Gastric perforation

　　The most common cause of gastric perforation is peptic ulcer. As the ulcer deepens continuously, it penetrates the muscular layer and serosal layer, finally penetrating the stomach or duodenal wall to cause perforation. After perforation, several different consequences may occur. If the base of the ulcer has already adhered to adjacent organs such as the pancreas and liver before perforation, forming a penetrating ulcer, this is a chronic perforation. In a few cases, the base of the ulcer adheres to the transverse colon, and a gastric colonic fistula is formed after perforation. Both of these situations mostly occur in the posterior wall ulcers of the stomach and duodenum. If the ulcer perforation quickly adheres to the omentum or adjacent organs, abscesses may form around the perforation.

　　The main cause of acute ulcer perforation is the necrosis of the base tissue of the active ulcer, penetrating the serosal layer, causing the stomach cavity to communicate with the peritoneal cavity. After the ulcer perforation, the contents of the stomach and duodenum, such as food, gastric juice, bile, and pancreatic juice, flow into the peritoneal cavity. Initially, the stimulation by gastric acid and bile causes chemical peritonitis, resulting in severe and persistent abdominal pain. Several hours later, as the outflow of gastrointestinal contents decreases, the exudate caused by peritoneal stimulation increases, and the gastrointestinal outflow is diluted, the pain may temporarily subside. Generally, 8 to 12 hours later, due to the growth and reproduction of bacteria in the abdominal cavity, bacterial peritonitis is formed, causing intestinal paralysis, sepsis, and toxic shock. In cases of chronic perforation, as the ulcer develops deeper, it often gradually forms adhesions with surrounding tissues, manifesting as chronic penetrating ulcers, gastric gallbladder fistula, or duodenal gallbladder fistula.

　　Complications caused by gastric perforation include shock, acute peritonitis, and other complications, which need to be paid attention to in daily life.

　　After shock perforation, severe chemical stimulation can cause shock symptoms. Patients begin to exhibit symptoms such as pale skin, cold extremities, increased heart rate and breathing, and reduced urine output. If timely diagnosis and treatment are provided in the early stage of shock, the shock can quickly improve. However, if not treated effectively and promptly, shock can further develop into shock phase. Patients may show symptoms such as restlessness, shallow breathing, rapid pulse, and unstable blood pressure. As the pain in the abdomen decreases, the condition may become more stable. Subsequently, as bacterial peritonitis worsens, the condition may again deteriorate, and severe cases may develop into infectious (toxic) shock.

　　2. Acute peritonitis presents with generalized muscle tension like a board, marked tenderness, resistance to palpation, and rebound tenderness throughout the abdomen. Laboratory examination: an increase in white blood cells can be seen. In general, the white blood cell count in cases of acute perforation is between 15,000 and 20,000/mm3, with an increase in neutrophils; hemoglobin and red blood cell count also increase due to varying degrees of dehydration. Tentative abdominal puncture, and the fluid withdrawn is examined under a microscope. If a full field of white blood cells or pus cells is seen, it indicates inflammatory ascites, which is evidence of peritonitis. The ammonia content can also be measured. If it exceeds 3 μg/ml, it indicates gastrointestinal perforation.

　　The clinical stages of gastric perforation can be divided into three stages, with different symptoms in each stage:

　　First stage: Sudden, severe abdominal pain, like a knife cut, may be continuous or exacerbate intermittently. The pain initially located in the upper abdomen or below the xiphoid process quickly spreads to the whole abdomen, with the upper abdomen being more severe. Sometimes it may be accompanied by radiation to the shoulder and back. If the gastric contents flow along the right paracolic sulcus to the lower right abdomen, right lower quadrant pain may occur. Due to the severe pain, symptoms such as pale complexion, cold extremities, cold sweat, rapid pulse, and shallow breathing may occur, often accompanied by nausea and vomiting, and shock may occur.

　　Physical examination shows the patient with an acute painful expression, lying supine and refusing to move, with weakened abdominal breathing. The whole abdomen has tenderness, rebound tenderness, and muscle tension may present as 'board-like' rigidity. A decrease or disappearance of the liver dullness suggests the presence of pneumoperitoneum. Bowel sounds are decreased or absent, and abdominal puncture may withdraw gastrointestinal contents.

　　Second stage: After 1-5 hours of perforation, due to the increased peritoneal effusion in the patient's abdominal cavity, the gastrointestinal contents flowing into the abdominal cavity are diluted, and the abdominal pain may temporarily subside. Patients may feel improved, and their pulse, blood pressure, and facial color, as well as respiration, may return to normal. However, they still cannot perform actions involving the abdominal muscles. The signs of acute peritoneal irritation, such as muscle tension, tenderness, and decreased or absent bowel sounds, still continue to exist.

　　Third stage: After 8-12 hours of perforation, it often turns into bacterial peritonitis, and the clinical manifestations are similar to those caused by bacterial peritonitis from any cause. Patients present with an acute severe appearance, and symptoms such as fever, dry mouth, weakness, increased respiratory and pulse rates, and decreased blood pressure may occur as systemic infection and poisoning symptoms. Abdominal distension, generalized muscle tension, tenderness, rebound tenderness, and positive mobile dullness. Abdominal puncture may withdraw whitish or yellowish turbid fluid. In severe cases, those who fail to receive timely rescue often die due to paralytic ileus, sepsis, or septicemia, and infectious toxic shock.

　　Gastric perforation is a disease with an acute onset and severe condition in clinical practice. Therefore, special attention should be paid to prevention, and the following are several common preventive methods:

　　(1) Patients with gastric and duodenal ulcers should undergo early gastroscopy to clarify the nature, location, and severity of the ulcer, and receive timely systemic medical treatment. Gastric perforation is a serious complication of gastric ulcers, and therefore, it is necessary to seek medical treatment promptly after the discovery of gastric ulcers to avoid the occurrence of gastric perforation.

　　(2) Patients with ineffective systemic treatment or recurrence after ulcer healing should undergo early surgical treatment. It is important to treat gastric ulcers and their recurrence as soon as possible.

　　(3) Avoid stimulation: Regular diet, eat less and more meals, avoid cold, rough, spicy and other stimulating foods, quit smoking and limit alcohol, relieve mental tension. Do not smoke because smoking causes the contraction of stomach blood vessels, affects the blood supply to the gastric wall cells, reduces the resistance of the gastric mucosa and induces gastric disease. It should be less drunk, less spicy food such as chili and pepper.

　　(4) Avoid drugs that damage the gastric mucosa, such as aspirin, indomethacin, and other non-steroidal anti-inflammatory drugs, hormone drugs, etc. If they must be used, protective gastric mucosa drugs and acid-suppressing drugs should be added.

　　(5) Pay attention to cold prevention: After the stomach is cooled, its function will be damaged, so attention should be paid to keeping the stomach warm and not catching a cold. Clothing should be added in a timely manner, and cold water and hard food should not be consumed in excess.

　　The examination items for gastric perforation include upper gastrointestinal X-ray barium meal, gastrointestinal CT examination, gastric ultrasound examination, and gastrointestinal imaging endoscopy. Specifically, it includes the following content:

　　1. Physical examination: Abdominal wall tenderness, rebound pain, muscle tension, symptoms of peritonitis, reduced or disappeared liver dullness area.

　　2. Abdominal puncture to extract purulent fluid, the diagnosis is relatively clear.

　　3. Gastrointestinal imaging endoscopy: Gastrointestinal imaging can clearly identify the location and extent of gastrointestinal bleeding, providing useful information for clinical treatment. Abnormal cases of gastrointestinal bleeding include diffuse gastric mucosal islands on the small intestine, ectopic gastric mucosa, smooth muscle sarcoma of the small intestine, 'Blue rubber bleb nevus syndrome' (Bean's syndrome), varicose veins of the small intestine, traumatic pseudo-aneurysm of the colonic artery, rupture of abdominal aortic aneurysm, angiosarcoma, and other lesions.

　　4. X-ray examination, about 75% to 80% of cases can see crescent-shaped free gas under the diaphragm. Free gas under the diaphragm is an important evidence for the diagnosis of gastric perforation. Combined with the patient's past history of ulcer and recent history of ulcer activity, the severe abdominal pain and symptoms of acute diffuse peritonitis after perforation, abdominal puncture to extract digestive fluid containing gastrointestinal contents, it is not difficult to diagnose.

　　5. Gastric ultrasound examination: The greatest advantage of gastric ultrasound is that the sound beam can penetrate the gastric wall, thus displaying the stratified structure of the gastric wall. As a non-invasive diagnostic method, it can provide clinical information on the location, size, and shape of gastric wall tumors, and sometimes can estimate the extent of the lesion invasion of the gastric wall.

　　Patients with gastric perforation should pay special attention to their diet, as the stomach, as the main digestive organ, is very sensitive to the stimulation of food. Whether before or after surgery, attention should be paid to the following aspects:

　　1. Eat less fried food: Because these foods are not easy to digest, they will increase the burden on the digestive tract, cause indigestion, and increase blood lipids, which is not good for health.

　　2. Eat less preserved food: These foods contain a lot of salt and certain carcinogens, and should not be eaten in large quantities.

　　3. Eat less cold and spicy food: Cold and spicy foods have a strong stimulating effect on the mucous membrane of the digestive tract, which is easy to cause diarrhea or inflammation of the digestive tract.

　　4. Regular diet: Studies have shown that eating regularly, at fixed times and amounts, can form a conditioned reflex, which is beneficial for the secretion of digestive glands and more conducive to digestion.

　　5. Regular and Quantitative Eating: It is necessary to ensure moderate food intake for each meal, three meals a day at regular times. At the designated time, regardless of whether the stomach is hungry or not, active eating should be done to avoid being too hungry or too full.

　　6. Chewing Slowly: To reduce the burden on the gastrointestinal tract. The more thoroughly the food is chewed, the more saliva is secreted, which has a protective effect on the gastric mucosa.

　　7. Drinking Water at the Right Time: The best time to drink water is in the morning on an empty stomach and one hour before each meal. Drinking water immediately after meals will dilute the gastric juice, and using soup to cook rice will also affect the digestion of food.

　　7. Supplementing Vitamin C: Vitamin C has a protective effect on the stomach, maintaining a normal content of vitamin C in the gastric juice can effectively exert the function of the stomach, protect the stomach, and enhance the stomach's ability to resist diseases. Therefore, it is necessary to eat more vegetables and fruits rich in vitamin C.

　　For the treatment of gastric perforation, the principle should be to seek surgical treatment as soon as possible. Delayed treatment, especially over 24 hours, will significantly increase the mortality rate and the incidence of complications, and prolong the hospital stay. Therefore, patients should choose the treatment method as soon as possible when they are ill.

　　The choice of surgical method should be based on the patient's general condition, age, ulcer location, perforation time, abdominal contamination degree, and whether the frozen section result is malignant.

　　(1) Simple perforation repair after peripheral biopsy of gastric perforation: For patients with poor general condition, accompanied by serious diseases of the heart, lungs, liver, and kidneys, perforation time exceeding 8 to 12 hours, severe intra-abdominal inflammation, and severe duodenal edema, etc., the risk of radical surgery is estimated to be high. After peripheral biopsy of gastric perforation is negative, simple perforation repair is suitable. Repair can be divided into open repair and laparoscopic repair.

　　(2) Radical Surgery: The advantage of radical surgery lies in the fact that it solves both the problems of perforation and ulceration at the same time. It is suitable for patients with generally good conditions, perforation within 8 to 12 hours, mild intra-abdominal infection and duodenal edema, and no concurrent diseases of important organs. Radical surgery includes: ① subtotal gastrectomy; ② perforation repair combined with vagotomy; ③ perforation repair, vagotomy, and partial gastrectomy or pyloroplasty. The first two surgical methods are more effective.