Another name for Gastric Perforation is Perforated Ulcer.

A person with a perforated ulcer has a hole in the wall of the stomach, small intestine, or esophagus, caused by peptic ulcer disease. The perforated ulcer allows food and blood to leak into the abdomen. The food or blood causes severe inflammation of the inside of the abdomen, called peritonitis.

●Peptic ulcer disease

●Zollinger-Ellison syndrome

●Gastrointestinal bleeding

●Peritonitis

Symptoms of a perforated ulcer include severe abdominal pain, abdominal swelling, abdominal tenderness, nausea, vomiting, and fever.

●Pain is usually severe

●Pain often starts abruptly

●Pain worsens with movement

●Pain usually occurs all over the abdomen, rather than in one region

●Lower abdominal pain

●Upper abdominal pain

●Pain may radiate to the back

●Right lower abdominal tenderness

●Left lower abdominal tenderness

●Right upper abdominal tenderness

●Left upper abdominal tenderness

●Upper abdominal tenderness

●Lower abdominal tenderness

●Abdominal swelling

●Back pain

●Nausea

●Vomiting

●Hiccups

●Fever

●Chills

●Constipation

●Faintness

●Fainting

●Fatigue

●Difficulty breathing

●Rapid pulse

●On X-rays, free gas/air may be visible in the abdominal cavity.

●The perforation can often be visualised using computed tomography.

●White blood cells are often elevated.

●Visible signs can occasionally include a ridged abdomen on palpation.

Treatment for a perforated ulcer requires surgery to repair the hole in the stomach, intestine, or esophagus.

Below from: Primary Surgery, Volume One: Non-trauma, Chapter 5. The surgery of the stomach

non-operative treatment for a perforated peptic ulcer indications.

●A perforation which appears to have sealed itself already, as shown by diminished pain and improved abdominal signs.

●Heart or lung disease, which increases the surgical and anaesthetic risks.

●The patient who is admitted after a day or two and is almost moribund with diffuse peritonitis. Non-operative treatment may be best, because it is unlikely that he would have survived so long with an open perforation.

contraindications.

●An uncertain diagnosis.

●The absence of really good nursing by day and night.

●The seriously ill patient, with a short history, whose only hope is vigorous resuscitation and an urgent laparotomy. If you do decide that such a patient is ‘not fit for surgery', wait to do so until vigorous resuscitation has failed [md] don't make the decision when he is first admitted.

method.

Give him morphine 5 to 10 mg intravenously. As soon as this has had time to act, pass a large tube and empty his stomach. When it is empty, pass as wide a radio-opaque nasogastric tube as he will tolerate. Take him to the X-ray department and take AP erect films of his chest and lower abdomen. These should show that there are no fluid levels in his stomach, and that the tube is well placed. If not, adjust it and take more films. Look for subdiaphragmatic gas to confirm the diagnosis.

Back in the ward, ask a nurse to aspirate his stomach every 15 minutes initially. Set up an intravenous drip, and monitor his pulse and blood pressure hourly.

He is progressing well if:

●His pain eases, so that he does not need more analgesics.

●Another erect film 12 hours later (optional) shows no fluid level, and no increase in the gas under his diaphragm. Continue to ‘'suck and drip him' for 4 or 5 days, until his abdomen is no longer tender and rigid, and his bowel sounds return.

●If pain persists, or the gas under his diaphragm increases, operate.

laparotomy for a perforated peptic ulcer equipment. A general set. Several litres of warm saline. Two assistants make upper abdominal surgery easier.

PREPARATION. Pass a nasogastric tube and aspirate his stomach. He will have lost much fluid into his peritoneal cavity, so correct at least part of his fluid loss before you operate. If he is dehydrated or hypotensive, give him 1 to 3 litres of fluid rapidly. If more than 12 hours have elapsed since he perforated, he will need even more. Operate soon, but not before you have resuscitated him. He has not bled, so he does not need blood.

perioperative antibiotics. are only indicated in late cases with peritonitis.

anaesthesia.

●General anaesthesia with good relaxation.

●If this is contraindicated because of lung disease, do an intercostal block, from T6 to T11.

Premedicate him with intravenous morphine, and palpate his abdomen when this has taken effect. If his rigidity is generalized, morphine will make little difference if he has a perforation, but if he has appendicitis, rigidity will now be localized to his right iliac fossa.

incision. Make a midline or upper right paramedian incision. The escape of gas as you incise his peritoneum confirms the diagnosis.

Initial examination will probably show a pool of exudate under his liver, with food and fluid everywhere, and an inflamed peritoneum. The fluid may be odourless and colourless with yellowish flecks, or bile-stained if it is pure bile, he has biliary peritonitis. If you see patches of fat necrosis, he has acute pancreatitis. If there is no fluid or little fluid, push a swab on a holder beside his ascending colon towards his caecum. If you withdraw it soaked with fluid, this suggests a perforation. Draw his stomach and transverse colon downwards: you may see flecks of fibrin, and perhaps pieces of food.

To expose his stomach and duodenum place a self- retaining retractor in the wound. Place a moist abdominal pack on the greater curvature of his stomach. Draw this downwards, and ask your assistant to hold it; at the same time ask him to hold the patient's liver upwards with a deep retractor. Put an abdominal pack between the retractor and his liver to protect it. If necessary, get the help of a second assistant.

Suck away any fluid, looking carefully to see where it is coming from.

Search for a small (1 to 10 mm or more) circular hole on the anterior surface of his duodenum, looking as if it has just been drilled out. Feel it. The tissues around it will be oedematous, thickened, scarred, and friable. If his duodenum is normal, look at his stomach, especially its lesser curve. If the hole is small, there may be more to feel than to see. Sometimes, a gastric ulcer is sealed off by adhesions to the liver. Remember that a gastric ulcer may be malignant: consider biopsy.

If his stomach is adherent to his liver, separate it.

Open his lesser sac through his lesser omentum. Feel the posterior surface of his stomach. An ulcer high up posteriorly may be difficult to find. Feel carefully.

If his stomach and duodenum are normal, feel gently downwards towards his appendix. If there is a mass or it is obviously inflamed, close the midline incision and make a gridiron one. Two smaller incisions are better than one huge one.

To close the perforation, use 2/0 chromic catgut on an atraumatic needle to bring its edges together with 1 to 3 deep stitches. If the tissue is so rigid that the stitches cut out, you may be able to reduce the size of the hole with loose sutures, or by using a purse string suture. Always sew omentum over the perforation, by bringing up a fold of greater omentum. A hole so plugged is unlikely to leak.

Wash out his peritoneal cavity. This is absolutely critical, and may be more important than closing the hole. Tip a litre of warm saline into his peritoneal cavity, spread it well, and then suck it out again. Repeat this several times, and try to wash out every possible recess in his upper abdomen. Mop the upper surface of his liver. Instil tetracycline 1 g in a litre of of saline and leave it in. This may be unnecessary if you operate within 6 hours of the perforation.

further procedures. If:

●his general condition is good, and you are operating early (within 6 to 8 hours of a duodenal, or particularly a gastric perforation).

●he has severe ulcer disease (uncontrollable symptoms, or a previous bleed or perforation).

you are experienced, consider doing a vagotomy and gastroenterostomy. Otherwise, proceed to close his abdomen.

closure. Close his abdomen securely with non-absorbable sutures in a single layer, because it is particularly likely to burst. Don't insert drains.

postoperatively. Nurse him sitting up in a high Fowler's position. He will breathe more easily, he will be less likely to have chest complications, and any exudate will gravitate downwards. Continue with nasogastric suction and intravenous fluids. Replace gastric aspirate with 0.9% saline. If he is likely to get lung complications, chest physiotherapy is vital.

fainting ['feintiŋ] n. v.昏厥

gastroenterostomy ['gæstrəu,entə'rɔstəmi] n.胃肠造口吻合术

inflammation [infə'meiʃ(ə)n] n.炎症

laparotomy [,læpə'rɒtəmi] n.剖腹探查术

malignant [mə'lignənt] n.恶变

nausea ['nɔːsiə; -z-] n.恶心

radiate ['reidieit] v.放射,辐射

tenderness ['tendənəs] n.疼痛，压痛

vagotomy [vei'gɒtəmi] n.迷走神经切断术

vomiting ['vɔmitiŋ] v.呕吐

abdominal pain 腹痛

abdominal swelling 腹胀

biliary peritonitis 胆汁性腹膜炎

diffuse peritonitis 弥漫性腹膜炎

intercostal block 肋间神经阻滞

lesser sac 小网膜囊

perforated ulcer 穿孔性溃疡

rapid pulse 脉速

subdiaphragmatic gas 膈下游离气体