Gastric ulcer perforation

　　First, etiology

　　There are many factors causing DU patients to perforate, and the main risk factors include:

　　1. Tension and fatigue Overly tense or tired mental state can increase vagal nerve activity, causing ulcers to worsen and perforate.

　　2. Overeating Excessive eating increases intragastric pressure, promoting gastric ulcer perforation.

　　3. The use of non-steroidal anti-inflammatory drugs The use of non-steroidal anti-inflammatory drugs is closely related to the perforation of GU and DU. Observation of patients using such drugs shows that non-steroidal anti-inflammatory drugs are the main promoting factors for DU perforation.

　　4. The use of immunosuppressants, especially the use of hormone therapy in organ transplant patients, promotes the occurrence of DU perforation.

　　5. Other factors include increasing age of patients, chronic obstructive pulmonary disease, trauma, extensive burns, and multiple organ failure.

　　Second, pathogenesis

　　Gastric ulcer perforation often occurs on the pathological basis of chronic ulcer. Under the influence of factors such as emotional tension, fatigue, diet, or medication, the active lesions of gastric ulcer during the active period can gradually deepen, erode the gastric wall from the mucosa to the muscular layer, and then to the serosal layer, finally leading to perforation. Perforation is often located on the anterior wall, and most gastric ulcer perforations are located in the anterior or superior part of the lesser curvature. Perforation is usually solitary, but occasionally it can be multiple perforations. 70% of perforations have a diameter less than 0.5 cm, and perforations greater than 1.0 cm account for 5% to 10%. After ulcer perforation, the contents of the stomach overflow into the abdominal cavity, and highly acidic or alkaline contents can cause chemical peritonitis. After about 6 hours, it can transform into bacterial peritonitis. The pathogen is mostly Escherichia coli. Before the posterior ulcer erodes to the serosal layer, it has often adhered to adjacent organs, forming a chronic penetrating ulcer, so acute perforation rarely occurs.

　　1. Sepsis is clinically confirmed to have bacteria or highly suspicious infection foci. Although sepsis is caused by infection, once it occurs, its development follows its own pathological process and law, so in essence, sepsis is the body's response to infectious factors.

　　Infectious shock, also known as septic shock, refers to a sepsis syndrome accompanied by shock caused by microorganisms and their toxins and other products. Microorganisms and toxins, as well as cell wall products, in the focus of infection enter the blood circulation, activate various cells and body fluid systems of the host; produce cytokines and endogenous mediators, acting on various organs and systems of the body, affecting their perfusion, leading to ischemia and hypoxia of tissue cells, metabolic disorders, dysfunction, and even multiple organ failure. This severe syndrome is known as infectious shock.

　　70% of acute ulcer perforation cases have a history of ulcer, 15% can have no history of ulcer at all, and 15% of cases may have brief upper abdominal discomfort for a few weeks before perforation. Patients with a history of ulcer often have a course of general symptoms加重 before perforation, but a few cases may occur during the process of regular medical treatment, even in a state of calm rest or sleep.

　　3. Signs: Patients present with a serious illness appearance, an强迫 position, shallow breathing, diffuse abdominal tenderness, rebound tenderness, but the most obvious is in the upper abdomen, presenting a 'board-like abdomen'. After stomach perforation, the air in the stomach can enter the abdominal cavity. When standing or semi-recumbent, the gas is located below the diaphragm. percussion of the liver dullness border is reduced or disappears, known as the 'gas abdomen sign'. If the fluid in the abdominal cavity accumulates more than 500ml, it can produce mobile dullness on percussion. Auscultation of bowel sounds may disappear as soon as they begin, known as 'silent abdomen', accompanied by high fever.

　　2. Typical symptoms of DU perforation are sudden severe upper abdominal pain, like a knife cut, which can radiate to the shoulder and quickly spread to the entire abdomen. Sometimes digestive juices can flow downward along the right colonic fossa to the lower right abdomen, causing lower right abdominal pain. Patients often show symptoms of shock, such as pale complexion, cold sweat, cold limbs, thin pulse, accompanied by nausea and vomiting. Patients often clearly remember the exact time when this sudden severe pain occurred. 2-6 hours later, a large amount of effusion in the abdominal cavity dilutes the digestive juices, and abdominal pain can slightly ease. Further on, due to the progression to the bacterial peritonitis stage, symptoms gradually worsen.

　　The premise of preventing stomach perforation is to prevent stomach ulcers. Stomach ulcers are more common in cold seasons, and pain can easily recur. Since there are many causes of stomach ulcers, targeted prevention should be carried out:

　　1. Be careful with eating

　　Helicobacter pylori is one of the causes of stomach ulcers. As the saying goes, 'Disease enters through the mouth,' and in daily life, especially attention should be paid to food hygiene. Do not drink unboiled water, eat less or no raw food, and ensure the disinfection of food and tableware to keep Helicobacter pylori out of the mouth.

　　2. Focus on nutrition and regularity

　　A reasonable diet and balanced diet are very important. Diet should not only be nutritious but also regular. You should not eat and drink excessively, or have irregular eating habits. You should eat at regular times and in appropriate amounts. Eat less food that is difficult to digest or has a strong irritant, such as nuts and chili.

　　3. Say 'no' to smoking and alcohol

　　According to the common understanding of people, smoking will damage the lungs. In fact, excessive smoking also has a significant impact on the stomach. Components such as nicotine in tobacco can increase stomach acid secretion, and there is a classic saying in the medical field, 'Without acid, there is no ulcer.' Excessive stomach acid can become an attacking factor and an erosive factor, which is easy to cause stomach ulcers. Similarly, if you have an ulcer and do not quit smoking, the ulcer is also difficult to heal, and it may plant landmines for stomach perforation. Although drinking a little red wine is beneficial to the digestion and absorption of food, excessive drinking or alcoholism will stimulate the stomach mucosa, cause ulcers, and increase the risk of stomach perforation.

　　4. Refuse overwork and relax your mind

　　Maintain an optimistic and cheerful attitude, keep the mental state as relaxed as possible, and adjust and relax in time when stress is too high. It is necessary to ensure enough sleep time, because the stomach is controlled and regulated by the nervous system. If you often work overtime and stay up late, the brain does not get enough rest, and the central nervous system is often in a state of excessive tension, fatigue, or depression, which will greatly affect stomach health.

　　一、血常规检查

　　5What laboratory tests need to be done for gastric ulcer perforation

　　One, blood routine examination1, White blood cell count:

　　2, Hemoglobin and red blood cells:

　　It often increases due to dehydration and blood concentration.

　　Two, serum amylase

　　It can moderately increase, but the ratio of serum amylase to creatinine clearance rate (CAM/CCr) is within the normal range.

　　Three, other auxiliary examinations

　　1, Abdominal puncture or lavage

　　2, X-ray examination, 80% of the patients can see a crescent-shaped free gas shadow below the diaphragm, and in cases with large perforations and abundant exudate, an intraperitoneal liquid level can be found, and the extraperitoneal fat line may disappear or become blurred.

　　3, Ultrasound examination

　　When the patient lies on their back, gas hyper echoes can be displayed in the prehepatic space between the anterior edge of the liver and the abdominal wall, and there are often multiple reflections behind it. When examined in a sitting position, gas echoes can be displayed between the diaphragm and the liver.

　　Therapeutic diet for gastric ulcer perforation:

　　1, White Pepper Stewed Pork Stomach Soup

　　15g of white pepper slightly crushed, 1 pork stomach (cleaned and free of impurities), add an appropriate amount of water, slow-boil, season after boiling, and serve. Suitable for ulcerative colitis due to deficiency-cold.

　　2, Lotus Seed Porridge

　　30g of lotus seeds, 100g of rice. Cook the porridge as usual, eat daily, and take for 1 month continuously. Suitable for patients with ulcerative colitis due to weak spleen and stomach.

　　3, Job's Tears Porridge

　　100g of Job's tears, 100g of long-grain rice. Cook into a thin porridge together with water, take as a single dose daily, and divide into 3 servings. Suitable for patients with ulcerative colitis due to weak spleen and stomach, and can treat gastric and duodenal ulcers.

　　4, Glutinous Rice Porridge

　　100g of glutinous rice or long-grain rice, 7 dates. Cook the porridge as usual, cook until extremely soft, and eat regularly. Suitable for patients with ulcerative colitis due to weak spleen and stomach, and can treat gastric and duodenal ulcers.

　　5, Panax Notoginseng Egg Pudding

　　3g of panax notoginseng powder, 30ml of lotus root juice, 1 egg, and a little sugar. Break the egg and beat it in a bowl; mix with fresh lotus root juice and panax notoginseng powder, add sugar, and beat with the egg. Steam and serve. It can treat blood stasis type gastric ulcer, duodenal ulcer, and hemorrhage.

　　6, Silver Ear and Date Porridge

　　20g of silver ear, 10 dates, and 150g of glutinous rice. Cook the porridge as usual. Suitable for patients with ulcerative colitis due to weak spleen and stomach.

　　7, Peach Kernel Pork Stomach Porridge

　　Ingredients and preparation: 10g of peach kernel (with peel and tip removed), 10g of raw rehmannia, 50g of cooked pork stomach slices, and 50g of rice, with appropriate seasoning. Cut the stomach slices into fine pieces; take twice the amount of water to boil and extract the juice, add the pork stomach and rice to cook into a thin porridge, season when cooked, and take it as a single dose daily.

　　Effect: It can tonify the Qi and activate the blood, resolve blood stasis and relieve pain.

　　8, Finger Citron and Adzuki Bean Porridge

　　Ingredients and preparation: 10g of finger citron, 30g each of white adzuki bean, Job's tears, and yam, stomach soup and salt to taste. Boil the finger citron in water to extract the juice, remove the residue, and add the adzuki bean, Job's tears, yam, and stomach soup. Cook into a thin porridge, add a little salt for seasoning, and take it as a single dose daily.

　　Effects: It can relieve heat and stomach, suitable for burning pain in the epigastrium, dry mouth and bitter taste, irritability, constipation, and other symptoms.

　　9. Egg and Sanqi stew

　　Ingredients and preparation: one egg, 30ml of honey, 3g of Sanqi powder. Beat the egg into a bowl, mix with Sanqi powder, steam until cooked, then mix with honey and take it.

　　There are two methods: surgical and non-surgical treatment.

　　First, non-surgical treatment

　　The main approach is to reduce leakage through gastrointestinal decompression, combined with antibiotic control of infection, waiting for the spontaneous closure of the ulcer perforation and the absorption of peritoneal effusion. Non-surgical treatment has a high mortality rate, especially in older patients with ulcer perforation. If surgery is delayed too long due to non-surgical treatment, it will increase the mortality rate of surgery. Half of the patients still have ulcer symptoms after non-surgical treatment, and ultimately, surgery is still required, with a re-perforation rate as high as 8.5%. In addition, there are a certain number of misdiagnoses and missed diagnoses. Therefore, strict indications should be followed when choosing non-surgical treatment:

　　1. Small perforation, perforation during fasting, minimal exudation, and mild symptoms;

　　2. Young patients with unclear medical history, uncertain diagnosis, and mild clinical manifestations;

　　3. Patients who cannot tolerate surgery or do not have the conditions for surgery;

　　4. Perforation time has exceeded 24 to 72 hours, with mild clinical manifestations or a tendency towards limitation (possibly forming an abscess). In summary, perforation after a heavy meal, refractory ulcer perforation, and those with massive hemorrhage and pyloric obstruction are not suitable for non-surgical treatment.

　　Second, surgical treatment

　　Currently, most hospitals in China apply perforation repair and subtotal gastrectomy. With the development of vagotomy, surgical treatment for gastric ulcer perforation has also seen new changes. In addition, a few hospitals have also carried out laparoscopic perforation repair or adhesion repair.

　　1. Simple perforation repair:

　　For the past 30 years, there has been a controversy over whether to perform simple perforation repair or curative surgery for ulcer perforation, with the focus being that more than half of the patients experience ulcer recurrence after simple perforation repair, and 20% to 40% of patients require curative surgery. Foreign reports indicate that the recurrence rate of ulcers after simple perforation repair can reach 61% to 80%, with 40% requiring further surgical treatment. In China, about 64.8% of cases have poor long-term outcomes, so some people do not advocate simple repair surgery and instead recommend curative surgery. However, Chinese data shows that emergency simple perforation repair accounts for a relatively high proportion (47.3% to 78.38%); Jcan-Maric et al. reported a proportion of 51.23%. The occurrence of this phenomenon may be due to the following reasons:

　　(1) The incidence of gastric ulcer is increasing compared to duodenal ulcer, and it is more common in older individuals. The mortality rate of curative resection of the greater curvature of the stomach is high.

　　(2) The progress of drug treatment has led to a conservative trend in gastroenterological surgeons regarding surgical treatment for peptic ulcers and the choice of surgical procedures. The Affiliated Zhongshan Hospital of Shanghai Medical University reported that in the 1990s, the proportion of simple repairs increased to 86.91%. The Second Affiliated Hospital of Hunan Medical University also reported that the proportion of simple repairs increased to over 90% after 1990. Regardless of the choice of surgical procedure, indications should be strictly followed.

　　The surgical method is to place a gastric tube, fasting, intravenous fluid, anti-infection, and other treatments before surgery, and to take a median incision. After entering the abdomen, check the location of the perforation, absorb the exudate, take a biopsy specimen around the perforation, and suture the perforation with three consecutive threads before or after tying the knot, and cover the omentum before or after tying the knot. Irrigate the abdominal cavity and place a drain.

　　2. Subtotal Gastrectomy:

　　The subtotal gastrectomy after gastric perforation should be performed as much as possible in the毕Ⅰtype operation, and the long-term effect is better than that of the毕Ⅱtype operation. The indications for subtotal gastrectomy are:

　　(1) Chronic gastric duodenal ulcer perforation, perforation time

　　(2) DU perforation with recurrence after suture repair.

　　(3) DU perforation, close to the pyloric ring, where suture may cause stenosis.

　　(4) Perforation with hemorrhage or obstruction.

　　(5) Perforation during the treatment period of chronic ulcer disease.

　　3. Gastric perforation repair + gastric vagotomy:

　　In addition to the above two surgical methods, there are also people in China who propose that it is feasible to add a gastric vagotomy after perforation repair. Li Shiyong and others performed repair and extended wall cell vagotomy on 60 patients with perforation, followed up for 6 years after surgery, with a recurrence rate of 2.3%, only 1 case of recurrence perforation (1.7%). The long-term efficacy is good. The advantage of performing HSV+perforation repair without resection of the gastric body is that the mortality rate of surgery is low. Boey et al. (1982) reported 350 cases, of which only 2 died. Boey et al. also compared perforation repair with high selective vagotomy, simple repair, and vagotomy with drainage. Follow-up for more than 3 years found that the recurrence rates of ulcers were 3.8%, 63.3%, and 11.8%, respectively. Jordan reported a group of 60 cases, with HSV+repair, without any deaths, few postoperative sequelae, and a recurrence rate of about 1.7%.

　　4. Treatment of gastric perforation under laparoscopy:

　　With the application of laparoscopy, a few units in China have also carried out laparoscopic repair of ulcer perforation or glue repair.