1. Ulcerative bleeding

2. Perforation

3. Penetration

4. Periviscerite

5. Pyloric stenosis

6. Malignancy

Complications of ulcer. In 15–20% of cases, certain complications are observed during the course of a peptic ulcer. There are complications that arise suddenly and directly threaten the patient’s life (bleeding, perforation), as well as those that develop gradually (penetration, pyloric stenosis, malignancy of the ulcer). Complications of peptic ulcer disease require a special diagnostic approach and treatment tactics:

Bleeding is the most common complication of ulcer. Hidden bleeding, as a rule, accompanies almost every relapse of the disease, but has no practical significance and is usually not recorded. Obvious bleeding is observed in 10-15% of patients with ulcer. Gastroduodenal bleeding of ulcerative nature accounts for 45-55% of all gastrointestinal bleeding. Diagnosis of bleeding from the upper gastrointestinal tract should be aimed at confirming the fact of hemorrhage, establishing its source and assessing the degree of blood loss.

Gastrointestinal bleeding is clinically manifested by symptoms of acute blood loss, bloody vomiting, and tarry stools.

Bloody vomiting is more common with stomach ulcers. It is usually noted when the volume of blood loss is more than 500 ml. The gastric contents have the appearance of coffee grounds, which is due to the conversion of blood hemoglobin under the influence of HCL into hematin, which is black in color. However, with heavy bleeding, HCL does not have time to react with hemoglobin, and vomiting in these cases is scarlet blood.

Black coloration of stool (melena) is observed after the loss of more than 200 ml of blood. With heavy bleeding, the stool becomes liquid and resembles tar. It should be remembered that black coloration of stool can be observed after taking iron, bismuth, carbolene, blueberries, etc.

Clinical manifestations of acute blood loss depend on the rate and volume of bleeding. Bleeding not exceeding 500 ml usually does not cause significant symptoms unless there are significant impairments in the body’s compensatory capabilities. A slight decrease in circulating blood volume (CBV) is quickly compensated by the inclusion of deposited blood in the bloodstream. With massive blood loss, when over a short time, measured in minutes or hours, the patient loses more than 1500 ml of blood or 25% of the blood volume, collapse develops, and with a further increase in blood loss - hypovolemic shock. With heavy blood loss, kidney and liver failure often occurs. The first serious symptom of renal failure is a decrease in urine output to 20 ml/hour.

Based on severity, blood loss is divided into 4 degrees: mild, moderate, severe and extremely severe. To determine the degree of blood loss in

Currently, it is customary to mainly focus on the BCC. With a mild degree of blood loss, the deficit of blood volume does not exceed 20%, the patient’s condition remains satisfactory. You may experience weakness, dizziness, and moderate tachycardia. With moderate blood loss, the BCC deficit fluctuates between 21-30% and clear clinical signs of bleeding appear: the patient’s condition is of moderate severity, general weakness is noted, pulse up to 120 beats/min, moderate hypotension. Severe blood loss is characterized by a deficit of blood volume of 31-40%. The patient's condition is serious, pulse is over 120 beats/min; systolic blood pressure drops to 60 mm Hg. Art. With extremely severe blood loss, the BCC deficit decreases by more than 40%. The patient's condition is extremely serious, consciousness is often absent, blood pressure and pulse may not be determined (table).

Characteristics of blood loss by severity (Bryusov P.G., 1985)

Blood loss rates	Degree of blood loss
light	average	heavy	extremely heavy
Blood pressure, mm. rt. Art.	Normal or reduced		90-60	Below 60
Pulse rate, beats/min			Over 120	Over 120
Hemoglobin, g/l	100-120	80-100	Below 80	Below 80
Number of red blood cells per liter of blood	3,5	2,5	Less than 1.5	Less than 1.5
Venous hematocrit	0,35	0,25-0,30	Less than 0.25	Less than 0.25
Central venous pressure, mm. water Art.	50-160	Below 50	About 0	About 0
BCC deficit, %	Up to 20	21-30	31-40	More than 40
Approximate blood loss, ml			More than 1500	2000 or more

One of the important achievements of modern medicine has been the use of endoscopic examination to determine the source of bleeding from the upper gastrointestinal tract. Endoscopic examination makes it possible to diagnose the source of bleeding in 92-98% of cases and, equally important, determine whether the bleeding has stopped or continues. The table below shows the criteria for the degree of activity of gastrointestinal bleeding depending on endoscopic signs (according to Forrest).

The degree of activity of gastrointestinal bleeding depending on endoscopic signs (according to Forrest)

Perforation is a severe complication of ulcer, requiring urgent surgical intervention. This complication occurs in 5-20% of cases of ulcer, and in men it is 10-20 times more common than in women. Up to 80% of all perforations occur due to ulcers of the anterior wall of the duodenal bulb.

Diagnosis of perforation is usually not difficult, but sometimes the atypical course of the complication makes its recognition difficult.

Classic symptoms of perforation are acute “dagger” pain in the epigastric region, muscle tension in the anterior abdominal wall, signs of pneumoperitoneum, and then peritonitis with rapid deterioration of the patient’s condition. In 75-80% of cases with a perforated ulcer, it is possible to radiologically determine free gas in the abdominal cavity, most often under the dome of the diaphragm.

With a decrease in the body's reactivity in weakened and elderly patients, the disease can occur without severe pain. Despite the perforation into the free abdominal cavity, tension in the muscles of the anterior abdominal wall, pain on palpation and the Shchetkin-Blumberg symptom in these cases are mild or practically absent.

Atypical symptoms can be observed if the perforation is located in the proximal part of the stomach, as a result of which only air escapes into the abdominal cavity, and the hole soon closes.

An atypical clinical picture is also observed with covered perforation of the ulcer. The peculiarity of the course of covered perforation is that after the appearance of characteristic signs of perforation, severe pain and tension in the muscles of the anterior abdominal wall gradually decrease. Subsequently, extensive adhesions form in the area of ​​the covered perforation and the formation of abscesses is possible.

Penetration refers to the spread of an ulcer beyond the wall of the stomach and duodenum into surrounding tissues and organs. The possibility of ulcer penetration is, first of all, indicated by changed clinical symptoms. The clinical picture of penetration depends on the depth of penetration of the ulcer and which organ is involved in the process.

If the ulcer reaches the serous membrane of the stomach or duodenum, but does not contact other organs, there is an increase in pain and its resistance to therapy. Painful sensations usually do not lose connection with food intake. With superficial palpation of the abdomen, local tension in the muscles of the anterior abdominal wall and local soreness are often determined.

When the ulcer penetrates into the surrounding tissues and adjacent organs, the pain loses its circadian rhythm and connection with food intake, and is not relieved by taking antacids. Ulcers of the posterior wall of the duodenal bulb and the pyloric part of the stomach often penetrate into the pancreas, the pain radiating to the back, sometimes becoming encircling. An ulcer of the lesser curvature of the gastric body usually penetrates into the lesser omentum, causing pain to spread to the right hypochondrium. An ulcer of the subcardial and cardiac parts of the stomach, penetrating to the diaphragm, leads to irradiation of pain up and to the left, often simulating coronary artery disease. When an ulcer penetrates into the mesentery of the small intestine (postbulbar ulcer), pain occurs in the navel area.

General signs of inflammation may also be observed: low-grade fever, leukocytosis, increased ESR.

There are no direct endoscopic signs indicating penetration of the ulcer. The possibility of this complication can be assumed when a deep ulcer with steep, undermined edges and a pronounced inflammatory shaft is detected. The X-ray method is more informative in these cases. Characteristic signs of a penetrating ulcer are an additional shadow of a suspension of barium sulfate next to the silhouette of the organ, three layers in the ulcer niche (barium suspension, liquid, air), palpable immobility of an additional formation, the presence of an isthmus and prolonged barium retention. Endosonography can provide more accurate data on the presence of penetration, but this method is not widely used due to the lack of equipment.

Peptic ulcer in 6-15% of cases is complicated by stenosis. The most common are pyloric stenosis and postbulbar stenosis. There are organic stenosis caused by post-ulcer scar changes, and functional narrowing that occurs during an exacerbation of ulcer due to spastic contractions and swelling of the mucous membrane.

Organic pylorobulbar stenosis is accompanied by a constant violation of the evacuation function of the stomach and duodenum. The clinical picture of stenosis depends on the degree of its severity. There are three degrees of severity of stenosis: 1) compensated; 2) subcompensated, 3) decompensated.

With compensated stenosis, the general condition of the patient is not disturbed, although a feeling of heaviness in the epigastrium after eating, sour belching, and vomiting, which brings relief, are often observed. With subcompensated stenosis, intense pain in the epigastric region predominates, and a feeling of fullness appears after eating small amounts of food. Typical features of this stage of stenosis include rotten belching, profuse vomiting that brings relief, and the presence of food eaten the day before in the vomit. Increased vomiting, leading to progressive exhaustion and dehydration of the patient, indicates decompensation of pyloroduodenal stenosis. The patient's condition becomes severe, the skin is dry, flabby, and there is a sharp loss of weight. With frequent vomiting and loss of large amounts of fluid and electrolytes (primarily chlorine and sodium), a hypochloremic coma may develop.

The clinical picture of functional narrowing is the same as with organic stenosis, but unlike the latter, the symptoms of obstruction disappear as the ulcer heals and the inflammatory edema decreases. In the remission phase, only cicatricial-ulcerative deformation usually remains without disruption of the evacuation function of the stomach.

An important objective diagnostic sign of advanced stenosis is the splashing sound on an empty stomach, determined by jerky pressure on the epigastric area. When a patient loses weight, the contours of a distended stomach often appear through the thinned abdominal wall. In patients with decompensated pyloroduodenal stenosis, due to severe disturbances of water-salt metabolism, convulsions may be observed and positive Khvostek and Trousseau symptoms may be detected.

In order to definitively diagnose stenosis, its localization, and determine the severity of evacuation disorders, it is necessary to carry out both X-ray and endoscopic examinations. Endoscopic examination with targeted biopsy allows us to clarify the nature of the stenosis, and x-ray examination - the degree of its severity.

Malignancy of a gastric ulcer. The typical ulcer syndrome, healing of the ulcer, and a relatively long history are not sufficiently reliable criteria for the benign nature of a gastric ulcer. There are also no absolute differential endoscopic signs of benign and malignant gastric ulceration. Therefore, each gastric ulcer should be considered as potentially malignant, and both during initial detection and during subsequent control endoscopic examinations, a targeted biopsy (at least 5-6 biopsies from the edge and bottom of the ulcer) should be performed, followed by histological and cytological examination of the biopsy material.

Differential diagnosis of benign and malignant gastric ulcers is presented in the table.

Peptic ulcer

This is a chronic disease of the stomach and

duodenum, which is characterized by the formation

tissue defect in the walls of these organs. For peptic ulcer

characterized by a protracted course with seasonal exacerbations.

Among the causes of peptic ulcer development are:

Hereditary predisposition

Neuropsychological factors

Nutritional factors

Bad habits (smoking, alcohol)

Uncontrolled use of non-steroidal anti-inflammatory drugs

drugs

Infection (Helicobacter pylori).

Pathogenesis:

ulcers form as a result of imbalance

between aggressive and protective factors of the mucous membrane

stomach and duodenum.

Aggressive factors include: hydrochloric acid, pepsin,

bile acids (for duodenogastric reflux); to protective -

production of mucus, prostaglandins, epithelial renewal, adequate

blood supply and innervation. Currently, it is of great importance in

the pathogenesis of peptic ulcer disease, especially duodenal ulcer, is given

infectious agent - Helicobacter pylori (H. pylori). The role of H. pylori in

development of peptic ulcer disease is twofold: on the one hand, in the process of its

vital activity, it leads to constant hyperproduction of salt

acids; on the other hand, it releases cytotoxins that damage the mucous membrane

shell. All this leads to the development of antral gastritis,

gastric metaplasia of the duodenal epithelium, duodenitis, and with

the presence of a hereditary predisposition can develop into

peptic ulcer.

Features of pain syndrome in peptic ulcer disease.

As a rule, pain is localized in the epigastric region, and

with a stomach ulcer mainly in the center of the epigastrium or to the left of

midline, with duodenal and prepyloric ulcers

zones - in the epigastrium to the right of the midline. When the ulcer is localized in

in the cardiac part of the stomach, pain is felt behind the sternum, with

postbulbar ulcer - in the back or right epigastric region.

There are early, late, night and “hunger” pains.

Early pain is pain that occurs 0.5-1 hour after eating,

their intensity gradually increases, the pain bothers the patient for

for 1.5-2 hours and then, as the stomach evacuates

contents gradually disappear. Early pain is characteristic of ulcers,

localized in the upper parts of the stomach.

Late pain appears 1.5-2 hours after eating, night pain -

at night, hungry - 6-7 hours after eating, and stops after

before the patient eats, drinks milk or takes

antisecretory drugs. Late, night, hunger pains are most

are characteristic of the localization of the ulcer in the antrum of the stomach and

duodenum.

Approximately 50% of patients have mild, dull pain.

The pain can be aching, cutting, boring, cramping.

Characteristic decrease or disappearance of pain after taking

antapids, milk, food (“hunger” pains), early pains often go away

after vomiting. Exacerbation of peptic ulcer disease occurs in spring and autumn,

Seasonality is more typical for duodenal ulcers.

The mechanisms of pain are discussed in previous chapters.

Features of dyspeptic syndrome in peptic ulcer disease.

Vomiting food eaten at a height of pain brings relief to

patients with gastric ulcer. Constipation up to 2 days,

formed without admixture of blood and mucus, more characteristic of an ulcer

12 duodenum.

Also, with peptic ulcer disease there may be manifestations

neurotic syndrome.

Upon inspection:

the patient's position may be forced (with

severe pain syndrome, press the knees to the stomach) or

active. With prolonged pain and complications, it is possible

weight loss. The color of the skin and visible mucous membranes is pale.

Hyperhidrosis of the hands. Red dermographism. A tendency is revealed

to hypotension and bradycardia. When examining the abdomen, abdominal pigmentation

walls in the epigastrium due to the use of heating pads (currently observed

rarely). On palpation, local tension and pain in the epigastrium,

positive Mendelian sign (pain when tapping in

pyloroduodenal zone.).

FEGDS with mandatory biopsy determines the presence of Helicobacter

pylori, the nature and localization of ulcerative defects, the presence of precancerous

changes in the gastric mucosa.

X-ray of the stomach with contrast.

Exist

direct and indirect Rg-logical symptoms of peptic ulcer. Straight

symptom - ulcer niche ("minus" - tissue, "plus" - shadow). Indirect

symptoms: local soreness, convergence of folds to

specific area, spastic retraction of the stomach wall (symptom

"index finger") on the side opposite to the ulcer, the speed of onset

and completion of evacuation of the control mass from the stomach.

Laboratory diagnostics are carried out to the same extent as for

chronic gastritis.

Intragastric pH-metry and fractional study

gastric juice

reveal a hyperacid state.

Complications of peptic ulcer disease.

Perforation

(perforation) gastric and duodenal ulcers

intestines - this is a breakthrough of an ulcer into the free abdominal cavity with

the entry of gastroduodenal contents into it.

Perforation occurs more often in young people (from 19 to 45

years), more often in men than in women. Ulcers perforate more often

anterior wall of the prepyloric stomach and bulb

duodenum. The mechanism of ulcer perforation

consists in the progression of destructive-inflammatory

process in the ulcerative focus. Can contribute to perforation

mechanical factors leading to increased intra-abdominal

pressure (severe physical stress, heavy lifting, injury

abdomen); eating rough food and alcohol; psycho-emotional stress.

Mostly chronic callous ulcers perforate.

Perforations are always located in the center of the ulcer.

They are usually round or oval in shape, with smooth smooth edges,

as if knocked out with a punch, often small (0.3-0.5 cm in

diameter). As a rule, perforated ulcers are single, but may

be double (the so-called mirror ulcer on the anterior and posterior

walls of the stomach). Clinically, perforation manifests itself in three

syndromes: pain shock, period of imaginary (false)

well-being and peritonitis.

Pain shock period:

sharp, “dagger” pain in the epigastric

regions; tension of the anterior abdominal wall ("board-shaped"

abdomen), pronounced initially in the upper half of the abdomen. Stomach

somewhat retracted, does not participate in breathing. The patient takes

forced position - on the back or on the side with the

stomach with legs; positive Shchetkin-Blumberg sign,

Percussion reveals a zone of high tympanitis in the epigastric

areas, dullness in the lateral abdomen, as well as disappearance

liver dullness or reduction in its size due to ingestion

free gas into the abdominal cavity.

The period of shock corresponds directly to the perforation phase of the ulcer,

when the abdominal cavity suddenly pours out through a perforated hole

gastroduodenal contents. This period lasts about 6-7 hours and

manifests itself with a typical clinical picture of ulcer perforation. General

The patient's condition is serious and shock may occur. Some patients

excited, screaming in pain. Pallor of the skin is noted.

The face is covered with cold sweat, expressing fear and suffering. Breath

frequent, superficial, slow pulse, blood pressure

downgraded. The temperature is normal or low-grade.

A period of imaginary (false) prosperity

develops after a few

hours from the moment of perforation. The general condition and appearance of the patient are somewhat

improve: abdominal pain decreases (may even disappear completely);

a state of euphoria of varying severity occurs; languages

lips are dry; tachycardia, heart sounds are muffled on auscultation;

blood pressure is suppressed, arrhythmia may develop; voltage

the muscles of the anterior abdominal wall decrease; Shchetkin's symptom-

Bloomberg is preserved, but less pronounced; the decrease persists or

disappearance of hepatic dullness upon percussion; paresis develops

intestines, which is manifested by flatulence and disappearance

peristaltic bowel sounds in the abdomen.

The period of imaginary well-being lasts 8-12 hours and is replaced by

bacterial purulent peritonitis. This is the third stage of typical

perforation of a gastric or duodenal ulcer into a free

abdominal cavity. Clinical picture of a perforated ulcer during this period

does not differ from that with diffuse peritonitis of any other etiology.

Gastrointestinal bleeding syndrome

complicates

course of many diseases of the digestive tract and can

cause death. In case of massive

blood loss, circulating blood volume decreases,

blood pressure, heart rate increases, minute volume decreases

blood circulation, which causes an increase in total peripheral

vascular resistance due to compensatory,

generalized vasospasm. This compensatory mechanism

short-term, and with continued blood loss in the body can

irreversible hypoxic phenomena occur.

Classification.

By localization:

1) From a stomach ulcer.

2) From a duodenal ulcer.

By severity:

1) Mild degree (one-time vomiting and tarry stools, blood pressure and pulse

2) Moderate degree (repeated vomiting, decrease in systolic blood pressure to

90 mmHg art., pulse - 100 beats per minute).

3) Severe degree (profuse repeated vomiting, systolic blood pressure - 60

mmHg art., pulse - 120 beats per minute).

K l i n i k a:

the patient has anxiety or

lethargy, pallor, decreased blood pressure, tachycardia, and in some

cases in patients with severe blood loss may be recorded

and bradycardia associated with vagal influence.

You have bloody vomiting (hem atom esis) - typical for

bleeding from stomach ulcers. There may be coffee-ground vomiting.

or less often, scarlet blood with clots, which indicates massiveness

bleeding. Bloody stool (melena) - noted after a few

hours and even days from the onset of the disease. Characteristic symptom

Bergman - disappearance of abdominal pain after bleeding. At

objective study positive Mendelian symptom,

pain on palpation in the epigastrium.

The main method for diagnosing bleeding from the gastrointestinal tract is

endoscopic visualization of the bleeding site during FEGDS; For

Gregersen's test is used to diagnose hidden bleeding.

Pyloric and duodenal stenosis

is

is a phenomenon of narrowing of the junction of the stomach into the duodenum

intestine, which is called the pylorus, or directly

duodenum.

Stages of stenosis:

During this disease, it is customary to distinguish three clinical stages:

1. It is called pyloroduodenal compensated stenosis and

characterized by a moderately narrowed duodenal opening

intestines and pylorus. Gastric motor activity on

at this stage increases, since the gastric muscle walls

hypertrophy. This allows you to push into the duodenum

intestine from the stomach a lump of food entering during eating, as a result

how does the stomach adapt to existing problems in

food promotion.

Penetratsvya

Perforation, which is covered by a neighboring organ.

There are three stages in the development of ulcer penetration: intramural

penetration of the ulcer, stage of fibrous fusion, completed

penetration into a neighboring organ. Clinical manifestations depend on

stage of penetration and the organ into which the ulcer has penetrated. First of all,

noted: loss of rhythm of epigastric pain (pain becomes

constant), an increase in the intensity of the pain syndrome, not

amenable to therapeutic measures, irradiation of pain.

The appearance of back pain, girdle pain

observed when the ulcer penetrates into the pancreas. For

penetrating ulcer of the body of the stomach is characterized by irradiation of pain to the left

half of the chest, in the region of the heart. Development of jaundice

occurs when an ulcer penetrates into the head of the pancreas, in

hepatoduodenal ligament.

When examining the patient, tension in the abdominal muscles is revealed.

walls (viscero-motor reflex), local soreness. IN

The blood test may show leukocytosis, increased ESR.

A radiological sign of ulcer penetration is the presence

deep “niche” in the stomach or duodenum,

extending beyond the organ (with completed penetration).

Penetration of an ulcer into a hollow organ leads to the formation

pathological anastomosis (fistula) between the stomach or

duodenum, and the organ in which it occurred

penetration of the ulcer. The formation of a fistula is often preceded by a period

severe pain syndrome, accompanied by low-grade fever

body temperature, leukocytosis with a shift of the formula to the left.

If there is an anastomosis with the gallbladder or with the common bile

duct, there is irradiation of pain from the epigastric region under

right scapula, in the right supraclavicular region, vomiting with an admixture

a significant amount of bile, belching of a bitter taste. Hit

contents of the stomach or duodenum into the bile

ducts, gallbladder can cause the development of acute

cholangitis, acute cholecystitis. During the X-ray

studies can be detected in the projection of the gallbladder

horizontal level of liquid with gas above it (aerocholy),

filling the gallbladder and bile ducts with a contrast mass.

At the compensated stage of stenosis, the patient is bothered by acidic

belching, heartburn, feeling of fullness in the stomach after eating. In an hour

Tuyu is marked by vomiting of partially digested food. And after vomiting

the patient feels an improvement in his general condition. With X-ray

scopic analysis shows an increase in motor activity

stomach, frequent muscular contractions of its walls, but symptoms

slowing of gastric emptying and stenosis are not recorded.

Subcompensated stenosis

can be observed from

several months to several years. The patient immediately after

appears after eating or some time after eating

severe vomiting, followed by relief. Moreover, in

vomit contains food that was consumed in the previous

day. Many patients induce vomiting themselves because

the feeling of fullness in the stomach is extremely difficult to bear. At

in subcompensated stenosis, the taste of belching becomes rotten,

painful sensations form, even if there is no food

abundant. The patient begins to lose weight.

When palpating and examining the abdomen below the navel in the stomach

its expansion is observed (a “splashing” noise on an empty stomach).

Fluoroscopic analysis on an empty stomach notes a large volume

gastric contents. During fluoroscopy with

barium contrast shows a violation of the gastric evacuation

functions. The contrast mixture remains in the stomach for 6-8 hours.

Decompensated stenosis

occurs after 1.5-2 years, at this time

motor-evacuation gastric function weakens

at a progressive pace. As a rule, frequent vomiting is observed.

However, due to muscle weakness after vomiting, there is no relief,

since masses of food cannot completely leave the stomach. Rotten

belching becomes constant, the patient experiences a feeling of thirst,

which is associated with a large loss of water during vomiting. Moreover, in the blood

There is an electrolyte balance disorder, the manifestation of which is

are cramps and muscle twitching. A person loses his appetite

Often weight loss leads to exhaustion of the body.

X-ray examination records large volumes

gastric contents, decreased motor activity,

dilated stomach, severe gastroptosis.

As a result of the formation of a fistula between the stomach and the transverse

the colon passes food from the stomach into the large intestine, and

feces from the intestine penetrate into the stomach. Gastrointestinal signs

colonic fistula: vomiting mixed with feces, belching with

fecal odor, defecation soon after eating with the presence of

excrement of unchanged food, weight loss. With X-ray

the study reveals the entry of the contrast mass from the stomach through

fistula in the colon

Ulcer malignancy.

The etiology of stomach tumors is not completely clear

studied. Gastric cancer is a multifactorial disease.

The most significant factors are: food intake

large amounts of smoked animal products,

because they contain carcinogens; hereditary

predisposition; large amounts entering the stomach

nitrates and nitrites. Most often, stomach cancer occurs in patients

having pre-carcinogenic changes in the gastric mucosa.

To pre-tumor conditions

relate:

Atrophic gastritis with reduced acidity

Stomach polyps

Chronic stomach ulcer

History of gastric surgery

Morphology.

Gastric cancer is most often located in

pyloric region and along the lesser curvature. According to the nature of growth they distinguish

exophytic

(saucer-shaped) and

endophytic

(ulcerative-infiltrative,

diffuse-infiltrative) forms. From histological variants

the most common is adenocarcinoma, less often solid and colloid

cancer. Depending on the predominance of cancer parenchyma in the tumor or

stromas distinguish medullary (medullary) and fibrous (scirrhus) cancer.

Metastasis of stomach cancer is carried out by hematogenous and

lymphogenous routes. Most often, metastases are observed in regional

lymph nodes, lymph nodes on the left in the supraclavicular fossa

(Virchow's metastasis), liver, ovary in women (Krukenberg's metastasis), testicles

in men, rectum, axillary lymph nodes on the left.

at an early stage are represented by a decrease or

lack of appetite, aversion to certain types of food (usually

to meat), a feeling of heaviness in eating, fullness in the epigastrium,

unmotivated general weakness, weight loss. These symptoms

constitute the “small sign syndrome”, it occurs in 75-85%

patients with stomach cancer. Other patients have clinical manifestations

similar to peptic ulcer disease. In more advanced stages of cancer, pain

lose connection with food intake and become permanent. At

localization of cancer in the cardiac part of the stomach, symptoms develop

organic dysphagia, with a tumor of the pyloric region

A clinical picture of pyloric stenosis is observed.

Upon examination

weight loss, pale skin,

decreased skin turgor, coated tongue. In a third of patients

There is an increase in body temperature to subfebrile levels.

In advanced cases, cachexia is observed, palpable

axillary lymph nodes on the left and subclavian lymph nodes on the left

(Virchow's metastasis), there may be edema due to hypoproteinemia

Palpation of the abdomen:

Tumors of the lesser curvature of the stomach can be

palpate only in an upright position. Palpable

a stomach tumor indicates a late stage of the disease.

Characteristic signs of a stomach tumor are:

Localization in the area of ​​the tympanic sound of the stomach,

Movable with breathing and palpation,

If the tumor is localized on the posterior wall above it, it can be detected

splashing noise.

Palpable formations should be differentiated from tumors

and cysts of the left lobe of the liver, spleen, greater omentum,

pancreas and other organs.

Instrumental research methods

allow us to identify

early stages of stomach cancer, so they should be promptly

apply to all patients with precancerous conditions.

The most informative method that allows you to examine

mucous membrane of all parts of the stomach and perform a targeted biopsy

tissue followed by morphological examination of the biopsy sample.

X-ray of the stomach.

This method allows you to identify

a characteristic sign of stomach cancer is “filling defect”, this symptom

characterizes exophytic forms of cancer. Filling defect contours

often uneven. With an endophytic form of cancer in the affected area

there are no peristaltic movements.

Peptic ulcer disease in itself is not as terrible as its complications. Every year in Russia about 6,000 people die from complications of peptic ulcer disease.

Complications of peptic ulcer disease can be divided into three types:

1. pathological processes: perforation, penetration, bleeding, malignancy;
2. inflammatory processes: gastritis, duodenitis, inflammation of nearby organs;
3. anatomical changes stomach and duodenum.

Various combinations of the above complications are also possible.

Bleeding

The most common complication of peptic ulcer disease - 80% of cases. Bleeding, as a rule, occurs in “experienced” patients, in the elderly, while taking non-steroidal anti-inflammatory drugs (uncontrolled use of such drugs accounts for 66% of all gastrointestinal bleeding).

The immediate cause of bleeding is a violation of the integrity of the blood vessel at the site of the ulcer.

Clinical picture of gastrointestinal bleeding

1. Bloody vomiting. It has a "coffee grounds" color. Hemoglobin, which enters the stomach from a collapsed vessel, reacts with hydrochloric acid, forming hematin chloride, which has a dark brown color. It is for this reason that vomit resembles the color of coffee grounds. However, with heavy bleeding, when the chemical reaction does not have time to occur, blood may be present in the vomit.
2. Tarry stool. Again, hemoglobin, entering the intestines, forms iron compounds, which color the stool black. If there is heavy bleeding, the stool may contain blood directly. You need to know that some medications (activated carbon, bismuth, iron preparations) and food products (blueberries, bird cherry, blackberries, black currants) can turn stool a similar color.
3. Common symptoms of acute blood loss. They depend on the volume and speed of bleeding and can vary greatly: from mild discomfort to shock with loss of consciousness.

The clinical picture of bleeding does not always manifest itself with all three symptoms at once, which greatly complicates the diagnosis of this complication.

First aid for gastrointestinal bleeding:

• give the patient a horizontal position;
• call an ambulance;
• If you are confident in the diagnosis, put ice on your stomach or let you eat ice cream.

Perforation (perforation)

As a result of the deepening of the ulcer, destruction of the stomach wall occurs (perforation). In simple terms, a hole is formed in the stomach through which the contents of the stomach are poured into the abdominal cavity and retroperitoneal space.

This pathology occurs in 7-8% of all complications, and perforation of the duodenum is more common. In men, this complication develops 10 times more often than in women.

Intense physical activity, eating rough food, large doses of alcohol, and stress can provoke a perforated ulcer.

Clinical picture of a perforated ulcer

There are three possible scenarios for the development of “events” (depending on where the stomach contents ended up):

1. The contents of the gastrointestinal tract enter the abdominal cavity - the most common type of perforated ulcer. As a result, peritonitis develops - inflammation of the membrane lining the walls of the abdominal cavity and internal organs. The patient suddenly experiences a stabbing pain in the upper abdomen, which then spreads over the entire surface of the abdomen. To relieve pain, patients lie on their backs or on their sides with their knees bent. Then the pain may subside and disappear completely - a period of “imaginary well-being”, which lasts 1-12 hours and is replaced by signs of peritonitis: intolerable pain in the abdominal cavity, nausea, vomiting, thirst, drop in blood pressure, the skin becomes moist and sticky.
2. A perforated ulcer closes itself on its own with the omentum or neighboring organs, preventing gastric contents from escaping further. In this case, peritonitis does not develop, but an abscess and adhesions form.
3. The contents of the stomach enter the retroperitoneal space. Sharp pains are also noted, which subside, and after 2 days retroperitoneal phlegmon develops - the temperature rises, swelling of the 10-12 sternal vertebrae forms.

The last two options are much less common than the first.

First aid for a perforated stomach ulcer is to immediately call an ambulance.

Penetration

In 1-1.5% of cases, an ulcer, having “pierced” the stomach wall, “bumps” into another organ that is adjacent directly to the stomach wall. In this case, the contents of the stomach are not poured out, because the resulting hole is closed by the adjacent organ. The ulcer continues to grow further and penetrates into the neighboring organ, which is adjacent to the stomach at the site of the ulcer formation.

Clinical picture of penetration

Acute intense pain that spreads to various areas: back, lower back, heart, collarbone. The pain loses connection with food intake, and body temperature rises. The further course of the disease is characterized by signs of damage to the organ to which the ulcer has spread.

First aid for penetration is to immediately call an ambulance.

Stenosis

With a long course of peptic ulcer disease and frequent exacerbations, a narrowing of the outlet of the stomach or duodenal bulb may develop. This pathology prevents normal emptying of the stomach and evacuation of its contents into the duodenum. As a result, the stomach expands and food masses are retained in it. Stenosis is observed in 6-15% of all cases of complications of peptic ulcer.

There are three types of stenosis:

1. Compensated stenosis- the initial stage of development of complications, in which there is a feeling of heaviness and fullness in the stomach, belching sour after a heavy meal. Vomiting is rare and brings relief. The patient's health is satisfactory.
2. Subcompensated stenosis- the middle stage of development of the complication, in which there is a fullness of the stomach after eating small portions of food. Food stays in the stomach for a long time, causing rotten belching. Vomiting is profuse, bringing relief. The patient's health worsens.
3. Decompensated stenosis- the last stage of development of the complication, in which there is a significant deterioration in the patient’s condition. The food eaten remains in the stomach for a day or more. Vomiting no longer brings relief; the state of health improves only after washing the stomach with a tube. Dehydration occurs and muscle cramps appear.

Malignancy

The degeneration of an ulcer into cancer is not quite the correct way to pose the question. A true stomach ulcer cannot “become” cancer (at least this is what recent scientific research suggests). Apparently, an incorrect diagnosis is made at the initial stage of the disease. Therefore, when examining an ulcer, it is imperative to take pieces of tissue for a biopsy to exclude the possibility of developing a cancerous tumor. It should be said that duodenal cancer is extremely rare.

Unlike ulcers, cancer is characterized by constant pain that has no connection with food intake, decreased appetite, exhaustion of the body, nausea, vomiting, fever, and pale skin.

Inflammation

The inflammatory process that develops with a peptic ulcer can spread to surrounding organs. In addition to gastritis and duodenitis, inflammation of the tissues surrounding these organs may occur. In this case, adhesions form between the stomach or duodenum and neighboring organs - the pain becomes constant, does not depend on food intake, its intensity increases, and an increase in temperature is observed. In a horizontal position, the pain decreases.

In case of inflammation of internal organs, hospitalization in a medical institution is necessary.

ATTENTION! The information presented on this site is for reference only. We are not responsible for possible negative consequences of self-medication!

Library Gastroenterology What is limited perforation and penetration?

What is limited perforation and penetration?

The clinical picture of limited perforation corresponds to perforation, a severe attack of cholecystitis or cholelithiasis, but it is still easier and takes less time. Possible outcome is an inflammatory infiltrate, an abscess, a secondary breakthrough into the abdominal cavity followed by peritonitis. The clinical picture is polymorphic depending on the location of the lesion and its relationship to neighboring organs. For the most part (up to 90%), perforation is preceded by an ulcer history.

Penetration is a slow perforation into neighboring organs (pancreas, hepatogastric or duodenal ligament, lesser omentum, liver) 1 Most often occurs when the ulcer is localized on the posterior and lateral walls of the duodenum.

Clinical picture. Polymorphic. A penetrating ulcer is characterized by a severe course of peptic ulcer disease together with the clinic of perivisceritis; encysted perforation is characterized by intense, prolonged constant pain, blood changes (leukocytosis, increased ROE), infiltration, changes in the function of the organ into which penetration occurred.

Perforation Most often, duodenal ulcers perforate. Perforation is always accompanied by a clinical picture of an “acute abdomen.” On X-ray examination, a sign of ulcer perforation is the presence of free gas in the abdominal cavity, which looks like a narrow crescent under one or both halves of the dome of the diaphragm. The presence of gas under the right dome of the diaphragm is of diagnostic significance, since the presence of gas under the left dome can simulate a gas bubble in the stomach or gas contained in the left half of the colon. Free gas is detected in an upright position of the patient, but the optimal later position is on the left side due to the presence in the image of a sharp contrast between the gas in the form of a segment, crescent or triangle and the abdominal wall, liver and diaphragm.

Penetration is the penetration of an ulcer beyond the wall of the stomach or duodenum into an adjacent organ fused with them - the liver, pancreas, omentum, gastrohepatic ligament, mesentery, spleen, abdominal wall.

Such a niche is fixed, loses its correct conical shape, its contours become uneven and unclear. The contents of the niche are often three-layered (the lower layer is barium suspension, the middle layer is liquid, the upper layer is air), the lack of displacement and the presence of significant compaction of the tissues surrounding the niche, long-term retention of barium in the ulcer crater.

Stenosis– this is one of the most common complications of the ulcerative process affecting the pyloroduodenal area.

Clinically, this condition is usually interpreted as pyloric stenosis. However, in most cases, the narrowing is not located in the area of ​​the pyloric canal, but in the duodenum.

Radiologically, stenosis is characterized by limited narrowing of the pyloric canal of the stomach or duodenum with suprastenotic expansion of varying severity.

Research methodology: X-ray examination should be preceded by careful preparation of the patient: gastric lavage with an alkaline solution. Emptying the stomach from its contents improves the coating of the mucous membrane with barium suspension, which facilitates better detection of pathological changes in the pyloroduodenal area.

The examination of the stomach and duodenum begins with the patient in an upright position using a standard barium suspension. At the same time, they get an idea of ​​the presence of contents on an empty stomach, the degree of expansion of the stomach, its position, and the nature of the initial evacuation. However, in an upright position it is often not possible to identify the location of the narrowing, which is associated with the concomitant significant expansion of the stomach above the narrowing, as a result of which the contrast mass accumulates not in the outlet section, but in the area of ​​the gastric sinus. In this case, the contrast mass in the stomach has a motley appearance due to its mixing with the liquid and food debris contained in the stomach on an empty stomach. Scar-ulcerative pyloric stenosis is accompanied by asymmetrical narrowing of the pylorus without its lengthening with a smooth transition of the dilated parts of the stomach into the narrowed area, typical deformations of the stomach in the form of shortening of the lesser curvature and pocket-like protrusion of the greater.

The relief of the gastric mucosa is preserved; thickening and tortuosity of the folds, sometimes a niche, are often noted. The duodenal bulb is deformed.

Evacuation from the stomach is untimely, often in a lying position on the right side. Peristaltic waves alternate with antiperistaltic ones.

Degrees of stenosis:

Forming stenosis (stage I) is not clinically or radiologically manifested.

With compensated stenosis (stage II), clinical manifestations of impaired gastric evacuation are noted. An X-ray examination reveals increased peristalsis, alternating with decreased tone and moderate expansion of the stomach. Evacuation is slow. Gastric emptying is delayed for up to 4 hours.

Subcompensated stenosis (III stenosis) has a typical clinical picture (vomiting, belching, nausea, decreased appetite, the presence of splashing noise, visible peristalsis). An X-ray examination shows reduced stomach tone and the presence of liquid and food masses on an empty stomach. Peristalsis is initially brisk, but soon fades and becomes exhausted. The radiopaque substance remains in the stomach for 6 to 12 hours.

Decompensated stenosis (stage IV) is characterized by a violation of the general condition and water-electrolyte balance, a significant increase in the size of the stomach with weak or absent peristalsis. The radiopaque substance remains in the stomach for 24-48 hours, settling in the form of a sickle or, more often, on the sinus.

Scar-ulcerative stenosis should be differentiated from cancerous pyloric stenosis, which is characterized by moderate expansion of the stomach, circular narrowing and lengthening of the pyloric canal, finely toothed contours of the lesser and greater curvature in the area of ​​narrowing, the absence of the usual relief of the mucosa, the absence of deformation of the bulb or the presence of a moderate concavity of its base, which may loom over the gatekeeper.

Malignancy

Large (2.5-3 cm) callous ulcers, especially those localized in the pyloric and subcardial parts of the stomach, often become malignant. In this case, the typical nature of pain for an ulcer usually changes, appetite decreases, anemia develops, and ESR increases.

Radiologically, in the previously identified typical ulcerative niche, new signs characteristic of a malignant process are revealed: uneven edges of the ulcerative crater, an increase in its size, asymmetry of the dense tuberous shaft, especially in the area facing the exit from the stomach, breakage of the folds of the mucous membrane at the border with this area, rigidity areas of the stomach wall adjacent to the niche.

In all cases, extreme gastrobiopsy and cytological examination are resorted to.