Surgery (Peptic ulcer). Peptic ulcer surgery Diagnosis of gastric ulcer

Surgery for stomach ulcers is indicated when lesions form on the mucous membrane of the organ. Ulcers usually do not exceed 1 cm in diameter and affect the upper layers of the mucosa. However, relapses of the pathology can provoke more serious damage to the digestive system. In any case, drug therapy is preferable for most patients. But sometimes surgery is the only adequate treatment method.

Reasons for the development of pathology

The causes of stomach ulcers are varied. But two main factors have a direct impact on the condition of the organ mucosa. One of them is increased stomach acidity. A high concentration of hydrochloric acid affects the mucous membrane, corroding it.

The second factor is the vital activity of Helicobacter pylori bacteria. These microorganisms were identified in almost all patients with gastric ulcers. In fact, they are classified as opportunistic. When the digestive system is stable, they “sleep” in the body.

As soon as the organs fail, favorable conditions are created for Helicobacter. They begin to multiply rapidly, negatively affecting the cells of the mucous membrane and destroying the protective mechanism of the stomach. Bacteria enter the body through household means and through infected saliva. In some cases, symptoms of a stomach ulcer do not appear; its development is indirectly affected by:

• neuro-emotional stress;
• hereditary predisposition;
• smoking, drinking stimulating drinks (coffee, alcohol);
• abuse of certain foods (sour, spicy, salty);
• eating disorders (“dry food”, long breaks between meals);
• chronic diseases (diabetes mellitus, hepatitis, pancreatitis, syphilis);
• overdose of certain medications (cytostatics, potassium preparations, anticoagulants, glucocorticoids, antihypertensive drugs).

The risk of developing pathology increases when the patient is over 65 years old and with recorded cases of gastric bleeding.

Important! An ulcer can result from stomach trauma, blood poisoning, any state of shock, burns of a large surface of the body and frostbite.

Indications for surgery

Surgery for a diagnosis of gastric ulcer is prescribed according to relative and absolute indications. If absolutely indicated, the operation is performed urgently, without attempting to cure the ulcer using traditional methods. The question of the most acceptable option for surgical intervention is being resolved. Relative indications suggest possible continuation of drug therapy and temporary delay of surgery.

Extensive bleeding in the gastrointestinal tract and the transition of the ulcer to a malignant state are considered absolute indications for surgical treatment of peptic ulcer. The operation is vital in case of pathological narrowing of the pylorus, when pieces of food physically cannot move from the stomach to the next section - the duodenum. A perforated stomach ulcer also requires emergency surgery.

Relative readings:

• germination of an ulcer to a neighboring organ (liver, duodenum);
• callous form of pathology (open wound 3-4 cm);
• severe deformations of the stomach (a consequence of scarring of healed ulcerations);
• noticeable disturbances in the movement of a bolus of food from the stomach to the duodenum;
• repeated stomach bleeding;
• regular relapses of the disease;
• long-term non-healing ulcers.

The outcome of planned surgical interventions for peptic ulcer disease is in most cases favorable, so they are more preferable. Emergency surgery for absolute indications may be ineffective. In addition, absolute indications for surgical intervention imply the presence of life-threatening conditions. A fatal outcome is not excluded even with a timely operation.

Important! Bloody vomiting and black stools– characteristic symptoms of a stomach ulcer with internal bleeding.

Surgical therapy for peptic ulcer

Surgical treatment of gastric ulcers involves performing organ-saving operations or manipulations using radical methods. In each case, the choice of type of surgical intervention is individual. The surgeon takes into account the general condition of the patient’s body, his age, manifestations of concomitant pathologies and complications. An important role is played by the type and degree of progression of the peptic ulcer itself, and the size of the lesions. For ulcerative pathologies of the gastrointestinal tract, several types of surgical interventions are used.

Vagotomy

Vagotomy is a surgical dissection of the branch of the vagus nerve, which is responsible for stimulating gastric secretion. After surgery, stimulation of hydrochloric acid-producing cells stops. The acidity of the stomach contents sharply decreases, which promotes the healing of ulcers.

Dissection of the vagus nerve is carried out using mechanical, chemical (with coagulation) and combined methods. This type of surgery is rarely used. Sometimes in patients who have undergone vagotomy, the removal of stomach contents is impaired, which leads to serious consequences, even fatal.

Resection

Resection is one of the most common methods in the treatment of gastric ulcers. The operation is performed both routinely (recurrent or long-lasting ulcers) and emergency (perforated gastric ulcer, bleeding). During surgery, from a third of the stomach (if the ulcers are localized near the outlet) to three-quarters of the organ are removed. If the doctor suspects that the ulcer is malignant, he may order a total resection (gastrectomy).

Surgery is performed under general anesthesia. An incision is made along the midline from the chest to the navel. The doctor gives mobility to the stomach by cutting off ligaments and ligating the vessels leading to the organ fragment being removed. At the site of removal, it is stitched with an atraumatic needle or a special device.

The stomach fragment to be removed is cut off. The remaining part of the organ is combined with the duodenum (anastomosis), and sometimes with the small intestine. A drainage is left in the peritoneum, and a probe is left in the stomach. The wound is sutured. The drain is usually removed on the third day. The stitches are removed after a week. The patient takes antibacterial and painkillers.

Local excision

The operation to remove ulcers is characterized by low trauma. But this method eliminates only the consequences of the pathology, without affecting the causes of its occurrence, which often leads to recurrent cases. Rough scars often form in the suture area, disrupting the process of gastric emptying. Such situations lead to repeated surgical interventions.

Palliative suturing

Suturing is usually performed when the ulcer is perforated. The operation is performed under general anesthesia. The perforation discovered during examination of the abdominal cavity is sutured with an absorbable thread. Sometimes, for reliability, a fold of the peritoneum (greater omentum) is sutured to the hole.

The stomach contents and exudate that have penetrated there are removed from the abdominal cavity. The cavity is washed and drainage is provided. A tube is inserted into the stomach to drain the contents. The wound is sutured in layers. The patient is prescribed broad-spectrum antibiotics. If symptoms of peritonitis appear, repeated surgery is required.

Gastroenterostomy

Operation to create a gastrointestinal anastomosis. A channel is artificially formed that connects the stomach to the small intestine. In this case, the digested food does not enter the duodenum and the pylorus.

The purpose of such a surgical intervention is to ensure rapid emptying of the stomach and the progress of reactions to partially neutralize the contents of the stomach with alkaline digestive juice released from the intestines. Often such surgical interventions not only improve well-being, but also lead to complete recovery of patients. However, sometimes patients get worse because the causes of the ulcer are not eliminated. Moreover: ulcers do not just recur, but contribute to the development of ulcerative anastomositis.

Laparoscopy

Laparoscopic interventions are gradually replacing open operations. Using this method, almost any surgical intervention is performed (suturing a hole in the wall of the stomach, its resection). During laparoscopy, manipulations are performed using special equipment through several small punctures. The sequence of stages and anesthesia are the same as for open operations.

During resection, the walls of the stomach are sutured with a regular suture (the operation in this case takes longer) or with a stapler. To remove part of the organ, one of the punctures is widened to 3-4 cm. Such treatment of stomach ulcers has a number of undeniable advantages. But this technique is not applicable in all cases of peptic ulcer. For example, laparoscopy will not be performed if the patient has peritonitis or a significant perforated gastric ulcer.

Interesting! Fresh potato juice helps neutralize the hydrochloric acid contained in gastric juice.

Recovery period

After surgery, long-term therapy with antiulcer drugs is necessary. In the first ten days, bed rest is indicated. However, certain physical activity is recommended for operated patients. You can move your legs immediately after waking up from anesthesia. From the first day after surgery, the patient is prescribed breathing exercises. You are allowed to get out of bed on the second or third day after surgery - in the absence of contraindications.

An important component of effective therapy for ulcers is a strict diet after surgery. It must be followed for several months. The basic principle of nutrition during this period is the limitation of simple carbohydrates, liquids and salt. Such nutrition after gastric ulcer surgery prevents inflammation and helps the body recover.

On the first day after surgery, the patient should neither eat nor drink. Nutrients are introduced into his body intravenously. On the second or third day, he is allowed to drink some still mineral water, weakly brewed tea or unsweetened fruit jelly. After a few days, you can add rosehip decoction, soft-boiled eggs, pureed soups, rice or buckwheat porridge, and steamed cottage cheese soufflé to the patient’s diet.

10 days after surgery, the diet includes pureed vegetables (zucchini, potatoes, carrots, pumpkin), steamed fish or meat cutlets. All dishes are prepared without oil. The bread can be eaten only after a month, and not fresh, but slightly stale. Fermented milk products are allowed to be consumed two months after surgery. With favorable postoperative rehabilitation, you can expand your diet more fully after two to four months.

Products – useful and not so useful

A few months after surgery, a strict diet is no longer necessary, but you should not overload your stomach. You need to eat in small portions, at least six times a day. You need to give up fatty fish and meat dishes, mushrooms and mushroom soups, smoked meats and any canned food.

Avoid the use of seasonings, pickles, marinades, and vegetables rich in fiber (cabbage, radishes). Fresh fruits are also undesirable; they are recommended to be consumed in jelly or compotes. The consumption of fresh bread should be limited, and alcohol should be completely eliminated.

Prevention of pathology

To prevent Helicobacter pylori bacteria from being active, it is necessary to follow the rules of personal hygiene. If an infection is detected, you should take medications prescribed by your doctor. In addition, to prevent stomach ulcers, you should be periodically examined, especially by a gastroenterologist and dentist. These measures are necessary for timely diagnosis and treatment of diseases that can provoke gastric pathologies.

To avoid developing peptic ulcers, you need to eat well and lead a healthy lifestyle. It is important to learn to control your emotions and not get nervous over minor reasons. And, of course, it is necessary to give up bad habits. Smoking and alcohol abuse directly affect all internal organs, including the stomach. And this effect is not at all favorable.

Surgical therapy for gastric ulcers can provoke the development of complications. But so far this is the most effective method of combating the disease. It is effective in 85-90% of cases of gastric ulcer. With an adequate approach, the correct choice of type of surgical intervention and sufficient qualifications of the operating doctor, the possible risks of surgical treatment are minimal.

St. Petersburg State Medical Academy named after I.I. Mechnikov.

Department of Faculty Surgery named after V.A. Oppel.

on the topic: Peptic ulcer

ORGAN ANATOMY

Ventriculus , stomach, represents a pouch-like expansion of the digestive tract. The accumulation of food occurs in the stomach after it passes through the esophagus and the first stages of digestion occur, when the solid components of the food turn into a liquid or mushy mixture. The stomach has anterior and posterior walls. The concave edge of the stomach, facing up and to the right, is called the lesser curvature, curvatura ventriculi minor; the convex edge, facing down and to the left, is the greater curvature, curvatura ventriculi major. On the lesser curvature, closer to the outlet end of the stomach than to the inlet, a notch is noticeable, where two sections of the lesser curvature converge at an acute angle, angulus ventriculi.

The following parts are distinguished in the stomach: the place where the esophagus enters the stomach is called the ostium cardiacum; adjacent part of the stomach - pars cardiaca; exit site - pylorus, pylorus, adjacent part of the stomach - pars pylorica; the dome-shaped part of the stomach to the left of the ostium cardiacum is called the bottom or fornix. The body extends from the fornix of the stomach to the paras pu1orica. Pars pylorica is in turn divided into the antrum pyloricum - the section closest to the body of the stomach and the canalis pyloricus - a narrower, tube-shaped part adjacent directly to the pylorus.

Topography of the stomach. The stomach is located in the epigastrium; most of the stomach (about 5/6) is to the left of the median plane; the greater curvature of the stomach, when it is filled, is projected into the umbilical region. With its long axis, the stomach is directed from top to bottom, from left to right and from back to front; in this case, the inlet is located to the left of the spine behind the cartilage of the VII left rib, at a distance of 2.5-3 cm from the edge of the sternum; its posterior projection corresponds to the XI thoracic vertebra; it is significantly removed from the anterior wall of the abdomen. The gastric vault reaches the lower edge of the 5th rib along lin. Mamillaris sin. When the stomach is empty, the pylorus lies along the midline or slightly to the right of it against the right VIII costal cartilage, which corresponds to the level of the XII thoracic or I lumbar vertebra. When the stomach is full, at the top it comes into contact with the lower surface of the left lobe of the liver and the left dome of the diaphragm, behind - with the upper pole of the left kidney and adrenal gland, with the spleen, with the anterior surface of the pancreas, further below - with the mesocolon and colon transversum, in front - with the abdominal wall between the liver on the right and the ribs on the left. When the stomach is empty, due to the contraction of its walls, it goes deep and the free space is occupied by the transverse colon, so that it can lie in front of the stomach directly under the diaphragm. The size of the stomach varies greatly both individually and depending on its filling. With an average degree of stretching, its length is about 21-25 cm.

Structure. The wall of the stomach consists of three membranes: 1) mucous membrane with a highly developed submucosa; 2) muscular layer; 3) serous membrane.

Arteries of the stomach come from truncus coeliacus and a. lienalis. Along the lesser curvature there is an anastomosis between a. gastrica sinistra (from truncus coeliacus) and a. gastrica dextra (from a. hepatica communis), large - aa. gastroepiploica sinistra (from a. lienalis) et gastroepiploica dextra (from a. gastroduodenalis). Aa is suitable for the fornix of the stomach. gastricae breves from a. lienalis. The arterial arches surrounding the stomach are a functional adaptation necessary for the stomach as an organ that changes its shape and size: when the stomach contracts, the arteries twist, when it stretches, the arteries straighten.

Vienna stomach, corresponding along the course of the arteries, flow into v. portae.

Nerves stomach - these are branches of n. vagus et truncus sympathicus. N. vagus enhances gastric peristalsis and the secretion of its glands, relaxes the pyloric sphincter. Sympathetic nerves reduce peristalsis, cause contraction of the pyloric sphincter, constrict blood vessels, and transmit the feeling of pain.

duodenum, duodenum, curves around the head of the pancreas in a horseshoe shape. There are four main parts in it: 1) pars superior is directed at the level of the first lumbar vertebra to the right and back and, forming a downward bend, flexura duodeni superior, passes into 2) pars descendens, which descends, located to the right of the spinal column, to the third lumbar vertebra ; here the second turn occurs, and the intestine goes to the left and forms 3) pars horisontalis, running transversely in front of the inferior vena cava and aorta, and 4) pars ascendens, rising to the level of the I-II lumbar vertebra on the left and in front.

Topography of the duodenum. On its way, the duodenum fuses with the head of the pancreas along the inner side of its bend; in addition, the pars superior is in contact with the quadrate lobe of the liver, the pars descendens is in contact with the right kidney, the pars horisontalis passes between the upper mesenteric artery and vein in front and the aorta and inferior vena cava in the back. Duodenum does not have a mesentery and is only partially covered by peritoneum, mainly in the front. The anterior surface of the pars descendens remains uncovered by the peritoneum in its middle section, where the pars descendens is intersected in front by the root of the mesentery of the transverse colon; The pars horisontalis is covered with peritoneum in front, with the exception of a small area where the duodenum is crossed by the root of the mesentery of the small intestine, which contains the vasa mesenterica superiores. Thus, duodenum can be classified as extraperitoneal organs.

When the pars ascendens passes into the jejunum on the left side of the I or, more often, II lumbar vertebra, a sharp bend of the intestinal tube, flexura duodenojejunalis, is obtained, with the initial part of the jejunum directed downward, forward and to the left. Flexura duodenojejunalis, due to its fixation on the left side of the II lumbar vertebra, serves as an identification point during operations to locate the beginning of the jejunum.

Blood supply duodenum. Duodenum feeds from aa. pancreaticoduodenales inferiores (from A. mesenterica superior). Venous blood flows through the veins of the same name into the portal vein.

Fig. 1 Anatomy of the stomach and duodenum.

1- incisura cardiaca ventriculi, 2- fundus ventriculi, 3- corpus ventriculi, 4- curvatura ventriculi major, 5- pars pylorica, 6- antrum pyloricum, 7- curvatura ventriculi minor, 8- pars cardiaca, 9- incisura angularis, 10- pylorus, 11- pars superior duodeni, 12- pars descendens duodeni, 13- pars horisontalis duodeni, 14- pars ascendens duodeni, 15- truncus caeliacus, 16- a. lienalis, 17- a. gastro-duodenalis, 18-a. hepatica communis, 19-a. pancreatico-duodenalis superior, 20-a. duodenalis superior, 21-a. gastrica sinistra, 22-a. gastro-epiploica sinistra, 23-a. gastro-epiploica dextra, 24-aa. gastrici breves, 25-a. duodenalis inferior, 26- aorta, 27- a. gastrica dextra.

ETIOLOGY AND PATHOGENESIS OF GASTROINTESTINAL BLEEDINGS

Acute gastrointestinal bleeding occurs in a number of diseases that differ from each other in their origin and mechanism of development. In this regard, gastrointestinal bleeding is divided into ulcerative and non-ulcerative.

Ulcerative hemorrhages account for about 60% of all acute gastrointestinal bleeding. They are massive in nature and great care has been taken. However, the etiology and pathogenesis of ulcerative bleeding has not yet been sufficiently studied. Development mechanism gastroduodenal bleeding is closely related to pathogenesis gastric and duodenal ulcers and therefore should be considered together.

Numerous clinical and experimental research showed that explain the pathogenesis of peptic ulcer uni container theory is impossible, since a significant amount of o common and local factors that have close connections between the

To general factors the occurrence and development of peptic ulcer disease should include:

1) disturbance of nervous regulation

2) disorders of hormonal mechanisms.

The significance of the listed factors in the occurrence of ulcerative b diseases stomach and duodenum, complicated by bleeding, and their pathogenetic role are not the same.

Acute bleeding from the duodenum accounts for 24.5%. They were in cases of chronic ulcer (23.2%), acute ulcer (0.45%), diverticulum (0.25%), duodenal cancer (0.25%), pancreatic cancer (0.2%), rupture aortic aneurysm (0.05%), hemobilia (0.05%), hysteria (0.05%). Bleeding has been published for: pancreatic adenoma, omental volvulus, sepsis, appendicitis, syringomyelia, cholelithiasis, vitamin deficiency, food intoxication, uremia, radiation sickness, allergies, medicinal ulcers and surgical interventions.

Acute bleeding from the small intestine occurs in 1.1%. For cancer (0.3%), thrombosis of mesenteric vessels (0.2%), acute ulcer (0.2%), ulcerative enterocolitis (0.2%), diabetes (0.1%), retroperitoneal lymphosarcoma (0.05%), Rendu-Osler disease (0.05%). Bleeding has been described in Meckel's diverticulum, polyposis, typhus and typhoid fever, cholera, intussusception, benign neoplasms, helminthic infestation, blood diseases and other diseases.

Acute bleeding from the colon is 2.55%: with cancer (1%), colitis (0.85%), polyposis (0.35%), dysentery (0.15%), diverticulum (0.1%), acute ulcer (0.1%). Acute bleeding in cholera, tuberculosis, intussusception, thrombosis of mesenteric vessels and other pathologies have been published.

Acute bleeding from the rectum and anal canal is observed in 4.03%: with hemorrhoids (2.93%), cancer (0.4%), anal fissures (0.25%), rectal injuries (0.2%), polyp (0.2%), biopsy (0.05%). Bleeding can occur with rectal prolapse, specific and nonspecific ulcers, proctitis, acute and chronic paraproctitis and other diseases.

When developing a classification of acute gastrointestinal bleeding, the degree of blood loss is given very important importance. The degree of blood loss often determines the patient’s condition and forces him to seek medical help). There is a variety of terminology in the literature, using which the authors tried to emphasize the severity of bleeding and its intensity.

However, all these names (severe, medium, light, large, moderate, small, profuse, massive, dangerous, uncontrollable, life-threatening, etc.) reflect only a subjective assessment of the patient’s condition and cannot characterize the degree of blood loss.

When determining the degree of blood loss, most authors used: 1) reports from the patient, relatives, others and medical workers about the amount of blood lost, calculated in various volumetric units (liters, glasses, basins, etc.); 2) color of the skin and mucous membranes, respiratory rate, pulse and level of arterial and venous pressure; 3) relative indicators of a clinical blood test (number of red blood cells, hemoglobin, color index value); 4) level of hematocrit number, specific gravity of blood and plasma.

The use of these indicators to determine the degree of blood loss cannot be controversial. However, it should be remembered that subjective information, objective external signs and laboratory relative indicators (calculated in % or mg%) can only provide approximate data on the amount of blood loss. Even hematocrit, the specific gravity of blood and plasma, examined in the first hours after the start of bleeding, does not reflect the true extent of blood loss, since the blood remaining in the body does not dilute immediately, but only after several hours and even days.

One of the objective and most accurate methods for determining blood loss is the study of the blood volume and its components and the calculation of the deficit of hematological parameters. Only the determination of the bcc and its components makes it possible to determine what part of the blood remains in the body after hemorrhage and takes part in the circulation.

Based on numerous clinical observations, studies of the blood volume and its components and comparison of the data obtained, we have come to the conclusion that it is possible to determine with the greatest probability the degree of blood loss and correctly assess the patient’s condition only after a comprehensive study of clinical data, indicators of laboratory and instrumental diagnostic methods.

Depending on the intensity of bleeding, it should be divided into obvious bleeding, manifested by bloody vomiting or tarry stools, and hidden-occult bleeding, which can only be determined with the help of p. Gregersen. Obvious hemorrhages can be acute or chronic, appearing for the first time or repeatedly. Acute gastrointestinal bleeding can be single or multiple, that is, recurrent during a given post-hemorrhagic period, when the consequences of anemia have not yet been eliminated. These bleedings pose the greatest danger to the patient.

Repeated acute gastrointestinal bleeding that occurs against the background of normovolemia after a significant period of time after the first episode of hemorrhage is usually no different from the first bleeding. The situation is different with hemorrhages that recur within a short time, measured in hours and even minutes. These bleedings cause severe changes in the homeostasis system and are extremely life-threatening.

Classifications of the severity of acute gastrointestinal bleeding, developed by domestic surgeons (E. L. Berezov, 1955; B. S. Rozanov, 1960; V. I. Struchkov and E. V. Lutsevich, 1961; V. D. Bratus, 1972, etc.), are important for improving the quality of early diagnosis, choosing a treatment method and improving immediate results.

When the patient is admitted to the hospital after 24 h and later from the onset of bleeding, when, due to the hydremic reaction, a significant restoration of the mass of circulating blood has already occurred, and consequently its dilution, the number of red blood cells, hemoglobin level, hematocrit number, specific gravity of blood and plasma reflect the degree of anemia and can be used to determine the degree of blood loss . Data from these studies provide an approximate idea of ​​the severity of bleeding. Using the indicators of these studies and clinical data, it is customary to distinguish three degrees of blood loss: mild, moderate and severe.

Mild blood loss: the number of red blood cells is above 3,500,000, the hemoglobin level is more than 60 units, the hematocrit number is above 30%, the pulse rate is up to 80 per minute , blood pressure above 110 mm Hg. Art.

Average degree of blood loss: number of red blood cells in the range of 250,000-3,500,000, hemoglobin level from 50 to 60 units, hematocrit number from 25 to 30%, pulse rate from 80 to 100 per minute , systolic blood pressure from 100 to 1 10 mm Hg. st .

Severe blood loss: the number of red blood cells is less than 2,500,000, the hemoglobin level is below 50 units, the hematocrit number is below 25%, the pulse rate is above 100 per minute , systolic blood pressure below 100 mm Hg. Art.

This classification of the degree of blood loss gives only an approximate idea of ​​the severity of anemia and the patient’s condition and does not reflect the amount of blood loss and the degree of hypovolemia. In patients with severe and rapid blood loss, death may occur before the development of the hydremic reaction, i.e., before the appearance of anemia (S. S. Yudin, 1955). Therefore, only the determination of blood volume and its components can indicate the degree of blood loss and the degree of hypovolemia. This allows a more objective assessment of the patients’ condition, which is important for the choice of surgeon tactics.

Based on our numerous studies of BCC and its components and comparison of the identified deficiency of these indicators with clinical and laboratory tests, the following classification of the severity of acute gastrointestinal bleeding is advisable: mild degree of blood loss (deficiency of GO up to 20%), moderate degree of blood loss (deficiency of GO from 20 to 30%) and severe blood loss (HO deficiency 30% or more). Undoubtedly, the deficiency of blood volume and its components, and therefore the degree of blood loss, may vary. The amount of blood loss may increase and then the mild degree becomes moderate or severe.

Examination of the blood volume and its components allows one to determine ongoing or identify recurrent bleeding. Despite the dynamism of the hemorrhage process, determination of the BCC and its components makes it possible to identify the amount of remaining circulating blood, which cannot be done with the help of other studies.

Thus, the classification of acute gastrointestinal bleeding should reflect the cause and pathogenesis of hemorrhage, the location of the source of bleeding, the degree of blood loss and the fact of ongoing, stopped or recurrent bleeding.

Using the above classification, it is possible to formulate a clinical diagnosis quite fully, taking into account the cause and location of the source of hemorrhage, the frequency of bleeding and the degree of blood loss. This draws the doctor’s attention to the pathogenetic, pathomorphological and pathophysiological essence of the course of the disease. A detailed clinical diagnosis is the result of a comprehensive differential diagnosis and should be constructed approximately as follows: peptic ulcer, gastric ulcer, complicated by acute recurrent bleeding with severe blood loss. A correct detailed diagnosis allows you to timely outline and carry out the most appropriate treatment, determine the surgeon’s tactics and foresee the volume and nature of the surgical intervention.

Classifications of acute gastrointestinal bleeding, based on clinical signs of blood loss and relative hematological parameters, do not always objectively reflect the severity of hemorrhage and do not allow identifying identical groups of patients who need a specific set of therapeutic measures.

Supplementing the generally accepted classifications of acute gastrointestinal bleeding with information about the state of the blood volume and its components, the extent of the deficiency of these indicators and the degree of hypovolemia allows the most reliable and objective determination of the severity of blood loss and the correct assessment of the condition of patients.

The development and improvement of simple, but quite accurate, methods for studying the blood volume and its components, and their implementation in everyday practice will help improve the diagnosis of the degree and rate of blood loss. They will facilitate the selection of the most effective treatment method and will provide an opportunity to more objectively compare the results of treatment of identical groups of patients with acute gastrointestinal bleeding. Currently, methods for determining blood volume and its components have been so improved that they can be performed in any medical institution and should become mandatory when determining indications for planned and emergency surgical interventions.

DIFFERENTIAL DIAGNOSTICS

ACUTE ULCERS OF THE DIGESTIVE TRACT, COMPLICATED BY BLEEDING

Gastrointestinal bleeding from superficial and small gastric ulcers was first described by Dieulafoy (1897). In recent years, due to the use of more active tactics and emergency gastrofibroscopy, small ulcerations of the gastric mucosa have begun to be detected more often and Delafoy's ulcer has ceased to be a rarity. The frequency of acute bleeding ulcers varies, from isolated observations to 41.44% (Bulmer, 1927).

Acute ulcers of the digestive tract, complicated by bleeding, were found in 6.42% of patients treated for acute gastrointestinal hemorrhages. Among patients with ulcer bleeding they amounted to 12.19%.

Acute ulcers of the digestive organs are observed at any age, both in newborns (Lloid, 1969) and in elderly people (N.K. Matveev, N.O. Nikolaev, 1970). Thus, acute ulcers in 74.56% were observed among elderly and senile people. The same ratio was found by V.P. Melnikova et al. (1970).

The etiology and pathogenesis of acute ulcers of the digestive organs, complicated by bleeding, have not been sufficiently studied to date. There are a large number of diseases or their complications that cause acute ulcers (Table 1). One of the leading factors involved in the formation of an acute ulcer is an increase in the activity of the acid-peptic factor. This is confirmed by the most common localization of acute ulcers in the stomach, which occurred in 84.21% of patients. An acute ulcer of the esophagus was found in 5.27% of patients, an acute ulcer of the duodenum in 5.27%, a small intestine in 3.5%, and a large intestine in 1.76%.

Another equally important pathogenetic factor is a decrease in the resistance of the digestive tract mucosa to the effects of hydrochloric acid, enzymes, foods, drugs and other agents. Numerous diseases and complications resulting from circulatory disorders lead to the development of hypoxia of the gastrointestinal mucosa.

Acute ulcers in 63.15% of patients were multiple, their sizes ranged from 0.1-0.2 mm to 3 cm in diameter. The edges of the ulcers were soft, their bottom penetrated to the submucosal layer, less often the muscle layer. Macroscopically detected at the bottom of acute ulcers in 75.44% arrozed vessel.

In diagnosing the cause and localization of the source of acute bleeding, emergency X-ray examination of the digestive tract is important.

BENIGN TUMORS AND POLYPS OF THE DIGESTIVE TRACT ORGANS

Acute bleeding from benign tumors and polyps of the digestive tract is not common. Messages usually concern several observations (V. D. Brother, 1972). The most common cause of acute bleeding in benign lesions is polyps. Their clinical diagnosis presents certain difficulties, and the cause of hemorrhage can only be determined using fluoroscopy, gastro-fibroscopy And sigmoidoscopy. Benign tumors and polyps, undergoing inflammation, necrosis and decay, lead to bleeding, which in some patients can take profuse character.

When bleeding occurs, clinical manifestations will depend on the location of the source. 1.93% of patients with benign tumors in the esophagus and stomach had bloody vomiting and general signs of hemorrhage. In 2.9% of patients, benign tumors and polyps were localized in the small and large intestine. In 0.65% the bleeding was manifested by melena and in 2.26% of patients by the discharge of scarlet blood during bowel movements. The abdominal pain was vague. In this regard, establishing the cause and location of the source of bleeding, especially in an emergency, can be very difficult.

EROSIVE HEMORRHAGIC GASTRITIS

Acute and chronic gastritis in the acute stage become more complicated acute bleeding and range from 5 (C. M. Bova, 1967) to 17.4% (S.I. Korkhov With co-author, 1957) among gastrointestinal bleeding of various etiologies.

Recognizing the cause of acute gastrointestinal bleeding in erosive gastritis presents significant difficulties, since there are no absolute signs of this disease. Despite this, in such patients it is necessary to carefully study the anamnesis and complaints. Upon admission to the clinic, the main complaint in 61% of patients was vomiting of blood or coffee-ground-colored masses: in 43% it was one-time and in 18% it was repeated. Tarry 49% of patients had stool. 52.6% had complaints of pain in epigastric areas. On palpation, in 66.5% of patients the abdomen was painful in the epigastric region.

Undoubtedly, a more valuable study is gastrofibroscopy, allowing to detect direct objective signs of erosion.

The diagnostic value of studying the secretory and enzymatic functions of the stomach in erosive gastritis is small, since increases and decreases in these indicators occur equally often.

BLEEDING FROM ESOPHAGUS VARICOSE VEINS AND CARDIA

One of the manifestations of portal hypertension is acute bleeding from varicose veins of the esophagus and stomach. Portal hypertension occurs as a result intrahepatic and extrahepatic venous lesions. The cause of intrahepatic block is cirrhosis of the liver and, rarely, liver cancer. Damage to extrahepatic vessels leads to the development prehepatic block, as a result of obliteration of the portal vein and its large branches. Less common posthepatic damage to the hepatic veins - posthepatic block. According to M. D. Paciora And L. M. Karpman (1967), intrahepatic a form of portal hypertension is observed in 51%, extrahepatic form - in 49%.

Development of dilation of the veins of the esophagus and cardia two main factors usually contribute - an increase in portal pressure and the presence of atomic collaterals between the portal and cavalry systems. Portal hypertension promotes the reverse flow of blood from the portal vein through ve the intestinal vein of the stomach into the veins of the esophagus and the superior vena cava into the well. An increase in portal pressure with insufficiently developed anastomoses between the veins of the esophagus and the veins of the superior vena cava system causes dilation, elongation, tortuosity and the formation of nodes.

If there are no anatomical connections between the veins of the stomach and esophagus, then only the gastric veins dilate. The first option is when, as a result of damage to the splenic vein, the outflow occurs through the gastric veins into the portal vein or its anastomoses. The second option, when the development of anastomoses occurs through the veins of the stomach, adrenal, apertures nal And retroperitoneal veins with vessels cavalry systems.

Dilatation and disruption of the integrity of the veins is more often observed in the lower part, less often in the middle part, and very rarely throughout the entire length of the esophagus. In the stomach, the coronary vein dilates at the point where it passes into the veins of the esophagus and very rarely the veins dilate proximal parts of the stomach.

Acute bleeding from varicose veins of the esophagus and cardia found from 8.9 (B. S. Rozanov, 1960) to 10.43% (B. A. Petrov, I. I. Kucherenko, 1961). This type of bleeding ranks fourth among all bleedings and third among non-ulcer hemorrhages. Acute bleeding from dilated veins of the esophagus and cardia begins suddenly with bloody vomiting (76.91%), weakness, dizziness and tarry stool (21.38%) and fainting (1.71%). Bloody vomiting, as a rule, is profuse, characterized by the release of scarlet blood, and in 64.95% of patients it was repeated from 2 to 14 times. At profuse bleeding, blood is released in a “fountain” or “mouth full” and immediately quickly coagulates, turning into a jelly-like mass. Pain in epigastric region or right hypochondrium was noted by 34.19% of patients, 65.81 had no abdominal pain. More about this topic and the meaning of the book about the state of the world this is the case. About the other countries in the world ip.

HEAT HERNIA

One of the complications of hiatal hernias is bleeding and anemia, first described by Carman, Fineman, (1924) and Hedbloom (1925). The incidence of these complications among hiatal hernias ranges from 11 to 53.2%. Hiatal hernia stia what is the cause of gastric bleeding? not an hour That.

Acute hemorrhage is manifested by vomiting blood, vomiting masses the color of “coffee grounds”, black st street

Gastric bleeding is usually observed with large mixed hernias, less often with paraesophageal and sliding hernias (M.P. Gvozdev, 1972). Cause of gastric bleeding nia is a violation of the ratio of mucosal resistance to increase intragastric pressure, venous hypertension, mechanical trauma caused by rough food and other times teasing agents. The slightest damage to the mucous membrane with venous hypertension and gastritis in the hernial sac can yes cause stomach bleeding. In case of rupture of the mucous membrane, development of acute erro Zy and ulcers, bleeding can be massive.

Acute leukemia occurs suddenly and is manifested by weakness, dizziness, high fever, chills, pallor of the skin and mucous membranes, hemorrhages in the skin, bleeding from the gums, nose, uterus and mucous membranes of the gastrointestinal tract. Sometimes dense and painless lymph nodes appear, in 25-40% the liver and spleen are enlarged, in 30% there are necrotic changes in the pharynx and in the mucous membrane of the digestive tract. A constant symptom is anemia, which can be normochromic, hyperchromic And less often hypochromic character. The white blood cell count may achieve 100000-200000 in 1ml , and when leukopenic form, meeting Yu current in 40-50%, the number of leukocytes drops significantly. The most accurate diagnostic sign is the morphological picture of white blood, characterized by the appearance hemocytoblasts, myeloblasts, lymphoblasts and reticular leukemic x cells. Sometimes changes in peripheral blood can get busy insignificant and the diagnosis presents significant difficulties. In such cases, a very valuable diagnostic meaning acquires sternal puncture and study myelograms.

Only on the basis of myelogram data we were able to update cause of anemia. In the development of anemia in acute leukemia, reduction is important erythropoiesis in connection with the sharpest hemocytoblastic metaplasia, increased growth hemolysis And profuse bleeding (I.A. Kassirsky, G. A. Alekseev, 1970).

Profuse bleeding in leukemia occurs not only as a result of sudden bleeding of blood vessels, as is sch Italy V. D. Brother(1971), but also as a result ulcerative-necrotic lesions of the mucous membranes of the gastrointestinal tract with vaniyam acute ulcers

Chronic leukemia are more common than acute ones and can affect any age. Chronic myeloid leukemia observed in adults and children. Life expectancy ranges from 1 to 10 years or more. Chronic lymphocytic leukemia- disease of middle and old age. The lymph nodes lie separately from each other, dense and painless. The liver and spleen are enlarged, but do not reach the same size as in chronic myelosis. The diagnosis is confirmed by examining peripheral blood and bone marrow. Life expectancy with chronic lymphocytic leukemia more than in chronic myeloid leukemia. Patients live for 20-30 years. Forms of the disease with severe anemia, hemorrhagic diathesis (with thrombocytopenia) and general dystrophic disorders are more malignant (I.A. Kassirsky, G. A. Alekseev, 1970).

The surgeon usually has to deal with acute ate with small intestinal bleeding due to abdomyostic emergency gastrofibroscopy, allows you to detect hemorrhages and erosive changes in the gastric mucosa Urgent fluoroscopy can be useful in terms of differential diagnostics, as it allows to exclude gross morpho logical changes in the digestive organs.

Hemophilia. A hereditary disease manifested by blood clotting disorders and increased bleeding. Hemophilia affects men. The disease can be transmitted from hemophiliac father a healthy daughter to a grandson, although the women themselves, the “conductors” of hemophilia, rarely have bleeding symptoms. The main cause of hemophilia is insufficient production of plasma thromboplastin, which is necessary for rapid blood clotting at the time of injury and bleeding. If there is a shortage thromboplastinogen plasma or antihemophilic globulin

(VIII factor) hemophilia A is observed, which accounts for 85-90 of all patients; if there is a deficiency of the plasma component thromboplastin(factor IX), then hemophilia B develops, accounting for 10-15% of all cases of the disease.

Bleeding in hemophilia is usually detected in early childhood. Bleeding occurs with mechanical trauma and even with stress, when gastrointestinal bleeding, subcutaneous, intramuscular and intra-articular hemorrhages appear.

Acute gastrointestinal bleeding due to hemophilia is rare, its frequency is about 1:50,000.

We observed 1 patient with hemophilia A, who was admitted on the 3rd day from the onset of intestinal bleeding with complaints of black stool. The patient immediately reported that he suffered from hemophilia and was being monitored at the dispensary. Intestinal bleeding appeared for the first time. During examination, a cord was discovered e Konchalovsky. the syndrome is considered as a manifestation of endogenous B12 vitamin deficiency, leading to a disordermitotic processes in hematopoietic cells - erythroblasts bone marrow. The processes of hematopoiesis do not compensate for the processes of blood destruction, which leads to the development of anemia (I.A. Kassirsky, G. A. Alekseev, 1970).

Due to anemia, it develops hypoxic the state of the body, including the organs of the digestive system. Hypoxia has an adverse effect on atrophic the gastric mucosa, which becomes very unstable to the effects of spicy foods, medications and other irritating factors. During the period of recurrent exacerbation and increased breakdown of red blood cells, the formation of erosions of the gastric mucosa and the development of hemorrhagic diathesis, manifested by acute gastrointestinal bleeding, are possible.

Patients experience weakness, dizziness, tinnitus, loss of appetite, diarrhea, glossitis, pale skin with a lemon-yellow tint, puffiness of the face and swelling of the lower extremities. At gastrofibroscopy e oron autopsy. Apparently, spasm and thrombosis of small vessels of the stomach, observed in atherosclerosis and hypertension, cause hypoxia of the gastric mucosa and reduce its resistance to the effects of gastric juice, food and medicinal substances. Activity acid-peptic factor plays an important role in the development of acute ulcers, since they are most often localized in the stomach.

We observed 74 (4.17%) patients with acute gastrointestinal bleeding caused by atherosclerosis and hypertension. 51 of them had an acute ulcer complicated by bleeding. These hemorrhages are often massive. High blood pressure promotes excessive bleeding even from small vessels, which can be fatal. More than half of our patients (38 out of 74) had hemorrhages with severe blood loss.

The course of peptic ulcer disease at this age occurs in 26.9% (A. I. Gorbashko, 1967). Therefore, the patient’s history and complaints cannot always help in diagnosing the cause of bleeding. In this regard, fluoroscopy becomes important and gastrofibroscopy. If the first research method makes it possible to exclude or identify significant organic changes, then gastrofibroscopy makes it possible to detect structural changes in the mucous membrane, erosion and flat acute ulcers.

Diverticula of the digestive tract. Diverticula of the esophagus, stomach, duodenum, jejunum, ileum and colon can be complicated by bleeding. The cause of bleeding is inflammation, ulceration and arrosion of the arterial or venous vessels of the diverticulum wall. These bleedings, according to S. M. Bova(1967) and V.D. Bratus (1972), are found infrequently, and the authors provide only isolated observations. In his monograph A.G. Zemlya oi (1970) describes a large number of diverticula of various locations, complicated by acute bleeding.

The clinical picture of esophageal diverticula depends on the phenomena diverticulitis and the degree of blood loss. Patients complain of pain behind the sternum or in epigastric areas, vomiting blood, weakness and dizziness. The clinical picture of gastric diverticula, complicated by acute bleeding, most often resembles hemorrhage of ulcerative etiology. It is not easy to detect gastric diverticulum even during surgery. In this regard, A.G. Zemlyanoy (1970) suggests during surgery to resort to inflating the stomach with air and only after receiving negative results to perform a gastrotomy and examine the gastric mucosa

Syndrome Mallory -Weiss. Ruptures of the mucous membrane of the cardioesophageal zone were first described by Mallory and Weiss in 1929. Currently, this bleeding is not uncommon. The cause of bleeding is usually repeated vomiting, leading to increased intragastric pressure and rupture of the mucous membrane.

Under our supervision there were 3 patients delivered to the clinic with acute gastric bleeding with severe blood loss, in whom a rupture of the mucous membrane was established cardiac section of the stomach. These were young, strong men who regularly drank vodka. The disease occurred the next day after heavy intoxication and began with repeated painful vomiting. The first urge was accompanied by the release of gastric contents or ingested liquid. After 2-5 urges, copious discharge of unchanged blood and clots appeared. This onset of bleeding is typical for syndrome Mallory-Weiss. However, Mallory-Weiss syndrome can be combined with other diseases accompanied by repeated vomiting, and therefore is not a privilege for alcoholics. For hiatal hernias (M.P. Gvozdev, Gorbashko, E. N. Levkovets, 1971), penetrating into the thickness of the muscle layer.

BLEEDING FROM THE RESPIRATORY TRACT AND LUNGS, SIMULATING ACUTE GASTROINTESTINAL BLEEDING

Acute bleeding in diseases of the respiratory tract and lungs can simulate gastrointestinal hemorrhages and present significant difficulties for diagnosis, since their clinical course is not always typical.

If blood is released when coughing and has a scarlet foamy character, and there is a history of pulmonary disease, then establishing a diagnosis does not present any difficulties. Identification of characteristic signs during percussion and auscultation and an x-ray picture allow us to finally determine the cause of pulmonary hemorrhage: pulmonary tuberculosis, chronic abscess , cyst, lung cancer and bronchiectasis.

The choice of treatment for pulmonary hemorrhage is very difficult. Until now, it is believed that bleeding from the lungs is subject to conservative treatment, in which mortality ranges from 21.6 (Yu. D. Yatsozhinsky, et al., 1969) to 26.5% (I. V. Agofonov, 1965; P. N. Fuchs et al., 1965, etc.). Conservative treatment is ineffective, since pulmonary hemorrhages are massive and prone to relapse. In this regard, a number of surgeons (Yu. A. Kogosov, 1960; M. Z. Sorkin, 1965; V. A. Popiashvili, 1972, etc.) resort to lung resection in an emergency and planned manner. Lung resections for bleeding, performed urgently in a specialized institution, give a mortality rate of 7.52% (V. A. Popiashvili, 1972).

Thus, the surgeon’s tactics for acute pulmonary hemorrhage should be determined individually. Profuse bleeding with severe blood loss, especially recurrent bleeding, is an indication for emergency surgery-resection of the lungs.

BIBLIOGRAPHY.

1. Gain of M.G. “Human Anatomy”, M. “Medicine”, 1985

2. Gorbashko A.I. “Acute gastrointestinal bleeding”, M. “Medicine”, 1987

3. “Surgery”, 1976, No. 6.

4. “Healthcare of Tajikistan”, 1988, No. 3.

5. “Healthcare of Kazakhstan”, 1978, No. 9yu

6. “Surgery”, 1974, No. 4.

7. “Clinical surgery”, 1983, No. 4.

The content of the article

Etiology, pathogenesis of gastric ulcer

Clinic for stomach ulcers

Diagnosis of gastric ulcer

Complications of gastric ulcer

Peptic ulcer of the stomach and duodenum is the most common disease of internal organs, which, according to world statistics, is common in approximately 10% of the adult population. According to the Center for Medical Statistics of Ukraine, the incidence of peptic ulcer disease (PU) in our country has increased by 38.4% over the past 10 years.

In recent years, significant advances have been made in the diagnosis and treatment of peptic ulcer disease; numerous studies have significantly expanded our understanding of the etiological structure of the disease and its pathogenetic features. The prevalence of peptic ulcer disease in Ukraine, near and far abroad countries still does not tend to decrease, and the complications that arise often threaten the patient’s life and require surgical correction.

The most common cause of ulcer is currently considered to be Helicobacter pylori infection. Helicobacter pylori (HP) induces an inflammatory response and damage to the gastric mucosa. In addition, it disrupts the system of intercellular relationships that regulate the gastrin system, since when an “alkaline cloud” of ammonium ions forms around it, the normally existing inhibition in the acidic environment of gastrin secretion by G-cells is removed.

At the same time, the impact of aggressive factors on the mucous membrane of the gastroduodenal zone and a decrease in the functioning of protective factors is the main pathophysiological determinant in the development of peptic ulcer disease. Therefore, antiulcer therapy should include both antisecretory drugs and drugs intended to eradicate HP. Standard eradication therapy is a combination of a proton pump inhibitor (H+/K+-ATPase), two antibacterial drugs and bismuth subcitrate.

Despite the successes of modern conservative treatment, the severe course of peptic ulcer disease, often recurrent or accompanied by complications, the picture of the disease sometimes does not make it possible to make an unambiguous decision regarding the choice of treatment tactics. In such patients, sometimes only surgical intervention can have a significant impact on the course of the pathological process. And if we take into account that peptic ulcer disease is a chronic disease that can lead to a number of life-threatening complications, then the treatment of these patients can be both therapeutic and surgical. The joint decision of therapeutic and surgical specialists on algorithms and standards for treating patients is very important.

Unfortunately, a number of leading therapists are very aggressive about surgical treatment of peptic ulcer disease. We are doing a common cause and, first of all, we must think about patients, prevent life-threatening complications, which often have an unfavorable outcome or cause the functional ineffectiveness of surgical intervention.

In addition, the choice of treatment tactics for patients with ulcer cannot but be influenced by the specific socio-economic situation, when adequate drug therapy for some patients is very expensive and far exceeds the costs of surgical treatment. There is also a group of patients who are refractory to the action of antiulcer drugs. Thus, among all patients with ulcer, patients subject to surgical treatment have a large proportion.

At the same time, complicated forms of the disease are a complex problem that requires further scientific research and practical solutions, since drug therapy in a number of patients does not reduce the frequency of ulcer complications, but only postpones their appearance to a later date. There is an opinion that from 30 to 50% of patients with gastroduodenal ulcers respond poorly to antisecretory drug treatment; they constitute the main group of patients who experience complications of peptic ulcer disease. In such cases, only surgical treatment can have a significant impact on the course of the disease.

What, in our opinion, needs to be done to solve the problems that have arisen? How can this problem be considered when adopting a law on insurance medicine?

We believe that, firstly, it would be useful for gastroenterologists, therapists and surgeons to create a unified clinical and statistical classification of peptic ulcer disease based on ICD-10, which allows forming a clinical diagnosis taking into account the severity of the disease, the activity of the ulcerative process and the presence of complications. A unified approach to making a clinical diagnosis, a common understanding of the criteria characterizing individual classification criteria will make it possible to unify and standardize the distribution of medical resources.

Secondly, the presence of a unified classification approach will make it possible to create a list of conditions that distributes patients for outpatient and inpatient treatment, depending on the level of the medical institution providing medical care and the severity of the disease. This approach will greatly help solve the problem of choosing a treatment method, determine the list and scope of diagnostic procedures and medical care for a particular patient.

Peptic ulcer disease is a therapeutic problem throughout the world. But can we completely transfer Western standards to our healthcare? Apparently not. This should happen gradually, with the formation of drug therapy priorities.

What is happening here? Over the past 10 years, there has been a steady trend towards a decrease in the number of planned operations by 2-2.5 times, and in specialized surgical departments this dynamics is even more pronounced - by 6-12 times. At the same time, according to most authors (A. A. Grinberg, 1997; V. F. Saenko, 2002; P. E. Donahue et al., 1996; J. Herman et al., 1998), the number of emergency surgical interventions for perforated and bleeding ulcers, the mortality rate for which ranges from 5.6 to 20.4% (N. H. Chou et al., 2000; A. Garripoli et al., 2000; T. Sillakivi et al., 2001). According to our data, the number of perforated ulcers of the stomach and duodenum increases annually by 5-8%, over the past 10 years their number has increased 3.7 times.

The number of patients operated on for such a serious complication of ulcer as bleeding has remained virtually unchanged (0.6 per 10 thousand population), which is due to the development and implementation of effective methods of local minimally invasive hemostasis in the ulcer, while the number of patients requiring hospitalization in connection with this complication continues to grow. The importance of this problem is also due to the fact that mortality in this group of patients is 10-12 times higher than with routine treatment of peptic ulcer disease.

Surgical methods in the treatment of peptic ulcer

In our daily practice, we distinguish absolute and relative indications for surgical treatment. The absolute indications are urgent: ulcer perforation, profuse bleeding that cannot be controlled conservatively, and delayed: decompensated stenosis of the gastric outlet, unstable hemostasis or recurrent bleeding. Relative indications are ulcers refractory to conservative therapy or often recurrent (more than 2 times a year during complex treatment), with a history of complications, as well as ulcers in the cardia, greater curvature and in the pyloric part of the stomach, not amenable to conservative treatment within 8 weeks.

The experience of planned surgical treatment of peptic ulcer, based on more than 5 thousand operations, has allowed us to develop certain approaches to the surgical treatment of peptic ulcer. The main objective of planned surgical treatment for peptic ulcer disease is to create conditions in the postoperative period for eliminating factors of aggression in the gastroduodenal area while simultaneously reducing mortality and minimizing side effects. For duodenal ulcers, this is an effect on the acid-producing zone; the effectiveness of the operation is determined by the level of suppression of gastric secretion; for gastric ulcers - impact on the area of ​​ulcerative infiltrate, which subsequently allows normalizing trophic disorders and creating conditions for stabilizing histostructural changes in the gastric mucosa.

It should be noted that the main goal of urgent surgical intervention for a perforated gastric or duodenal ulcer is to save the patient’s life. The choice of surgical method and its radicalness largely depend on the specific clinical situation - the patient’s age, concomitant pathology, and the degree of surgical risk.

In the structure of surgical interventions for duodenal ulcer, the most justified when the nervous mechanism for regulating acid formation is dominant are selective proximal vagotomy or selective proximal vagotomy with various options for duodenoplasty. The prevalence of the humoral part of the regulatory mechanisms, which is expressed by hyperplasia of gastrin-producing cells in the antrum of the stomach with a simultaneous decrease in the number of somatostatin-producing cells, was noted in 10% of patients. In this case, subdiaphragmatic truncal vagotomy with anthrumectomy is indicated, as an operation that immediately affects two mechanisms for regulating acid formation in the stomach: nervous and humoral. The main operation for gastric ulcer remains resection with a tendency to reduce its volume and preserve the pylorus and passage through the duodenum.

An integral stage of preparing a patient for surgery is a course of antiulcer therapy, which helps not only to reduce the irritating effect of the acid-peptic factor on the gastric and duodenal mucosa, but also aimed at eliminating Helicobacter pylori contamination.

In the preoperative period, Helicobacter colonization of the mucous membrane of the antrum of the stomach was detected in 78% of cases with gastric ulcers and in 94% of cases with duodenal ulcers. According to E.M. Perkin et al. (1995), bacterial contamination after surgery not only corresponds to the initial level, but also tends to increase in the antrum and in the fornix of the stomach. Unresolved bacterial invasion in the postoperative period contributed to the development of erosive antral gastritis and duodenitis, reduced the physiological resistance of the integumentary epithelium, and hampered reparative processes.

Peptic Ulcer Surgery

Peptic ulcer of the stomach and duodenum is one of the most common diseases. According to WHO, it affects 5 to 10% of the world's population. However, the prevalence of the disease varies in different countries. The sad advantage in this case belongs to the developed countries of America and Europe - the USA, Great Britain, Germany, etc. The lowest incidence is recorded in the countries of Southeast Asia. This fact is probably explained by both genetic factors and the nature of the population’s diet. According to individual countries, the number of patients with peptic ulcer disease ranges from 1.5 to 5%. According to Wudvort, about 10% of US residents suffer from peptic ulcer disease. Currently, about 300,000 gastric resections and about 30,000 other operations for peptic ulcers are performed annually in the world. According to various researchers, about 45,000 gastric resections and 25,000 suturing operations for perforated ulcers are performed in Russia annually. Despite the long periods of surgical treatment of peptic ulcer (the first operations were performed more than a hundred years ago), there is still debate about the nature and effectiveness of various interventions for this disease.

Issues of surgical treatment of peptic ulcer disease were discussed at the XXV, XXIX, XXX All-Union Congresses of Surgeons, the V111 All-Russian Congress and a number of conferences.

The old idea that with an ulcer the therapist is powerless, the surgeon is dangerous, and God is merciful is becoming a thing of the past. Currently, the main principles of surgical treatment of this disease have been developed in detail and tested in life. This is the merit of many surgeons, especially S.I. Spasokukotsky, S.S. Yudina, A.G. Savinykh, V.S. Mayata, YM. Pantsyreva, V.S. Savelyeva, Drakstadt.

To understand the essence of the interventions performed for peptic ulcer disease, it is necessary to take into account that they must be primarily of a pathogenetic nature, that is, influence the factors causing the disease and eliminate the ulcerative defect in the wall of the stomach or duodenum. The main points of gastric secretion were studied in the laboratory of I.P. Pavlova and are carried out in three phases.

The first phase depends on irritation of the fibers of the vagus nerve - the secretory nerve of the stomach. It is reflexive in nature, also called. Irritation of the branches of the vagus nerve causes the secretion of gastric glands that produce gastric juice.

The second phase depends on the entry into the blood of a hormone - gastrin or Adkins prosecretin, which is produced by the mucous membrane of the antrum of the stomach and the initial part of the duodenum. This hormone is produced when food masses come into contact with the mucous membrane of these areas. This phase is called hormonal.

The third phase depends on the entry into the blood of the hormone enterokinase, produced by the mucous membrane of the small intestine upon contact with chyme. The specific gravity of each phase of gastric secretion is not the same. A healthy person secretes about 1.5 liters of gastric juice per day. In this case, the reflex phase of gastric secretion is about 80%, hormonal - about 15% and intestinal - about 5%. In case of illness, these phases in daily secretion can vary significantly. Many authors believe that the first, reflex phase, significantly prevails in patients with duodenal ulcers, and the second, hormonal, in patients with gastric ulcers. The proportion of the third phase (intestinal) is so small that it can practically not be taken into account when justifying surgical interventions.

According to most authors, of all patients with peptic ulcer, only 10% develop complications requiring surgical intervention. The rest should be treated with conservative methods. One of the largest domestic surgeons Yu.Yu. Janelidze argued that “No organ gives a person so much pleasure and so often as the stomach. Therefore, it should be removed only under very strict indications.”

All indications for surgery are divided into two large groups - absolute and relative indications.

Absolute indications for surgery when failure to perform it directly threatens the patient’s life. This:

1. Perforation of the ulcer;

2. Profuse gastrointestinal bleeding;

3. Cicatricial pyloric stenosis;

4. Malignancy of the ulcer or strong suspicion of such.

Perforation of an ulcer is a serious complication of peptic ulcer disease, requiring immediate surgery, since in this situation a delay in death is similar. Any type of perforation poses a threat to the patient’s life, since the entry of infected contents of the gastrointestinal tube into the abdominal cavity leads to the development of progressive fatal peritonitis.

Profuse gastric bleeding also directly threatens the patient's life. Rapidly growing anemia and metabolic disorders as a consequence of this require immediate surgical treatment to eliminate developing homeostasis disorders that directly threaten the patient’s life.

Pyloric stenosis due to cicatricial changes in the outlet of the stomach or in the initial part of the duodenum also directly threatens the patient’s life. Slower development of the process compared to previous complications, sometimes over months or even years, leads to a gradual but steady development of high obstruction of the gastrointestinal tract with all the ensuing consequences: chronic dehydration, serious disorders of mineral metabolism, of which the main one is hypochloremia , loss of juices and progressive loss of body weight, up to complete exhaustion. Convulsive syndrome in the form of chloroprivate tetany can simulate epileptic seizures, which makes timely diagnosis of the disease very difficult. All this leads to the death of the patient if surgical intervention is not undertaken to correct the current situation. This complication is most typical for duodenal ulcers and gastric outlet ulcers.

Malignancy of a chronic gastric ulcer is also an absolute indication for surgery. Surgery should be undertaken in cases of strong suspicion of malignant degeneration of the ulcer. In any of these situations, the immediate threat to the patient’s life due to the progression of the malignant process is beyond doubt. Delay in surgery can cost the patient his life, since in some cases the growth of a malignant tumor is rapid and dissemination in the form of distant metastases can exclude the possibility of radically helping the patient.

Malignization quite often complicates the course of chronic gastric ulcers, especially long-term callous or penetrating ones. Clinically, this process manifests itself in the form of a change in the nature of pain, which becomes constant, the appearance of constant microbleeding (determined by the Gregersen reaction), perversion of appetite, and increasing hypochromic anemia. The appearance of these symptoms requires the use of special research methods. But even negative results of special research methods, in the presence of strong clinical data in favor of malignant degeneration, require immediate surgery.

In addition to absolute indications for surgery, there are also relative indications for it. Delay in intervention in these cases does not always lead to the death of the patient, which significantly complicates the process and often leads to the development of additional complications that aggravate the patient’s situation. Relative indications include:

1. Callous ulcers;

2. Penetrating ulcers;

3. Repeated gastrointestinal bleeding, especially in the hospital;

4.Failure of conservative treatment for 2-3 years.

Callous ulcers (usually gastric) are very difficult to treat conservatively, since the dense calloused edges of a long-existing ulcerative defect prevent epithelization of the ulcer under the influence of drug therapy, and epithelial metaplasia, which develops with the long-term existence of an ulcer, contributes to its malignant degeneration.

Penetrating ulcers, when the ulcerative niche penetrates into neighboring nearby organs - the liver, pancreas, hepatoduodenal ligament, brings the patient significant suffering in the form of persistent pain and dysfunction of those organs into which the ulcer penetrates. The healing of such ulcers under the influence of conservative treatment is very problematic, and successful surgical intervention allows one to resolve the current difficult situation.

Repeated bleeding, especially repeated in the hospital, is certainly a strong indication for surgical intervention for the following reasons. Firstly, every recurrent bleeding, even very minor, can recur at any time or turn into profuse bleeding, which directly threatens the patient’s life. Secondly, repeated bleeding leads to the development of posthemorrhagic anemia. Under its conditions, surgical intervention becomes significantly more complicated due to the risk of developing post-hemorrhagic complications. The merit in intensifying surgical tactics for repeated bleeding belongs to the student S.S. Yudina B.S. Rozanov and A.A. Rusanov, who argued that every ulcerative bleeding should undergo surgical correction in the first day after its onset.

Many surgeons, including our clinic, consider the failure of conservative treatment to be an indication for surgical treatment. The fact is that conservative treatment, unfortunately, does not always (especially with duodenal ulcers) lead to a cure for the patient, but leads to a more or less long-term remission followed by relapse of the disease. This is especially often observed if the patient, after a course of treatment, remains in the same conditions of life, work, nutrition, etc. In such cases, the duration of remission becomes short-term, and exacerbations of the process are natural. We, like other surgeons, often have to deal with patients whose experience with peptic ulcer disease is calculated in years and even tens of years. These people are constant martyrs, suffering from pain, forced to limit themselves in their diet, and often losing their ability to work due to frequent exacerbations of the disease. At the same time, rational surgical therapy can restore their health and performance. Therefore, most surgeons believe that the failure of conservative treatment of an ulcer for two to three years, especially if during this period the patient underwent courses of antiulcer treatment in hospitals, is an indication for surgical treatment.

Currently, surgical operations for peptic ulcer disease are performed under modern anesthesia. But any intervention for this pathology can be carried out under local anesthesia and spinal anesthesia. The advantages of anesthesia in this situation are not only in the implementation of a painless operation, but in achieving muscle relaxation, which significantly facilitates the surgeon’s actions, as well as in the ability, during modern anesthesia, to control the vital functions of the body, which is no less important in a seriously ill patient.

Currently, most surgeons distinguish between two main forms of peptic ulcer - gastric ulcer and duodenal ulcer. This is probably due to the nature and causal factors of the formation of these types of pathology. According to G.K. Zherlova and G.E. Sokolovich, the leading moments of ulcerogenesis in gastric ulcers are a violation of the barrier function of the gastric mucosa (reduction of the protective properties of mucus and the regenerative ability of the epithelium, disturbances of blood flow and metabolism), changes in the motor and evacuation function of the stomach and damage to the mucosa by harmful substances (nicotine, ethyl alcohol, Helicobacter pylori). and etc.).

In case of duodenal ulcers, ulcerogenesis mainly depends on a high level of secretion of gastric juice, a decrease in the ability to neutralize gastric juice, and a decrease in the resistance of the intestinal mucosa to Helicobacter. With this localization of the ulcer, a major role in the development of the pathological process belongs to stressful situations, especially those that are frequently repeated.

The ratio of men and women among patients with gastric ulcers is 3:1, and in patients with duodenal ulcers it is 4:1 (S.S. Yudin, 1955, Yu.M. Pantsyrev, 1973).

The presented materials served as the basis for a number of surgeons to insist on individual selection of the nature of surgical intervention for different localizations of the ulcer (M.I. Lytkin, 1998; Yu.M. Pantsyrev, 1973; A.F. Chernousov, 1996). However, there are generally accepted provisions, knowledge of which will help the doctor choose the most optimal method of surgical treatment for peptic ulcer disease.

Currently, the following surgical procedures exist for the surgical treatment of ulcers:

1. Suturing the ulcer;

2. Stitching the ulcer;

3. Gastric resection;

4.Surgeries on the vagus nerves:

4.1.Trunk vagotomy;

4.2.Selective vagotomy (SV);

4.3.Selective proximal vagotomy (SPV);

4.4.Selective proximal vagotomy in combination with economical gastrectomy.

Suturing the ulcer. An operation that is performed only for perforation of a stomach or duodenal ulcer.

The first such intervention was carried out on October 7, 1880 by Iochan Miculiz. In Russia it was first performed in 1899 by G.F. Zeidler.

Usually, suturing a perforated ulcer is a fairly simple operation. After laparotomy and revision, the perforation site is found and sutured with interrupted sutures in two layers. The suture line can be covered with an omentum on the stem. After toileting, the abdominal cavity is sutured tightly or with a microirrigator. In the case of perforation of a large callous ulcer, when the sutures are cut, the ulcer should be sutured according to Opel-Polikarpov: taking a strand of the greater omentum on a needle, puncture the stomach wall from the side of the perforated hole. This manipulation is repeated twice with both ends of the thread. When tying the thread, the omentum in the form of a plug clogs the perforation hole. Additionally, several interrupted sutures are applied to fix the omentum to the wall of the stomach (Fig. Fig.). In recent years, with the development of endosurgery, suturing of the perforated hole during laparoscopy has begun to be carried out for perforated ulcers (Sazhin).

Mortality after ulcer suturing operations is low and mainly depends on the timing of the operation. Within a few hours after perforation it amounts to hundredths of a percent, and within a day after perforation it reaches 80% or more. According to D.F. Skripnichenko operations performed in the first 6 hours after perforation give a mortality rate of 1-2%, and those performed after 24 hours are accompanied by a mortality rate of 30%. According to V.S. Savelyev in 1972, the mortality rate in the RSFSR was 5.3%. According to V.D. Fedorov in Russia in 2000, the mortality rate after operations for perforated ulcers was %.

Advantages of ulcer suturing surgery. The surgical intervention is extremely simple technically and can be carried out in almost any conditions (local hospital, field conditions). With timely surgery in the first hours after perforation, the intervention has almost no mortality and saves the patient’s life.

The disadvantage of the operation is that it does not eliminate any of the factors leading to the formation of ulcers. Consequently, as one would expect, the percentage of relapses after suturing an ulcer is quite high and, according to various authors, is up to 67%. Thus, suturing an ulcer saves the patient’s life, but does not cure him of a peptic ulcer. In the literature, there are cases of repeated (up to 5 times) perforations of ulcers after suturing the perforations.

Stitching an ulcer is a rare operation, used as an extreme exception in cases where, with ulcerative bleeding, the patient’s condition is so severe that he is unable to withstand any other intervention, and other methods of stopping bleeding (laser or non-contact coagulation during gastroscopy) are ineffective. This operation is performed in extremely critically ill elderly patients. After laparotomy, a gastrotomy is performed, an ulcer and a bleeding vessel are found in its bottom, and the vessel is sutured with block sutures. After this, the dissected wall of the stomach and the abdominal wall are sutured in two layers.

The main operation currently used to treat peptic ulcer disease is gastric resection. The first gastric resection for cancer was performed by the French surgeon Jules Pean on April 9, 1879. The patient died on the fourth day after surgery. The first successful gastric resection, also for cancer, was performed in Vienna by Theodor Bilroth on January 29, 1981. A 38-year-old patient recovered after the operation. After the operation, Billroth connected the stump of the stomach with the duodenum by an end-to-end anastomosis. On January 15, 1885, during the resection, he, having failed to connect the stump of the stomach with the duodenum, sutured the latter, and connected the stomach with an end-to-side anastomosis to a loop of the jejunum. The first operation was called gastric resection according to Billroth I (the French call it resection according to Péan-Billroth), and the second operation was called gastric resection according to Billroth II. Each of these operations has up to 30 modifications, but the principle of the operation (connecting the stump of the stomach with the intestine) remains the same as it was carried out by Billroth. The first intervention is carried out almost according to the Billroth method with the difference that the gastric stump from the lesser curvature side is sutured. The second modification is most often carried out according to the Hofmeister-Finsterer or Gakker-Savinykh modification, when part of the gastric stump from the lesser curvature is sutured, and its stump is connected by an end-to-side anastomosis with the initial part of the jejunum.

For peptic ulcer disease, the first successful gastric resection was performed in Vienna by Riediger on November 21, 1881, and in Russia the same operation for peptic ulcer disease was also performed in 1881 by Kitaevsky.

The main principles according to which gastric resection should be carried out for peptic ulcer disease are formulated by S.S. Yudin 50 years ago and remain effective to this day. These requirements are based on S.S. Yudin laid down the conditions under which, as a result of the operation, the patient’s ulcer should be removed and gastric secretion should be suppressed as much as possible. These conditions are as follows:

1.During the operation, it is necessary to remove the acid-producing area of ​​the stomach. This is almost 2/3 of the stomach. With very high acidity ¾ of the stomach.

2. It is necessary to remove areas that produce gastrin (Adkins prosecretin), that is, remove the antral and pyloric sections of the stomach and the initial section (up to 2 cm) of the duodenum.

3. Along the resection line, it is necessary to cross the fibers of the vagus nerve (almost almost from the esophagus).

In this way, there is a radical effect on the first (reflex) and second (hormonal) phases of gastric secretion, the area producing gastric juice is reduced and the conditions that contribute to the formation of ulcers in the remaining parts of the stomach are eliminated.

Gastric resection surgery for peptic ulcer disease in most medical institutions is performed subject to these conditions. In our clinic, gastric resection, as it is more physiological, is performed for gastric ulcers and, when technically possible, for duodenal ulcers using the Billroth I method. During the operation, part of the gastric stump from the lesser curvature side is sutured and immersed in the lumen of the organ, and with the remaining part of the stump An end-to-end anastomosis with the duodenal stump is performed according to the general rules (Fig.). In case of duodenal ulcers with large changes in the initial part of the intestine, in case of penetration of duodenal ulcers, gastric resection is performed according to the Billroth II method in the modification of Hoffmeister-Finsterer, which consists in the fact that after removing part of the stomach and crossing the duodenum, part of the gastric stump from the side of the lesser curvature is sutured and immersed in the lumen of the stomach in the form of a keel. The duodenal stump is sutured tightly in the usual or atypical way. The stump of the stomach is connected by an end-to-side anastomosis to the initial part of the jejunum. Usually this anastomosis is performed behind the transverse colon through its mesentery (Fig.).

In case of difficulties with suturing the duodenal stump, a number of developed techniques are used: Yudin’s method when the duodenal stump is closed in the form of a snail (Fig.) or according to the Krivosheev method, when the sutured duodenal stump is immersed in a purse-string suture in the form of a “submersible hood” (Fig.) .

Advantages of gastric resection surgery: a stable and long-term cure for the patient occurs. If the operation is performed according to strict indications with strict adherence to the above rules, then good and satisfactory results after this operation are over 90% (A.G. Savinykh, S.S. Yudin). Unsatisfactory results reach only 5%. Mortality after planned gastrectomy is, according to most authors, from 2 to 5% (S.S. Yudin, V.S. Mayat, A.A. Grinberg). In the Savin clinic, after 1000 operations by 1963, it was zero.

Disadvantage of gastric resection: the operation is quite complex and requires scrupulous execution of all details of the intervention. It must be performed by a highly qualified surgeon. For a successful operation, certain conditions are required: the presence of a sufficiently equipped operating room, a qualified anesthesiologist, an experienced assistant and a sufficient supply of blood. The operation cannot be performed in conditions of peritonitis with perforation of the ulcer and in cases of severe anemia with ulcer bleeding.

If the operation is carried out as planned, then it is preceded by a test for dumping syndrome: glucose is injected into the patient’s stomach through a tube, the blood sugar level and the patient’s condition are monitored. If there are signs of dumping, it is advisable to perform resection using the Billroth I technique, since it is more physiological. If necessary, it is advisable to perform a Roux-en-Y operation, when the gastric stump, after suturing the lesser curvature, is connected to the jejunum by an end-to-side anastomosis of the jejunum mobilized according to the Roux-en-Y method, and the duodenal stump is tightly sutured.

In 1947, Dragstedt published his bilateral subphrenic vagotomy for the treatment of complicated duodenal ulcers. The purpose of the operation was to turn off the first reflex phase of gastric secretion to heal a duodenal ulcer with a high level of acidity. The ulcer has healed. Based on the materials of Dregstedt and his predecessors, who performed partial transections of the vagus nerves, similar operations began to be performed in the thousands for duodenal ulcers for the same purpose. It turned out that after such interventions, patients, despite the healing of the ulcer, developed severe complications in the form of persistent spasms of the pylorus and various disorders of the liver, pancreas and intestines, since they are also innervated by the vagus nerves. In this regard, to eliminate persistent spasms of the pylorus, Dregstedt carried out in addition to truncal vagotomy, stomach drainage operations in the form of pyloroplasty or gastroenterostomy. The same operations began to be used in emergency cases as an addition after suturing perforated duodenal ulcers (A.I. Krakovsky, Yu.M. Pantsyrev, etc.). Yet these interventions are rarely implemented today. At the XX1V International Congress of Surgeons in Moscow, Dregstedt announced that he is a student of the Russian scientist I.P. Pavlov and bases his conclusions on the basis of his work and 2000 operations on animals to study various options for vagotomies. At the same congress, he spoke in favor of bilateral selective vagotomy, proposed by Franksson in 1948, during which only the branches of the vagus nerve going to the stomach are crossed. In this case, one should spare the Latarjet nerve, which carries out the parasympathetic innervation of the elements of the solar plexus, that is, the innervation of the liver and pancreas (Fig.).

Advantages of truncal vagotomy. The operation is technically quite simple and has almost no mortality with a high therapeutic effect, that is, duodenal ulcers with high acidity in most cases heal after the operation. The disadvantages of the operation, as already mentioned, are the presence in all cases of persistent spasm of the pylorus and significant dysfunction of the liver, pancreas and intestinal motility, which makes the patients martyrs and regular clients of the surgeons who performed this operation. If vagotomy is not performed completely, the ulcer does not heal and all complications of the disease may develop. This operation should always be supplemented by stomach drainage operations - pyloroplasty or gastroenteroanastomosis.

Selective vagotomy. The advantages of the operation are that the ulcer heals in 80-90% of cases. The stomach is preserved. Mortality after it is significantly lower than after gastrectomy. Disadvantages of the operation: the complexity of its implementation - it requires careful preparation of the branches of the vagus nerve, taking into account their variants, the need, just like after a truncal vagotomy, to perform a pyloroplasty or gastroenterostomy operation that drains the stomach. In addition, in case of an incomplete operation, when individual branches of the vagus nerve remain uncrossed, the ulcer does not heal and the percentage of development of peptic ulcers of the anastomosis remains high. Their frequency, according to different authors, ranges from 6 to 19% (A.A. Kurygin, Yu.M. Pantsyrev, A.A. Grinberg).

Hart a. Holle (1966, 1968) proposed selective proximal vagotomy, during which only the branches of the vagus nerve going to the acid-producing zone of the latter are intersected while preserving the Latarget branch and the branches of the vagus nerve going to the pylorus (Fig.).