Peptic ulcer perforation

　　The occurrence of peptic ulcer perforation is related to the following factors:

　　One, mental state, during war or when completing urgent tasks, excessive tension and work can worsen peptic ulcer disease and lead to perforation.

　　Two, increased pressure, such as overeating or engaging in heavy physical labor, can cause the gastric wall to break through due to a sudden increase in intragastric pressure.

　　Three, the long-term use of aspirin, salicylate preparations, or hormones often causes an acute attack of peptic ulcer disease and progresses to perforation.

　　Four, insomnia and fatigue can increase the tension of the vagus nerve, thereby worsening peptic ulcer disease.

　　Five, smoking and drinking can directly stimulate the gastric mucosa, and alcohol can reduce the resistance of the mucosa to gastric acid erosion, promoting perforation.

　　Six, drivers, soldiers on the battlefield, and surgeons, among others, are prone to induce peptic ulcer perforation.

　　Perforation of peptic ulcer can easily trigger shock and acute peritonitis.

　　1. Shock

　　Severe chemical stimulation after perforation can cause shock symptoms. Patients may experience restlessness, shallow breathing, rapid pulse, and unstable blood pressure. As the pain of abdominal distension decreases, the condition can become stable. Subsequently, with the aggravation of bacterial peritonitis, the condition may worsen again, and severe cases may develop into infectious (toxic) shock.

　　2. Acute peritonitis

　　The whole abdominal muscles are tense like a board, with significant tenderness, refusal to press, and rebound pain can be elicited throughout the abdomen.

　　Several days before the occurrence of ulcer perforation, the pain in the stomach often worsens, but about 10% of patients may have no pain. This is not because the ulcer is developing rapidly, but because it has been present for a long time, and there may be no自觉 symptoms in clinical practice. Another 15% or so of patients have an unclear history of ulcer. Therefore, only about 3/4 of patients can be reminded of the possibility of ulcer perforation from the history. Once the ulcer suddenly perforates, the patient will suddenly feel severe pain in the upper abdomen, which is unbearable and forces them to lie down. Therefore, patients can often clearly recall the time and place of the attack and the situation at that time. The pain can radiate to the back or right shoulder, depending on the amount and direction of the spread of gastrointestinal contents in the abdomen. Stimulation of the top of the diaphragm causes the patient to feel shoulder pain. Stimulation of the diaphragm and peritoneum behind the gallbladder causes the patient to feel pain below the right scapula. Stimulation of the omental cavity causes the patient to feel corresponding lower back pain. When the gastrointestinal contents spread throughout the abdomen, it causes persistent severe pain throughout the abdomen. Since a large amount of gastrointestinal contents flow along the right paracolic沟 to the right iliac fossa, the symptoms in this area are particularly obvious and are easily misdiagnosed as appendicitis. After the onset of pain, accompanied by nausea and vomiting, if the vomit contains fresh blood, it has a suggestive significance for the diagnosis of ulcer perforation.

　　All patients with a history of ulcer should actively, standardly, and systematically treat. The following are specific precautions to be taken:

　　1. It is necessary to persist in long-term medication. Since gastric ulcer is a chronic disease and prone to recurrence, it is necessary to persist in long-term medication to achieve complete healing.

　　2. Avoid mental stress. Mental stress, emotional excitement, or excessive worry can produce adverse stimuli on the cerebral cortex, weaken or lose the regulatory function of the hypothalamus, and cause dysfunction of the autonomic nervous system, which is not conducive to the digestion of food and the healing of ulcers.

　　3. Pay attention to a regular lifestyle and changes in weather conditions.

　　4. Pay attention to dietary hygiene.

　　5. Avoid taking drugs that damage the gastric mucosa.

　　6. Eliminate the causes of bacterial infection.

　　White blood cell count increases. In general, for cases of acute perforation, the white blood cell count 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.

　　Percutaneous abdominal puncture, the extracted fluid is examined under a microscope. If there are numerous white blood cells or pus cells in the field of vision, it indicates inflammatory ascites, which is evidence of peritonitis. It can also be used to determine the content of ammonia. If it exceeds 3μg/ml, it indicates gastrointestinal perforation.

　　X-ray upright flat film examination shows that about 80% of patients have subdiaphragmatic gas, and B-ultrasound examination can detect abdominal abscess lesions.

　　Patients with ulcer perforation should have a light diet. During the active phase of the ulcer, it is advisable to eat light, soft, and easily digestible foods such as soft rice, noodles, milk, eggs, lotus root starch, lean meat, and fresh vegetables. After the condition stabilizes, they can eat like normal people.

　　Maintain a balanced diet, ensure sufficient energy and nutrition, and control fat intake appropriately. Animal fats such as lard should be eaten less, and vegetable oils such as soybean oil, peanut oil, and rapeseed oil can be used in cooking.

　　Chew slowly and thoroughly; chewing can increase saliva secretion, saliva can dilute and neutralize the hydrochloric acid in gastric juice, and can also improve the barrier protective effect of the gastric mucosa.

　　Specific treatment methods for ulcer disease perforation:

　　Firstly, non-surgical treatment:The purpose of non-surgical treatment is to reduce leakage through effective gastrointestinal decompression, combined with antibiotic control of infection, so that the perforation site of the stomach will close spontaneously, and the peritoneal effusion will gradually absorb, thus avoiding surgery and achieving recovery. However, it must be adopted under strict selection, with indications such as: early空腹 perforation, within 9 hours after onset; small perforation,空腹 perforation, not much effusion, and mild symptoms; elderly and weak patients who cannot tolerate surgery or do not have conditions for surgery; perforation time has been a few days, but the clinical symptoms are not severe or there is already localization. The methods of non-surgical treatment are as follows:

　　(1) Fasting and gastrointestinal decompression with placement of nasogastric tube for continuous decompression: The position of the gastric tube should ensure it is at the distal end of the greater curvature, with a sufficient diameter (18F), and the decompression device should be able to empty at regular intervals. Within 12 hours, it should be aspirated every half hour, and as the symptoms improve and the general condition improves, it should be changed to aspiration every hour.

　　(2) Fluid infusion: Intravenous fluid replacement to maintain water and electrolyte balance.

　　(3) Use of antibiotics: Perforated gastritis can cause peritonitis, in addition to chemical irritation, there is also a possibility of secondary bacterial infection, mainly due to contamination of bacteria from the oral and pharyngeal regions, with streptococci being the most common, so appropriate broad-spectrum antibiotics should be chosen for treatment.

　　(4) Monitoring: For patients with severe systemic toxic symptoms, they should be sent to the ICU for close monitoring, closely observing changes in the condition. If the condition worsens or the general condition deteriorates during the observation process, the surgical treatment should be changed without hesitation.

　　Secondly, surgical treatment:Surgical treatment is divided into simple suture of perforation or subtotal gastrectomy. Simple suture of perforation is applied to patients with abundant peritoneal effusion, severe contamination, weak physique, and poor general condition. When performing suture for gastric ulcer perforation, selective vagotomy and pyloroplasty can be performed at the same time, which not only solves the perforation problem but also treats the ulcer fundamentally, resulting in good effects.

　　For those suspected of having gastric ulcer perforation and cancer, it is recommended to perform a subtotal gastrectomy as much as possible, and take samples for pathological examination to avoid missing the diagnosis of gastric cancer.