco smoke products.
4. Long-term use of medications from the NSAID group (aspirin, paracetamol, ibuprofen, diclofenac and other analogues).
5. Rough and spicy food, dry food.

Predisposing factors that increase the risk of developing the disease are heredity, chronic hyperacid gastritis, especially with the presence of erosions, as well as diseases of other organs - liver, pancreas, intestines, diabetes mellitus, tuberculosis, cancer, decreased immunity.

Development mechanism

The pathogenesis of the development of peptic ulcer occurs as follows. Damaged by bacteria or other factors, the mucous membrane is constantly exposed to hydrochloric acid, the protein enzyme pepsin and food. Initially, a superficial ulceration forms, which gradually deepens, forming an ulcer.

In response to this, a pain reaction occurs, spasm of smooth muscles, and the process of digestion and evacuation from the stomach is disrupted. As a result, the entire gastrointestinal tract (gastrointestinal tract) suffers, and duodenitis and enterocolitis may develop. Dyskinesia of the biliary tract and pancreatic ducts occurs reflexively; cholecystitis and pancreatitis may develop.

Types of disease

Peptic ulcer disease is classified according to several criteria.

According to the nature of gastric secretion:

• with high and normal acidity;
• with reduced acid-forming function;

According to the location of the ulcerative defect:

According to the duration of the disease:

• acute stomach ulcer;
• chronic ulcer;

According to the phase of the disease:

• acute stage;
• subacute;
• remission.

According to severity:

• latent(hidden);
• lung(exacerbations less than once a year);
• moderate severity(exacerbations 1-2 times a year);
• heavy(exacerbations 3 or more times a year, presence of complications).

Why is a stomach ulcer dangerous?

The disease leads to digestive disorders and gradually developing changes in all organs and systems associated with a lack of protein, vitamins, iron, and a decrease in hemoglobin levels. This pathology is especially dangerous during pregnancy - both for the mother and for the unborn child, and an exacerbation can provoke a miscarriage.

Complications of peptic ulcer disease pose a threat to health and life:

• perforation (perforation);
• bleeding;
• stenosis of the pylorus (pylorus);
• malignancy.

Perforation

When the ulcerative defect is deep, a through hole may appear in the wall of the stomach. Through it, gastric contents leak into the abdominal cavity, and inflammation of the peritoneum develops - peritonitis.

Bleeding

If there are vessels in the defect area, they can be corroded by gastric juice and rupture, causing blood to pour into the stomach. Ulcers of the lesser curvature, where large vessels extending from the celiac artery, a branch of the abdominal aorta, pass through are especially dangerous. Such blood loss is very massive and is often fatal.

Pyloric stenosis

An ulcer that repeatedly scars in the area of ​​the outlet of the stomach causes its stenosis - narrowing. Food stagnates in the stomach, inflammation develops.

Malignancy

Long-term non-healing gastric ulcers, especially those with reduced or zero acid-forming function, are prone to developing into cancer. A dense tissue shaft forms around the defect - the so-called callous ulcer, in which malignant degeneration of cells occurs.

Clinical symptoms

How a gastric ulcer clinically manifests depends on its shape and location, the nature of gastric secretion, and the presence of complications. Common characteristic symptoms are:

• heartburn 1.5-2 hours after eating;
• epigastric pain after eating;
• belching after eating sour contents or food;
• nausea 30-60 minutes after eating, vomiting;
• a feeling of heaviness in the epigastric region, a feeling of fullness in the abdomen;
• bloating, stool retention.

During a latent course, these manifestations are not pronounced, but in the acute phase the clinical picture can be very dramatic.

If a perforation of the ulcer occurs, severe “dagger” pain appears, tension in the abdominal muscles, vomiting, and the general condition is disturbed. When bleeding, pain is not typical, vomiting occurs like coffee grounds (blood mixed with gastric juice), severe pallor, dizziness appear, blood pressure decreases, and the pulse quickens. Hemorrhagic shock may develop.

With pyloric stenosis, frequent vomiting and rapid weight loss occur. A malignant ulcer causes constant abdominal pain, vomiting, loss of appetite, sudden weight loss; enlarged lymph nodes (metastases) may appear on the left side of the neck and above the collarbone.

Diagnostics

When examining the patient, attention is drawn to a thick white coating on the tongue, bloating, and painful palpation in the epigastrium. An x-ray of the stomach with contrast is preliminarily prescribed, this allows us to identify a defect in the mucous membrane, deformation with scars, and the presence of a tumor.

The most reliable is FGDS - fiberoptic gastroscopy, when a probe with a video camera examines the entire stomach from the inside, and a biopsy can be taken.

Diagnostics includes the study of gastric secretion by probing, clinical blood tests, urine tests, and all biochemical studies. A test for the presence of Helicobacter is required using one of the methods (endoscopic, respiratory, laboratory).

Useful video

What causes the development of the disease and how to treat it are told by experienced specialists in this matter.

Treatment methods

Treatment of peptic ulcer is complex, it includes:

• diet therapy;
• medications;
• physiotherapy.

The diet should consist of well-digested food that does not irritate the stomach, with repeated intake 5-6 times a day in small portions. The diet includes a sufficient amount of protein, vitamins, coarse fiber, spicy seasonings, salty, fried and canned foods are excluded.

The medication program is compiled individually. If Helicobacter is detected, antimicrobial drugs are prescribed. If the acidity is high, antacids are given; if the acidity is low, hydrochloric acid and pepsin are given. In all cases, gastroprotectors, vitamins, and biostimulants are prescribed to accelerate the epithelization of the defect.

Physiotherapeutic procedures include magnetotherapy, iontophoresis, galvanization, electrosleep, and laser therapy—stimulating irradiation through a probe—provides good results. The treatment course is carried out until the onset of scarring, which is detected during control endoscopy.

Surgical treatment is indicated in cases of complications. In case of bleeding or perforation, the operation is performed according to vital indications. For pyloric stenosis, the patient is prepared and operated on as planned. Malignant ulcers are treated in oncology.

Prognosis and prevention

It is difficult to achieve complete cure of an ulcer; with proper treatment, long-term remissions can be achieved, so the health prognosis is relatively favorable. It is unfavorable for life if severe complications develop, which have a high mortality rate. Surviving patients often become disabled after surgery.

As for military service, depending on the nature and stage of the illness, a deferment may be given, and after a re-examination the issue of suitability for service is decided. Most often, in peacetime, such patients are not called up for service.

Prevention of peptic ulcer disease consists of proper nutrition, getting rid of bad habits, observing personal hygiene rules, and timely treatment of existing chronic diseases.

RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols of the Ministry of Health of the Republic of Kazakhstan - 2014

Acute with bleeding (K25.0), Acute with bleeding (K26.0), Acute with bleeding (K28.0), Chronic or unspecified with bleeding (K25.4), Chronic or unspecified with bleeding (K26.4), Chronic or unspecified with bleeding (K28.4)

Gastroenterology, Surgery

general information

Short description

Recommended
Expert Council of the Republican State Enterprise at the Republican Exhibition Center "Republican Center for Healthcare Development"
Ministry of Health and Social Development of the Republic of Kazakhstan
dated December 12, 2014, protocol No. 9

Peptic ulcer is a chronic relapsing disease that occurs with alternating periods of exacerbation and remission, the main symptom of which is the formation of a defect (ulcer) in the wall of the stomach and duodenum. The main complications of peptic ulcer disease: bleeding, ulcer perforation, penetration, pyloric stenosis, malignancy, cicatricial deformation of the stomach and duodenum, perivisciritis.

I. INTRODUCTORY PART

Protocol name: Gastric and duodenal ulcers and gastroenteroanastomosis, complicated by bleeding
Protocol code:

ICD 10 code:
K25 - Stomach ulcer
K25.0 - Acute with bleeding
K25.4 - Chronic or unspecified with bleeding
K26 - Duodenal ulcer
K26.0 - Acute with bleeding
K26.4 - Chronic or unspecified with bleeding
K28 - Gastrojejunal ulcer
K28.0 - Acute with bleeding
K28.4 - Chronic or unspecified with bleeding

Abbreviations used in the protocol:
HSH - hemorrhagic shock
DIC - disseminated intravascular coagulation
Duodenum - duodenum
PPIs - proton pump inhibitors
ITT - infusion-transfusion therapy
INR - international normalized ratio
NSAIDs - non-steroidal anti-inflammatory drugs
BCC - circulating blood volume
PTI - prothrombin index
SPV - selective proximal vagotomy
PH - portal hypertension syndrome
StV - truncal vagotomy
LE - level of evidence
Ultrasound - ultrasound examination
CVP - central venous pressure
RR - respiratory rate
ECG - electrocardiography
EFGDS - esophagogastroduodenoscopy
PU - peptic ulcer
Hb - hemoglobin
Ht - hematocrit

Date of development of the protocol: year 2014.

Protocol users: surgeons, anesthesiologists-resuscitators, gastroenterologists, local therapists, general practitioners, ambulance and emergency doctors, paramedics, functional diagnostic doctors (endoscopists).

Assessment of the degree of evidence of the recommendations provided.
Level of evidence scale:

A	A high-quality meta-analysis, systematic review of RCTs or large RCTs with a very low probability (++) of bias, the results of which can be generalized to the relevant Russian population.
IN	High-quality (++) systematic review of cohort or case-control studies or high-quality (++) cohort or case-control studies with very low risk of bias or RCTs with low (+) risk of bias, the results of which can be generalized to the relevant Russian population.
WITH	Cohort or case-control study or controlled trial without randomization with low risk of bias (+). Results that can be generalized to the relevant Russian population or RCTs with very low or low risk of bias (++ or +), the results of which cannot be directly generalized to the relevant Russian population.
D	Case series or uncontrolled study or expert opinion.

Classification

Clinical classification of peptic ulcer

Depending on the location there are:

Stomach ulcers;

Ulcers of the duodenum.

Depending on the location of ulcers in the stomach, there are:

Cardiac ulcer;

Subcardial department;

Body of the stomach (lesser, greater curvature);

Antrum;

Pyloric canal.

Depending on the location of ulcers in the duodenum, they are divided into:

Onion ulcer;

Postbulbar ulcer;

Juxtapyloric (near-pyloric).

Combined ulcers: gastric and duodenal ulcers

According to the number of ulcerative lesions, they are distinguished:

Single ulcers;

Multiple ulcers.

By size of ulcers:

Small sizes (up to 0.5 cm in diameter);

Medium (0.6-1.9 cm in diameter) sizes;

Large (2.0-3.0 cm in diameter);

Giant (over 3.0 cm in diameter).

By flow phase:

Exacerbation;

Incomplete remission;

Remission.

Stages of ulcer development:

Active stage;

Healing stage;

Scarring stage (red scar, white scar).

Complications:

Bleeding;

Penetration;

Perforation;

Stenosis;

Periviscerite.

According to severity:

Latent, mild, moderate, severe

Classification of gastroduodenal bleeding

I By localization:

From stomach ulcers;

From duodenal ulcer.

II By nature:

Ongoing;

Jet;

Laminar;

Capillary;

Recurrent;

Unstable hemostasis.

III According to the severity of blood loss:

Mild degree;

Average degree;

Severe degree.

In order to clarify the state of hemostasis J.A. classification is used. Forrest (1974):
Continued bleeding:

FIA - ongoing jet bleeding

FIb - ongoing capillary in the form of diffuse blood leakage;

Stopped bleeding with unstable hemostasis:

FIIa - visible large thrombosed vessel (loose blood clot);

FIIb - tightly fixed thrombus clot in an ulcerative crater;

FIIc - small thrombosed vessels in the form of colored spots;

No signs of bleeding:

FIII - absence of bleeding stigmas in the ulcer crater;

Clinical classification of GS:

Shock of the first degree: consciousness is preserved, the patient is communicative, slightly lethargic, systolic blood pressure exceeds 90 mmHg, pulse is rapid;

Second degree shock: consciousness is preserved, the patient is lethargic, systolic blood pressure is 90-70 mmHg, pulse is 100-120 per minute, weak filling, shallow breathing;

III degree shock: the patient is adynamic, lethargic, systolic blood pressure is below 70 mm Hg, pulse is more than 120 per minute, threadlike, central venous pressure is 0 or negative, there is an absence of urine (anuria);

IV degree shock: terminal state, systolic blood pressure below 50 mmHg or not determined, shallow or convulsive breathing, loss of consciousness.

Diagnostics

II. METHODS, APPROACHES AND PROCEDURES FOR DIAGNOSIS AND TREATMENT

List of basic and additional diagnostic measures

Basic (mandatory) diagnostic examinations performed on an outpatient basis: (if the patient contacts the clinic):

Complete blood count (Hb, Ht, red blood cells).

The minimum list of examinations that must be carried out when referring for planned hospitalization: not carried out.

Basic (mandatory) diagnostic examinations carried out at the hospital level

Physical examination (pulse count, RR, blood pressure measurement, digital examination of the rectum);

General blood analysis;

General urine analysis;

Biochemical analysis (total protein and its fractions, bilirubin, ALT, AST, alkaline phosphatase, cholesterol, creatinine, urea, residual nitrogen, blood sugar);

Determination of blood group;

Determination of Rh factor;

Coagulogram (PTI, fibrinogen, FA, clotting time, INR);

Relative contraindications: extremely serious condition with low blood pressure below 90 mmHg (EGD must be carried out after correction of the patient’s condition in the intensive care unit and an increase in systolic blood pressure of at least 100 mmHg) (UD-C).
Absolute contraindications: agonal state of the patient, acute myocardial infarction, stroke. 1

Additional diagnostic examinations carried out at the hospital level(in case of emergency hospitalization, diagnostic examinations not performed at the outpatient level are carried out):

Biopsy from a stomach/duodenal ulcer (for large and gigantic sizes);

Determination of tumor markers using ELISA;

Diagnosis of H.pylori (HELIK test) (UD - B);

Ultrasound of the abdominal organs.

Diagnostic measures carried out at the stage of emergency care:

Collection of complaints, medical history and life history;

Physical examination (counting pulse, heart rate, counting respiratory rate, measuring blood pressure, assessing the nature of vomit, digital examination of the rectum).

Diagnostic criteria(description of reliable signs of the disease depending on the severity of the process)

Complaints: Clinical signs of bleeding: vomiting of scarlet (fresh) blood or coffee grounds, tarry stools or loose stools with little changed blood. Clinical signs of blood loss: weakness, dizziness, cold sticky sweat, tinnitus, rapid heartbeat, short-term loss of consciousness, thirst.

History of the disease:

Presence of pain in the epigastrium, heartburn to bleeding;

The presence of Bergmann's symptom is the disappearance of epigastric pain after bleeding;

Presence of a history of ulcers, a hereditarily determined disease,

A history of bleeding episodes;

Previously undergone suturing of a perforated ulcer;

The presence of factors that provoked bleeding (taking medications (NSAIDs and thrombolytics), alcohol, stress).

Physical examination:

Patient behavior: anxiety, fear or apathy, drowsiness, with severe blood loss - psychomotor agitation, delirium, hallucinations,

Pale skin, skin covered with sweat;

Character of the pulse: frequent, weak filling;

Blood pressure: tendency to decrease depending on the degree of blood loss;

BH: tendency to increase.

Clinical signs of unstable hemostasis:

GSH in the patient at the time of admission;

Severe blood loss;

Signs of hemocoagulation syndrome (DIC).

Laboratory research:
General blood analysis: decreased red blood cell count, hemoglobin levels and hematocrit.
Blood chemistry: increased blood sugar, AST, ALT, bilirubin, residual nitrogen, urea, creatinin; decrease in total protein.
Coagulogram: decrease in PTI, fibrinogen, increase in INR, prolongation of clotting time.
Treatment tactics are determined in accordance with the degree of blood loss and BCC deficiency (Appendix 1).

Instrumental studies
EFGDS:
Endoscopic picture(UD-A):

The presence of fresh blood with clots or coffee grounds in the stomach or duodenum indicates fresh bleeding;

The presence of an ulcerative defect of the mucosa (with a description of the size, depth, shape), a visible bleeding vessel in the ulcer, jet/capillary leakage of blood;

The presence of a loose clot, a dark fixed thrombus, hematin at the bottom of the ulcer.

Signs of unstable hemostasis on endoscopy(UD-A):

The presence of fresh blood or clots in the lumen of the stomach and duodenum;

The presence of a pulsating vessel in the wound with a red or yellow-brown thrombus;

The presence of small blood clots along the edge of the ulcer;

The presence of a large or giant gastric or duodenal ulcer;

Localization of the ulcer on the posterior wall of the duodenal bulb and in the projection of the lesser curvature of the stomach with signs of penetration.

Indications for consultation with specialists:

Consultation with a therapist/general practitioner to exclude concomitant somatic pathology;

Consultation with an endocrinologist in the presence of concomitant diabetes mellitus;

Consultation with a cardiologist for concomitant ischemic heart disease, hypertension with signs of heart failure;

Consultation with an oncologist if malignancy or primary ulcerative form of gastric cancer is suspected.

Differential diagnosis

Diseases	Features of the disease history and clinical manifestations	Endoscopic signs
Bleeding from acute ulcers and erosions of the stomach and duodenum	More often, stress, medication use, severe trauma, major surgery, diabetes mellitus, warfarin use, heart failure	The presence of an ulcerative defect within the mucous membrane of the stomach and duodenum, of various diameters, often multiple
Hemorrhagic gastritis	More often after prolonged use of drugs, alcohol, against the background of sepsis, acute renal failure and chronic renal failure	Absence of ulcers in the stomach or duodenum, the mucous membrane is swollen, hyperemic, abundantly covered with mucus
Mallory-Weiss syndrome	Suffers from toxicosis of pregnancy, acute pancreatitis, cholecystitis. More often after prolonged and heavy drinking of alcohol, repeated vomiting, first with food, then with blood	More often, the presence of longitudinal ruptures of the mucous membrane in the esophagus, gastric cardia of varying lengths
Bleeding from the esophagus and stomach	History of hepatitis, abuses alcohol, suffers from cirrhosis and hypothyroidism	The presence of varicose veins of the esophagus and gastric cardia of various diameters and shapes
Bleeding from disintegrating cancer of the esophagus, stomach	Presence of minor symptoms: increased fatigue, increasing weakness, weight loss, taste distortion, change in pain irradiation	The presence of a large ulcerative defect of the mucous membrane, undermined edges, bleeding on contact, signs of mucosal atrophy

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Treatment

Treatment goals:

Replenishment of the BCC deficit;

Prevention of recurrent bleeding,

Stabilization of hemostasis (drug correction, endoscopic hemostasis, surgical treatment)

Treatment tactics***

Non-drug treatment
The diet of patients with ulcer should have a weak juice effect: drinking water, alkaline waters devoid of carbon dioxide, full-fat milk, cream, egg whites, boiled meat, boiled fish, vegetable puree, soups from various cereals. Foods and dishes that have a strong juice effect are excluded from the diet: broths, strong infusions from vegetables, alcoholic drinks, fried and smoked foods, pickles, alcoholic drinks, etc.
Diet therapy for peptic ulcer disease consists of three cycles (diets No. 1a, No. 1b, and No. 1, each lasting 10-12 days during an exacerbation. In the future, in the absence of a sharp exacerbation and anti-relapse therapy, an unprocessed version of diet No. 1 can be prescribed. The anti-ulcer diet should contain juices of raw vegetables and fruits rich in vitamins (especially cabbage juice), and rosehip decoction.
Nutrition for peptic ulcer complicated by bleeding, the patient is not given food for 1-3 days, and he is on parenteral nutrition. After the bleeding has stopped or significantly reduced, liquid and semi-liquid chilled food is given in tablespoons every 2 hours up to 1.5-2 glasses per day (milk, cream, slimy soup, thin jelly, jelly, fruit juices, rosehip decoction, table of Meulengracht). Then the amount of food is gradually increased with soft-boiled eggs, meat and fish soufflé, butter, liquid semolina, thoroughly pureed fruits and vegetables.
Diet: every 2 hours in small portions. Subsequently, the patient is transferred first to diet No. 1a, and then to No. 1b, with an increase in the content of animal proteins (meat, fish and curd steamed dishes, protein omelettes).
It is advisable to use enpits, in particular protein and antianemic. The patient is on diet No. 1a until bleeding stops completely, on diet No. 1b - 10-12 days. Next, pureed diet No. 1 is prescribed for 2-3 months.

Drug treatment

ITT for mild blood loss:

Blood loss 10-15% of the volume of blood volume (500-700 ml): intravenous transfusion of crystalloids (dextrose, sodium acetate, sodium lactate, sodium chloride 0.9%) in a volume of 200% of the volume of blood loss (1-1.4 l);

ITT for moderate blood loss:

Blood loss 15-30% of the bcc (750-1500 ml): intravenous crystalloids (dextrose, sodium chloride 0.9%, sodium acetate, sodium lactate) and colloids (succinylated gelatin, dextran solution, hydroxyethyl starch, aminoplasmal, povidone,

Complex of amino acids for parenteral nutrition) in a ratio of 3:1 with a total volume of 300% of the volume of blood loss (2.5-4.5 liters);

ITT for severe blood loss(UD-A):

For blood loss of 30-40% of the bcc (1500-2000 ml): intravenous crystalloids (dextrose, sodium chloride 0.9%, sodium acetate, sodium lactate) and colloids (succinylated gelatin, dextran solution, hydroxyethyl starch, aminoplasmal, povidone, complex amino acids for parenteral nutrition) in a 2:1 ratio with a total volume of 300% of the blood loss (3-6 liters). Transfusion of blood components is indicated (erythrocyte mass 20%, FFP 30% of the transfused volume, platelet concentrate when the platelet level is 50x109 and below, albumin);

The critical level of hemoglobin indicators is 65-70 g/l, hematocrit 25-28%. (adhere to order No. 501 of 2012 on the transfusion of blood components);

Criteria for the adequacy of the conducted ITT:

Increased central venous pressure (10-12 cm of water column);

Hourly diuresis (at least 30 ml/hour);

Until the central venous pressure reaches 10-12 cm of water column. and hourly diuresis of 30 ml/hour ITT must be continued.

With a rapid increase in central venous pressure above 15 cm of water column. it is necessary to reduce the rate of transfusion and reconsider the volume of infusion

Clinical criteria for BCC recovery(elimination of hypovolemia):

Increased blood pressure;

Decrease in heart rate;

Increased pulse pressure;

Warming and change in skin color (from pale to pink);

Antihypoxants should be included in ITT based on the pathogenesis of blood loss:

Perftoran in a dose of 10-15 ml per 1 kg of patient weight, administration rate - 100-120 drops per minute. But it must be remembered that perftoran does not replace hemoplasma transfusion;

Antioxidants:

Preparations for parenteral nutrition:

Fat emulsion for parenteral nutrition 250-500 mg intravenously in slow drops once.

Antiulcer therapy(UD-B):
According to the recommendation of the IV Maastricht meeting, in regions with a low prevalence of H. pylori strains resistant to clarithromycin (less than 15-20%) it is recommended: PPI, clarithromycin 500 mgx2 times a day and a second antibiotic: amoxicillin 1000 mgx2 times a day, metronidazole 500 mgx2 times a day day or levofloxacin. Duration of therapy is 10-14 days.

In the “quadruple therapy” regimen: tetracycline 500 mg 4 times a day, metronidazole 500 mg 2 times a day, bismuth tripotassium dicitrate 120 mg 4 times a day. In regions with >20% resistance, sequential therapy is recommended as an alternative to quadruple therapy in first-line therapy to overcome resistance to clarithromycin: PPI + amoxicillin (5 days), then PPI + clarithromycin + metronidazole (5 days).

Prevention of early postoperative complications:
Antibiotic therapy before surgery(UD-B):

Erythromycin 1 t. at 13:00, at 14:00, at 23:00 19 hours before surgery;

Cefazolin 2 g IV 30 minutes before surgery/Vancomycin 25 mg/kg IV 60-90 minutes before surgery.

Antibiotic therapy after surgery:

Cefazolin 2 g IV 30 minutes before surgery/Vancomycin 25 mg/kg for 3-5 days

Painkillers after surgery:

Trimeperidine 2% 1 ml the first day after surgery

Tramadol 100 mg 2 ml after 12 hours

Morphine hydrochloride 2% 1.0 ml the first day after surgery

Lornoxicam 8 mg IV as required

Metamizole sodium 50% 2 ml IM

Drugs that stimulate motor-evacuation activity of the gastrointestinal tract after surgery:

Metoclopramide solution for injection 10 mg/2 ml every 6 hours;

Neostigmine 0.5 mg 1 ml as required

Drug treatment provided on an outpatient basis

List of essential medicines (having a 100% probability of use): not carried out.

List of additional medications (less than 100% probability of use): sodium chloride 0.9% 400 ml i.v.

Drug treatment provided at the inpatient level

List of essential medicines(having a 100% probability of application):

Sodium chloride 0.9% 400 ml;

Dextrose solution for infusion;

Succinylated gelatin 4% 500 ml;

Dextran solution 500 ml;

Hydroxyethyl starch 6% 500 ml;

Aminoplasmal 500 ml;

Red blood cell mass;

Thromboconcentrate;

Albumin 5% 200, 10% 100 ml;

Omeprazole powder, lyophilized, for the preparation of solution for injection in bottles of 20, 40 mg capsules;

Pantoprazole 40 mg lyophilized powder for the preparation of solution for injection in vials, tablets;

Lansoprazole 30 mg capsules;

Esomeprazole 20, 40 mg capsules;

Clarithromycin 250 mg, 500 mg tablets;

Amoxicillin 250, 500 mg tablets;

Levofloxacin 500 mg, tablets;

Metronidazole 250, 500 mg tablets, solution for infusion 5 mg/100 ml

Tetracycline 100 mg tablets;

Bismuth tripotassium dicitrate 120 mg tablets;

Epinephrine solution for injection 0.18% 1 ml;

Erythromycin 250 mg tablets;

Cefazolin powder for solution for injection 1000 mg.

Perftoran emulsion for infusion 5-8 ml/kg;

Sodium acetate solution for infusion;

Sodium lactate solution for infusion.

List of additional medicines(less than 100% chance of application):

Aluminum phosphate gel 16 g in bags;

Aluminum hydroxide in bottles 170 ml;

Sodium alginate 10 ml suspension 141 mg;

Itopride 50 mg tablets;

Domperidone 10 mg tablets;

Metoclopramide solution for injection 10 mg/2 ml;

Vancomycin 500, 1000 mg powder for injection;

Trimeperidine 2% 1 ml;

Tramadol 100 mg/2 ml in ampoules;

Morphine hydrochloride 2% 1.0 ml;

Lornoxicam 8 mg solution for injection;

Metamizole sodium 500 mg/ml solution for injection;

Neostigmine 0.5 mg/ml solution for injection

Ascorbic acid tablets 50 mg, solution 5%

Fat emulsion for parenteral nutrition emulsion for infusion

Drug treatment provided at the emergency stage:

Sodium chloride solution 0.9% 400 ml intravenous drops.

Oxygen inhalation

Other treatments(for example: radiation, etc.): not carried out.

Other types of treatment provided on an outpatient basis: not provided.

Other types of services provided at the stationary level:

Endoscopic hemostasis shown (UD-A):

EG methods:

Irrigation;

Injection hemostasis (0.0001% solution of epinephrine and NaCl 0.9%) (UD-A).;

Diathermocoagulation;

Application of a thermal probe (UD-A);

Vessel clipping (UD-S);

Argon plasma coagulation (UD-A);

Combined methods (UD-A);

Combination therapy: epinephrine and hemoclips may result in a reduction in rebleeding and a potential reduction in mortality (UD-A).
Before the EG, a bolus injection of PPI 80 mg is required and after the procedure - an infusion of 8 mg/hour (UD - C)
Patients receiving NVP and thrombolytics need to continue antisecretory PPI therapy (UD-A):

Indications for EG:

Patients with a high risk of recurrent bleeding;

In the presence of pulsating or diffuse bleeding;

In the presence of a pigmented tubercle (visible vessel or protective clot in the ulcer);

In case of recurrent bleeding in elderly and senile patients with severe concomitant pathology with a high risk of surgery.

Contraindications for EG:

Inability to adequately access the source of bleeding;

Massive arterial bleeding, especially from a large dense fixed clot;

The risk of organ perforation during hemostasis.

Other types of treatment provided at the emergency stage: not provided.

Surgical intervention

Surgical interventions provided on an outpatient basis: not performed.

Surgical intervention provided in an inpatient setting:

Types of operations:

Organ-saving operations with vagotomy:

For bleeding from a duodenal ulcer shown:

Pyloroduodenotomy with excision or suturing of a bleeding ulcer + StV;

Extraduodenization (removal of the ulcerative crater from the intestinal lumen) with penetration of +StV and pyloroplasty;

Antrumectomy+StV modified by Billroth I;

Radical operations:

Gastric resection according to Billroth I - for gastric localization of the ulcer;

Gastric resection according to Billroth II - for large and giant ulcers with a combination of several complications at the same time

Palliative operations:

Gastrotomy and duodenotomy with suturing of a bleeding ulcer.

Indications: severe concomitant pathology in the stage of decompensation.

Indications for emergency surgery:

On an emergency basis:

Continuing jet bleeding (FIa)

Hemorrhagic shock;

Diffuse bleeding (FIb) of moderate and severe severity, except in the risk group for surgery with effective EG;

Recurrent bleeding;

Urgently:
In case of unstable hemostasis with a high risk of recurrent bleeding;
When bleeding has stopped after EG, but there is a continuing risk of relapse;
In case of severe blood loss in the risk group for surgery, who required drug correction at the time of admission;

Further management(postoperative care, clinical examinations indicating the frequency of visits to primary care doctors and specialists, primary rehabilitation carried out at the hospital level):

Observation by a polyclinic surgeon;

EGD 1-3 months after surgery (UD-A);

Indicators of treatment effectiveness and safety of diagnostic and treatment methods:

No recurrent bleeding;

Absence of purulent-inflammatory complications in the abdominal cavity and postoperative wound;

Reduction in overall mortality from ulcerative stomach and duodenal ulcers by 10%;

Reduction in postoperative mortality 5-6%.

Drugs (active ingredients) used in treatment

Aluminum hydroxide

Albumin

Aluminum phosphate

Aminoacids for parenteral nutrition + Other medicines (Multimineral)

Amoxicillin

Ascorbic acid

Vancomycin

Bismuth tripotassium dicitratobismuthate

Hydroxyethyl starch

Dextran

Dextrose

Domperidone

A fat emulsion for parenteral nutrition

Itopride

Calcium carbonate

Clarithromycin

Complex of amino acids for parenteral nutrition

Lansoprazole

Levofloxacin

Lornoxicam

Metamizole sodium (Metamizole)

Metoclopramide

Metronidazole

Morphine

Sodium alginate

Sodium hydrocarbonate

Sodium lactate

Sodium chloride

Neostigmine

Omeprazole

Pantoprazole

Perftoran

Povidone - iodine

Succinylated gelatin

Tetracycline

Tramadol

Trimeperidine

Cefazolin

Esomeprazole

Epinephrine

Erythromycin

Hospitalization

Indications for hospitalization indicating the type of hospitalization

Indications for emergency hospitalization: bleeding from gastric and duodenal ulcers.

Indications for planned hospitalization: is not carried out.

Information

Sources and literature

1. Minutes of meetings of the Expert Council of the RCHR of the Ministry of Health of the Republic of Kazakhstan, 2014
   1. 1. Yaitsky N.A., Sedov V.M., Morozov V.P. Ulcers of the stomach and duodenum. – M.: MEDpress-inform. – 2002. – 376 p. 2. Grigoriev S.G., Koryttsev V.K. Surgical tactics for ulcerative duodenal bleeding. //Surgery. – 1999. - No. 6. – P. 20-22; 3. Ratner G.L., Koryttsev., Katkov V.K., Afanasenko V.P. Bleeding duodenal ulcer: tactics for unreliable hemostasis // Surgery. – 1999. - No. 6. – P. 23-24; 4. ASGE Standards of Practice Committee, Banerjee S, Cash BD, Dominitz JA, Baron TH, Anderson MA, Ben-Menachem T, Fisher L, Fukami N, Harrison ME, Ikenberry SO, Khan K, Krinsky ML, Maple J, Fanelli RD, Strohmeyer L. The role of endoscopy in the management of patients with peptic ulcer disease. Gastrointest Endosc. 2010 Apr;71(4):663-8 5. Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, Fish DN, Napolitano LM, Sawyer RG, Slain D, Steinberg JP, Weinstein RA. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013 Feb 1;70(3):195-283. 6. Endoclips vs large or small-volume epinephrine in peptic ulcer recurrent bleeding Author(s): Ljubicic, N (Ljubicic, Neven)1; Budimir, I (Budimir, Ivan)1; Biscanin, A (Biscanin, Alen)1; Nikolic, M (Nikolic, Marko)1; Supanc, V (Supanc, Vladimir)1; Hrabar, D (Hrabar, Davor)1; Pavic, T (Pavic, Tajana)1 WORLD JOURNAL OF GASTROENTEROLOGY Volume: 18 Issue: 18 Pages: 2219-2224. Published:MAY142012 7. Management of Patients with Ulcer Bleeding Loren Laine, MD1,2 and Dennis M. Jensen, MD3–5 Am J Gastroenterol 2012; 107:345–360; doi: 10.1038/ajg.2011.480; published online 7 February 2012 Received 31 July 2011; accepted 21 December 2011. 8. Hwang JH, Fisher DA, Ben-Menachem T, Chandrasekhara V, Chathadi K, Decker GA, Early DS, Evans JA, Fanelli RD, Foley K, Fukami N, Jain R, Jue TL, Khan KM , Lightdale J, Malpas PM, Maple JT, Pasha S, Saltzman J, Sharaf R, Shergill AK, Dominitz JA, Cash BD. The role of endoscopy in the management of acute non-variceal upper GI bleeding. Gastrointest Endosc. 2012 Jun;75(6):1132-8. PubMed 9. Acute upper gastrointestinal bleeding: management Issued: June 2012 NICE clinical guideline 141 guidance.nice.org.uk/cg141 10. International Consensus Recommendations on the Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding Ann Int Med 2010; 152 (2):101-113
   revision of the protocol after 3 years and/or when new diagnostic/treatment methods with a higher level of evidence become available. 100-90 <90 Hematocrit number

   >30

   30-25 <25 Deficiency of civil defense from what it should be

   up to 20

   from 20-30 >30

   Using Moore's Formula: V=P*q*(Ht1-Ht2)/Ht1
   V - volume of blood loss, ml;
   P - patient’s weight, kg
   q is an empirical number reflecting the amount of blood per kilogram of mass - 70 ml for men, 65 ml for women
   Ht1 - normal hematocrit (for men - 50, for women - 45);
   Ht2 is the patient’s hematocrit 12-24 hours after the onset of bleeding;

   Determination of the degree of HS using the Algover index: P/SBP (pulse/systolic blood pressure ratio).
   Normal is 0.5 (60\120).
   With I degree - 0.8-0.9, with II degree - 0.9-1.2, with III degree - 1.3 and higher.

   Assessment of the severity of HS and BCC deficiency:

   Index	Decrease in BCC, %	Volume of blood loss, ml	Clinical picture
   0.8 or less	10	500	No symptoms
   0,9-1,2	20	750-1250	Minimal tachycardia, decreased blood pressure, cold extremities
   1,3-1,4	30	1250-1750	Tachycardia up to 120 per minute, decreased pulse pressure, systolic 90-100 mmHg, anxiety, sweating, pallor, oliguria
   1.5 or more	40	1750 or more	Tachycardia more than 120 per minute, decreased pulse pressure, systolic below 60 mmHg, stupor, severe pallor, cold extremities, anuria

   
   

   Attached files

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Perforated gastric ulcer is an acute surgical disease that is a complication of peptic ulcer disease. The term “perforated” means the appearance of a through hole in the wall of a hollow organ. In medicine, the synonym “perforated” (perforacio, which is translated from Latin as “to drill”) is used to define this condition.

Worldwide, ulcer perforation is considered one of the most dangerous conditions in emergency surgery with a high mortality rate.

Perforation is the formation of a hole in the wall of the stomach that opens into the abdominal cavity. Mostly (up to 85%) a perforated ulcer develops against the background of increased inflammatory-destructive processes in the focus of a chronic or acute ulcer. And in 20%, perforation is observed in people without previously observed symptoms of peptic ulcer.

Mechanism of disease development

Exacerbation of the chronic destructive process in ulcer tissues without signs of regeneration leads to gradual damage to all layers of the gastric wall. At the bottom of the ulcer, new foci of necrosis appear, the size of the ulcerative defect increases in depth and width, which causes the formation of a through opening in the wall of the organ.

From the resulting hole, gastric juice flows into the free abdominal cavity. All organs of the abdominal cavity are covered with a special protective membrane - the peritoneum. Gastric secretions have physical, chemical, and later bacterial effects on the peritoneum. The body reacts to perforation with a state of shock as a result of a burn of the serous membrane by acidic gastric juice. Then comes the stage of serous-fibrous peritonitis with the transition to diffuse purulent or local peritonitis.

Sometimes perforation of an ulcer occurs unexpectedly against the background of health in young people without connection with a gastric ulcer. This is explained by the development of autoimmune processes in the body, when produced antibodies show aggression towards its own cells.

At the lesion site, an inflammatory response is activated with the release of a large number of inflammatory mediators (serotonin, prostaglandins). The aggressive acidic environment of the gastric chyme contributes to the destruction of the gastric wall, which leads to the appearance of a hole.

It is still not possible to fully elucidate the mechanisms of ulcer perforation.

Types of perforated ulcers

In addition to cases of typical perforation into the abdominal cavity, which account for 80-90%, there are other variants of perforation.

Covered perforation observed in 5–8% of cases, when the hole in the stomach is closed by the wall of an adjacent adjacent organ, part of the omentum, fibrin film or a piece of food bolus. The clinical picture has a two-phase course: an acute onset, as in a typical case, then the extinction of symptoms, as the opening closes and gastric juice no longer exits into the abdominal cavity.

Atypical perforation(0.5%) occurs when gastric secretions spill into a closed area limited by fibrous adhesions.

Combined option. In 10% of all cases of perforated ulcers, a combination of perforation and internal bleeding occurs. This significantly changes the symptoms, which leads to late diagnosis and unfavorable outcome of the disease.

Danger of perforation of a stomach ulcer

Perforated gastric ulcer is a serious condition; even with timely surgery, the mortality rate is 5–18%. With delayed diagnosis and treatment, mortality reaches 60–70%.

A conditionally favorable result is observed in young people under 45 years of age without concomitant pathologies of other organs and systems.

A conditionally unfavorable outcome of the disease awaits elderly patients and people suffering from systemic diseases (diabetes, AIDS, autoimmune pathologies).

With the development of peritonitis occurs:

• blood poisoning - sepsis;
• formation of purulent abscesses in the abdominal cavity;
• thrombosis of mesenteric vessels and intestinal necrosis.

Massive internal bleeding leads to hemolytic shock with neurological symptoms and the patient's transition to a coma.

Complications in the postoperative period:

ICD-10 code

Perforated gastric ulcer according to ICD-10 (International Classification of Diseases, 10th revision) has code K25 with clarifications depending on the stage of the process and the presence or absence of bleeding.

• acute forms with only perforation, or with perforation and bleeding: K25.1; K25.2.
• chronic or unspecified forms with perforation, or a combination of perforation of the ulcer with bleeding: K25.5; K25.6.

Causes and risk factors

The condition can be provoked by:

The causes of perforation of a stomach ulcer are varied, but there is not always a direct connection between the frequency of occurrence of the pathology and risk factors.

Useful video

Why a perforated ulcer occurs and how it is diagnosed is discussed in this video.

Diagnostics

A perforated gastric ulcer is an acute surgical condition, and immediate surgery is the only way to save the patient’s life.

Laboratory and instrumental examination methods are used for diagnosis.

Criteria confirming the diagnosis of ulcer perforation:

1. A clinical blood test revealed leukocytosis and accelerated ESR.
2. The x-ray shows free gas under the dome of the diaphragm. X-rays are taken with the patient in an upright or lateral position.
3. Ultrasound reveals gas and effusion in the abdominal cavity.
4. FGDS is performed in the absence of characteristic symptoms of peritonitis and if a covered perforated ulcer is suspected.
5. Computed tomography shows the location of the ulcer, signs of perforation: free gas and liquid, thickening of the gastric wall.
6. In case of unclear clinical symptoms in the case of atypical forms of perforated gastric ulcer, diagnosis is carried out using the laparoscopic method. A miniature video camera not only allows you to visually determine the perforation, assess the extent of the pathological process in the abdominal cavity, but also take photos and videos. This may be necessary for a collegial decision on the issue of further treatment tactics for the patient.
7. An ECG must be done to assess the state of cardiac activity and exclude myocardial infarction, which, in the abdominal form, has symptoms similar to the clinical picture of an “acute” abdomen.