Definition and classification
Gastroduodenal ulcer is a lesion characterized by loss of substance in the gastric or duodenal mucosa . It is more common in older than 40 years .
Gastroduodenal ulcer develops clinically in 90% of cases, acute flare-ups amid periods of remission of variable duration . Lately there has been a reduction in frequency but maintaining the same duodenal ulcers limits .
Although gastric and duodenal pathology at different ulceration final result is an imbalance between the factors of aggression and defense . The ulcer gradually destroys layer by layer wall ulceration , perforating the peritoneum , hollow organs or viscera penetrate parenchyma .
From an evolutionary perspective there are two forms of gastric ulcer :
– Acute ulcer , usually small in size ( cca.1cm ) surrounded by edema ;
– Chronic ulcer , usually exceeding 2 – 5cm diameter and edema place is taken by a fibrosis that while welded body stomach neighbor.
Factors of aggression against gastric cell barrier can be:
• Hypersecretion of acid- peptic ;
• Hypersecretion of gastrin ;
• gastric motility disorders ( discharge end ) ;
• duodenogastral reflux ;
• Helicobacter pylori ;
• Exogenous factors : anticancer drugs , smoking , alcohol etc.
Clinical and laboratory diagnosis
Clinical signs of disease are:
– Exacerbation of chronic alternation ;
– Epigastric pain localized in the form of cramps or torsion , exacerbated by food and relieved by vomiting or evacuation of gastric contents ;
– Nausea and vomiting ;
– Heartburn ( heartburn ) Postprandial are rare, they may precede or be pain with it .
Laboratory diagnosis is established after the following analysis :
– Barium Radiography established niche position , size and depth of them. Often located on the lesser curvature she is seen in profile outside contour stomach .
– Endoscopy allows direct examination (visualization ) lesion also allows sampling ( biopsy ) , makes it possible to fully explore the pylorus of the stomach even with the duodenal bulb . It is the only method that can provide sufficient information to diagnose stomach ulcers and can determine whether a lesion is benign or malignant .
– Examination of gastric secretion is trivial because the diagnosis is not strong secreting gastric ulcer .
In gastric ulcers dietary measures on food composition and the frequency of meals are important , however the duodenal ulcer diet has not been shown to have a beneficial effect evident.
The correct attitude is to establish a therapeutic medication for gastric ulcer uncomplicated and verified endoscopically . But if exploration results converge to a lesion suspicious , transformed or malignant is established indication for surgery .
Drug treatment is established for a period of 4-6 weeks and aims to increase mucosal resistance to aggression acidopeptică where inhibition of gastric ulcers and gastric hypersecretion in duodenal ulcer . For this purpose are used :
– Antacids that neutralize stomach acid ;
– Histamine H2 receptor antagonists ( ranitidine, cimetidine and others);
– Anticholinergic agents ( atropine and synthetic derivatives ) :
– Carbonic anhydrase inhibitors ;
– Medications that increase the mucosal defense ( sucralfate , colloidal bismuth compounds ) ;
– Anticholinergic ;
– Prostaglandin analogues ( misoprostol ) ;
– Gastric mucus secretion stimulants ( carbenoxolone ) ;
– Diet ( no caffeine , alcohol and tobacco).
Surgical treatment is applied to patients with perforated ulcer , duodenopilorică stenosis , recurrent gastrointestinal bleeding , gastric cancer or ulcer refractory to medical treatment . Ulcerative lesion location is determined by the surgeon choosing the type of intervention ( vagotomy , distal gastrectomy or saddle etc).
Definition and classification
Intestinal obstruction is characterized by the complete and persistent bowel , resulting from a mechanical or dynamic , which results in the occurrence of metabolic disorders with expression of the entire body.
Intestinal obstruction is one of the most common surgical diseases accounting for 20 % of all cases of acute abdomen .
Classification most useful in practical terms occlusions divided into :
• Mechanical occlusions , which are the consequence stop bowel obstructions due to the presence . Implies a bowel obstruction due to obstruction of the bowel wall injury , foreign bodies intralumenali , external compression or faulty position intestine ( hernias , volvulus , evisceraţii , intussusception ) ;
• dynamic or functional occlusions , which are due to stop bowel intestinal disturbances dynamics .
In terms of location occlusions can be: the small intestine – high (near jejunum ) or low (near ileum ), the large intestine.
Depending on the criterion of evolutionary occlusions may be: acute ( sudden and rapidly developing and severe ) , subacute ( slower -moving ) and chronic ( slow onset and long evolution ) .
By type of obstruction occlusion can be: simple obliteration (without vascular damage ) , strangulation ( with vascular damage ) and loop closed at both ends.
Clinical and laboratory diagnosis
The diagnosis of intestinal obstruction should be established urgently to act in a timely manner for the patient .
The existence of occlusion can be determined clinically on the basis of :
a) anamnesis , after discussion with the patient ;
b ) Clinical signs : diffuse pain , umbilicus , vomiting, intestinal transit stop ;
c ) Physical signs : abdominal bloating , accentuated peristaltic movements over the obstacle ; palpation points hernia or tumor formations ; Auscultation indicates hiperperistaltismul noisy living frequent DRE determines whether rectal ampulla is empty ; dehydration.
Laboratory occlusion is determined by :
– Empty abdominal radiograph shows gaseous distention of the bowel loops and multiple air-liquid picture ;
– Barium enema colonic obstruction established headquarters ;
– X-rays show based gastrografie obstruction but is recommended only in very difficult ;
Biochemical – CBC, blood proteinemia , ionograma blood and urine , blood pH , amilazemia , amilazuria allow a more accurate assessment .
Evolution and complications
The disease consists of three phases:
– The onset may be gradual or sudden . Often it is dramatic and brutal. Abdominal pain can be vivid and sharp , but sometimes occurs gradually.
– During the state , you add it emphasizes vomiting and pain . Without surgical treatment , changes are made to the terminal phase ;
– Terminal when faeces are vomiting , abdominal distension reaches extreme without peristaltic movements , general signs of intoxication ( sunken eyes , facies changes, breathing becomes shallow , weak pulse , lips cianozează , falling blood pressure, oliguria and uremia ) .
Complications that can occur are :
• Flooding tracheobronchial ( aspiration pneumonia ) with liquid vomiting ;
• Atelectaziileşi pneumonia ;
• Internal Dehydration and acid-base disturbances ;
• Acute renal failure ;
• Peritonitis by transudate and bowel wall necrosis ;
• Shock occluded .
Treatment of intestinal obstruction is complex medical and surgical . Emergency surgery aimed at removing or bypassing the obstacle and evacuation of intestinal contents remains fundamental therapeutic gesture .
Medical treatment aims to:
– Correction of electrolyte disorders ( is done by infusions of saline and glucose ) , balancing fluid and acid-base ( from metabolic acidosis bicarbonate solution administered 14% Na and Cl in metabolic alkalosis administration is essential ) ;
– Nasogastric suction ;
– oxygen for hypoxemia and fight to reduce abdominal distension ;
– Broad-spectrum antibiotic therapy is particularly useful in occlusions with strangulation .
Surgery is fundamental therapeutic act has two main objectives: removing or bypassing the obstacle and evacuating the bowel and peritoneal effusion .
If the plug occlusion period of training can take up to max . 24 hours but the occlusion by throttling it can not exceed 2-6 hours. Timing of surgery is when the patient became hemodynamically stable (pulse , BP ) , and diuresis resumed and disappeared signs of shock ( hypotension , vasoconstriction , hypothermia ) .
The most convenient is the general anesthesia with oro -tracheal intubation and incision most commonly used is the median which gives the possibility of a good exploration of the peritoneal cavity . Operation can be performed and laparoscopic .
Postoperative Treatment will include:
– Nasogastric aspiration , which is maintained until the resumption of transit;
– Balancing fluids, and acid-base electolitică ;
– Broad-spectrum antibiotics ;
– Symptomatic treatment ;
– Treatment of complications ( pulmonary , cardiovascular , peritoneal , hepatic , urinary infections , etc.), if they occur.
Dynamic occlusion occurring after discontinuation due to loss of the ability bowel propulsion of intestinal contents due to functional disorders .
They occur more often and may be:
• spastic bowel obstruction ( meet at overly and hysterical ) ;
• paralytic intestinal obstruction encountered more often than the previous , be due to peritoneal irritation , retroperitoneal or vascular disturbances ( embolism or thrombosis of mesenteric vessels ) .