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Acute complications of ulcerous illness of stomach

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					                      THE HEALTH OFFICE OF UKRAINE
                  BUKOVINIAN OF STATE MEDICAL UNIVERSITY




   “Ratified”
on and methodical conference
departments of surgery
Head of of department
professor               I.Yu. Polyanskiy
“___” ___________ 20__y.




                         METHODICAL DIRECTION
                  to the students of ІV course medical faculties
                          FOR INDEPENDENT WORK
                 AT PREPARATION TO PRACTICAL LESSON
                                   MODULE 1
                             BASES of SURGERY 1"
                            "
                                  Thematic of module 1
                     URGENT ABDOMINAL SURGERY"
                    "
    THEME OF LESSON: "ACUTE COMPLICATIONS OF ULCER’S DISEASE OF
                       STOMACH AND DUODENUM"




                                                         Educational of discipline:
                                                         Surgery
                                                         ІV course, Medical faculty
                                                         6 hours


                                                         Methodical of direction made
                                                         As. Tarabanchuk V.V.


                                     Chernivtsy – 2010
1. Actuality of theme: The acute complications of ulcerous illness of stomach and duodenum
are ulcerous bleeding of stomach and duodenum and perforation gastro-duodenal ulcers.
        Acute ulcerous bleeding of stomach and duodenum - this threatening, frequent
complication of ulcerous illness and other diseases, which differs weight of diagnostics and
unsatisfactory results of conservative and operative treatment. It is one of principal reasons of
mortality at acute surgical pathology, which hesitates within the limits of 8-30%.
        Frequency of gastro-duodenal perforations makes on the average 15% in relation to all of
patients with ulcerous illness. Among other acute surgical diseases of organs of abdominal
region this pathology occupies a ІІІ place and hesitates from 3,2 to 5,4% in relation to all of
patients of surgical permanent establishments. Thus, perforative gastro-duodenal ulcers are
widespread enough pathology, with which is to meet not only surgeons but also doctors of other
specialities.
        Perforations considerably more frequent meet for men attitude of which toward women
with this disease is 10:1. Most often perforations meet in age from 20 to 50, although can
develop in dear age – from 2th days after birth to 95. The row of factors influences on frequency
of development of this complication: stress situations, violations of diet, harmful habits (abuse of
alcohol, smoking), duration of disease on an ulcer but other
        The clinical displays of perforative ulcers are characteristic enough. However, there can
be considerable diagnostic difficulties at the covered and atypical perforations, especially on the
before hospital stage.
        In this connection, the study of this theme has an important practical value.

    2. Duration of employment: 6 hours

     3. Educational purpose (concrete aims):
3.1. To know:
determination of concept «bleeding and perforative gastro-duodenal ulcer»;
etiology and pathogenesis of bleeding and perforative of gastro-duodenal ulcer;
classification of bleeding and perforative of gastro-duodenal ulcer;
clinical picture of typical and atypical perforation of gastro-duodenal ulcer;
 clinical picture of bleeding gastro duodenal ulcer;
additional methods of research of bleeding and perforative gastro duodenal ulcer;
differential diagnostics of bleeding and perforative gastro duodenal ulcer;
 medical tactic at bleeding and perforation gastro of duodenal ulcers;
 methods of conservative and surgical treatment of bleeding ulcer and its complications;
 before operation preparation of patients, its task and maintenance;
 shows are to operative interference at a bleeding and perforation gastric and duodenum ulcer;
 methods of operative interferences are depending on time after a perforation and localization
    of ulcer;
 postoperative conduct of patients;
 postoperative complications, their prophylaxis;
 medical tactic at the covered perforations;
 prophylaxis of bleeding and perforative gastro duodenal ulcer.
 rehabilitation of patients in a postoperative period.

         3.2. Able:
   To collect complaints and anamnesis of disease;
   to work out a plan of inspection sick;
   to conduct clinic – laboratory diagnostics of bleeding and perforative gastro duodenal ulcer;
   to analyse results laboratory, X-ray, ultrasonic, endoscopic inspections;
   to propose a previous diagnosis at bleeding and perforative gastro-duodenal ulcer;
   to differentiate the different forms of perforative and bleeding gastro duodenal ulcer
   to determine medical tactic at the proposed diagnosis of bleeding or perforation.
   to formulate the grounded clinical diagnosis at bleeding and perforative gastro-duodenal ulcer
    in obedience to classification;
   to design a medical document.
   to define shows and conduct blood and its components transfusion.
   to make a plan conducts sick in a postoperative period.
   to determine the rehabilitation of patients in a postoperative period and conduct sanitation
    work on prevention of relapse of the ulcerous bleeding and perforation.

         3.3. to Capture practical skills:
   to collection of anamnesis for a patient on perforative and bleeding gastric and duodenum
    ulcer;
   inspections sick on perforative and bleeding gastric and duodenum ulcer;
   exposure of symptoms of perforative and bleeding gastric and duodenum ulcer;
   an exposure of X-ray signs of free gas and liquid is in a peritoneal cavity;
   to analyse information of FGDS;
   leadthrough of digit inspection of rectum;
   estimations of these labtests;

    4  Base knowledges, abilities, skills, necessary for a study themes (interdiscipline
       integration)
 №      Name of discipline and
                                                To know                          Able
п/п       proper department
Base departments
     Anatomy,         topographical Anatomy and topographical To conduct palpation of
     anatomy (departments of anatomy of stomach and stomach
     anatomy         of       man, duodenum.
     topographical anatomy and
     operative surgery)
     Pathoanatomy (department of Morphological description of  To                         define
     pathoanatomy)                  changes of mucus shell         of   morphological changes,
                                    stomach and duodenum                inherent to bleeding and
                                                                        perforative gastro to the
                                                                        duodenal ulcer;

     Anatomy,         topographical   Operative accesses, methods of To choose the correct
     anatomy (departments of          operations                     method of operation
     anatomy         of       man,
     topographical anatomy and
     operative surgery)
4    Propedevtic     of    internal   Subjective, objective methods of To conduct an inspection
     disease     (department     of   inspection    of    organs    of patient with bleeding and
     propedevtic     of    internal   abdominal region                 perforative gastro duodenal
     disease)                                                          ulcer.
Type clinical departments
       General surgery (department Basic principles of work of Hospitalize a patient in
       of general surgery)          surgical separation and operating surgical          permanent
                                    blVCB are on the grant of establishment, to prepare to
                                    medicare.                         the treatment diagnostic
                                                                      measures and operative
                                                                      interferences.
       Internal disease (department Methods of diagnostics bleeding To find out the complaints
       of internal disease and and perforative gastro duodenal of             patient,      collect
       endocrinology)               ulcer, pathogenesis and variants anamnesis of disease,
                                    of clinical motion. Methods of conduct an inspection sick,
                                    inspection sick.                  ground      a     diagnosis,
                                                                      conduct     a    differential
                                                                      diagnosis, work out a plan
                                                                      of additional inspection.

   5    Advices to the student.

        5.1. Table of contents of theme:
        Bleeding from ulcers is heavy complication of ulcerous illness, which is predefined
progress of necrobiotic processes in an ulcer and receipt of blood in a gastric intestinal highway.
Frequency of bleeding at ulcerous illness arrives at 22-28%, patients have them mainly after 40.
For the women of bleeding from ulcers meet twice rarer than for men. Bleeding from gastric
ulcers happen more frequent than from the ulcers of duodenum. The ulcers of small curvature of
stomach and back wall of duodenum bleed especially often.
        Etiology and pathogenesis
        Principal reason of the ulcerous bleeding is acuteening of ulcerous illness with progress
of necrobiotic process in the area of ulcer and distribution of him on surrounding fabrics.
Acuteening of pathological process is related to the action of different exogenous and
endogenous factors (psychical trauma, violation of the neyrohumor adjusting of the gastro-
duodenal system but other), which result in violation of trophism of fabric directly near an ulcer,
strengthening of inflammatory process in this area, which spreads on the wall of vessels, and also
peptic action of gastric juice, strengthening of local fibrinolysis, origin of incoagulability and
increase of fibrinolytic activity of blood.
        A bleeding source can be an artery, vein or shallow vessels of bottom of ulcer.
        The main nosotropic mechanisms of bleedingness at ulcerous illness is:
        1. Permanent hyperemia of all of the vascular system of stomach, especially superficial
capillaries and veins, that results in hypoxia and violation of vascular-tissue permeability and as
a result - to massive hemorrhage.
        2. Acute degree of dystrophy of superficial layers of mucus shell and decline of exchange
of nucleic acids of, which results in formation of microerosions.
        3. Increase of accumulation of neutral mucopolysaharids of, which specifies on
disintegration of albumen-carbohydrate connections and increase of vascular permeability.
        4. Violation of rhythms of polymerization and depolymerisation of sour
mucopolysaharids is in the wall of vessels.
        5. Dystrophy processes, alteration and pathological regeneration all gaster systems of
glands which violate secretory activity of stomach and support expansion of vessels and tissue
hypoxia.
        Next nosotropic mechanisms can accompany bleeding
        1. Hypovolemic shock is as a result of diminishing of VCB (volume circulation blood).
        2. Kidney insufficiency is as a result of diminishing of filtration and hypoxia of
parenchym of buds.
        3. Hepatic insufficiency is in connection with diminishing of hepatic blood stream and
hypoxia.
        4. Hipoxia of myocardium, myocardial ischemia, heart attack of myocardium.
        5. Hipoxia of brain, was swollen a brain.
        6. Intoxication by the products of hydrolysis of albumens of blood which was outpoured
in an intestine.
          Classification
In obedience to classification of O.O. Shalimov, V.F. Saenko (1987), bleeding divide loss of
blood into 3 degrees of weight.
        I degree - easy, observed at a loss to 20% VCB (volume circulation blood) (till 1000 ml
with weight 70 kg).
        ІІ degree - middle weight, predefined a loss from 20% to 30% VCB (to 1500 ml).
        ІІІ degree is heavy which answers the loss of more than 1500 ml.
        On duration, bleeding divide on:
        1. Acute.
         2. Chronic.
        By localization - in accordance with localization of ulcers.
        Clinical symptoms.
        The clinical picture of bleeding is determined the degree of bleeding, bleeding duration,
character of basic disease, age of patient, presence of concomitant pathology.
        A making progress general weakness, dizziness, appears on a background acuteening of
ulcerous illness (more frequent all), sometimes loss of consciousness, "beauty-spot" before eyes,
in future is vomit blood (haematemesis). Depending on a volume and time of bleeding, vomit
can be "coffee-grounds", that it is related to formation of muriatic hematine in a stomach.
"Coffee-grounds" are the most characteristic symptom of bleeding, can be non-permanent and
repeated, that specifies on continuation of bleeding. At a bleeding gastric of vomit "coffee-
grounds" ulcer observed more frequent than at a duodenal ulcer.
        Sometimes preceded bleeding strengthening of pain and phenomena of dyspepsia, which
disappear after the beginning of bleeding (the Bergman,s sign). In the cases of the acute bleeding
with vomit the masses the littlechanged is selected, often with clots blood, what not similar to the
"coffee-grounds".
        By other reliable sign of bleeding black tarry emptying with an unpleasant smell
(melena). Education of them is related to entering road clearance of intestine of blood which is
gradually laid out, sulphuric iron which gives excrement the masses of black appears as a result.
At massive acute duodenal bleeding excrement the masses can be darkly cherry blossom, liquid
consistency, that is related to rapid advancement of blood on an intestine. At the moderate
bleeding excrement the masses are designed, ordinary consistency, black. At a bleeding duodenal
ulcer a melena meets more frequent, and presence of melena as the first sign at the gastric
bleeding testifies to moderate intensity of bleeding.
        At a review a patient is pale, fRt on face, lies mainly on the back, being afraid motion,
not to provoke bleeding (vomit blood), breathing is frequent. Person sick it is covered a sticky
death-damp which often testifies to continuation of bleeding. Pallor of skin of person and visible
mucus shells, dryness in a company are permanent signs of the early postbleeding state. A pulse
is frequent, soft, sometimes threadlike, on occasion is arrhythmia. A tongue is moist, almost
always assessed a white raid, quite often on him and gums evidently tailings of vomit the
masses. At a review a stomach is hollow, often noticeable pulsation in a epigastric area. At times
on the front wall of abdomen pigmental spots are determined as a result of the protracted
application of hot-water bottles. At the heavy bleeding a stomach is blown away as a result of
disintegration of blood in an intestine and intoxication. At auscultation of stomach for patients
with bleeding strengthening of peristaltic noises is determined, that it is related to the irritation of
intestine blood.
        Palpation at bleeding it admits only superficial, at it moderate painfulness is determined
in the projection of ulcer. Deep palpation of abdominal wall is risky, because it can provoke
tromb dug up and bleeding.
        At palpation painfulness is determined in the projection of ulcer on a front abdominal
wall (the Mendel,s sign).
        Patients with the gastroenteric bleeding have dactylar rectal research the obligatory
method of inspection. During the leadthrough of him liquid tarry excrement the masses appear in
a rectum, and also it is possible to find out other sources of bleeding: tumours of rectum,
haemorrhoidal knots, anal crack.
        Depending on the degree of bleeding, distinguish:
        Idegree - the general state of patient is satisfactory or middle weight, a skin is pale
(vascular spasm), pulse appears < 90-100 b/min., BP - 100-90/60 mm.Hg, an anxiety changes
easy dormancy, consciousness gums, breathing often, reflexes are mionectic, muscles are
weakened. The expressed disorders of circulation of blood are not observed.
        A ІІ degree is the general state of middle weight, a patient is put on the brakes, talks in a
low voice, slowly, determined the expressed pallor of skin covers, sticky sweat, pulse - 120-130
b/min., weak filling, BP - 90-80 /50 mm.Hg , frequent shallow breathing, oliguria. Considerable
violations of circulation of blood, metabolism, function of buds, liver, intestine are marked.
        ІІІ degree - the general state is heavy or extremely heavy, oppression of all of reflexes,
skin and visible mucus pale cyanochroic or macula’s (the spasm of vessels changes dilatation). A
patient with a question answers slowly, in a low voice, loses consciousness often, a pulse is
threadlike, 130-140 b/min., periodically on peripheral arteries can be not determined, maximal
BP - 0-60 mm.Hg, central venous pressure (CVP) is very low, breathing is superficial, not
frequent, extremities and body are cold by touch. Oliguriya passes to the anury. Without timely
indemnification bleeding sick die as a result of decline of cardiac activity, expressed metabolic
violations, necrocytosis liver, buds.
        Especially dangerous complication of ulcerous illness is combination of bleeding with the
perforation of ulcer which is observed in 3,2-8,4% patients with the complicated ulcerous illness.
In repressing majority at ulcerous illness, strengthening of stomach-ache is preceded the acute
gastroenteric bleeding and other dyspeptic displays which testify to intensifying of disease. But
after the origin of bleeding these displays, as a rule, the signs of the acute gastroenteric bleeding
disappear (symptom of Bergmana) and appear. If after the beginning of bleeding pains do not
disappear, but increase, the general state of patient is swiftly worsened, it is possible to think
about combination of it with the perforation of ulcer. For such patients of tension of muscles of
front abdominal wall can be not expressed. V.D. A brother (1972) considers that it by a caused
hit in the abdominal region of the changed blood, which irritates a peritoneum, than ordinary
gastric bridge less than.
        Laboratory and instrumental methods of diagnostics.
        Laboratory methods of inspection:
        1. Common analysis of blood (unfolded).
        2. Common analysis of urine.
        3. Determination of blood and Rh-factor type.
        4. Coagulogram.
        5. Bleeding time.
        6. Biochemical blood test.
        7. ECG.
          The decline of level of haemoglobin, amount of red corpuscles, Ht appears laboratory
researches. At the beginning of bleeding these indexes do not represent its veritable degree, the
decline of them is observed only in a few hours. There is also a decline of level of general
albumen in plasma of blood, violation of electrolyte and nitrous exchange. At the massive
bleeding with falling of arteriotony the increase of amount of urea takes a place in blood as a
result of diminishing of lauter function of buds.
           From the instrumental methods of inspection a major role is played by endoscopic
methods which enable to set not only a bleeding source and its reason but also bleeding stopped
to define or lasts.
           In 1987 year J. Forest and coauthors offered endoscopic classification of the ulcerous
bleeding, which selects the followings groups:
           I A – stream (arterial) bleeding from an ulcer
           I B – is the drop (venous) bleeding from an ulcer
           ІІ A – thromboses vessels are in an ulcer
           ІІ B – a blood which closes an ulcer cloth
           ІІ C – ulcer without the signs of bleeding
           ІІІ – not found out a bleeding source.
           At endoscopic signs are determined stable or unstable haemostasis. By signs stable
haemostasis there is absence of blood in a stomach and bulb of duodenum, the bottom of ulcer is
covered the fibrin of white or grey color, educations of salient above a crater ulcer of vessel
closed the blood clot of white color.
           By signs unstable haemostasis there is a presence of light blood, faltungs of blood at a
stomach, magnificent the package of blood of umber color above an ulcer, the pulsation of vessel
is determined. Absolute sign unstable haemostasis is a profluvium of blood from a vessel.
            In connection with wide introduction of ендоскопічних methods of inspection the role
of X-ray methods diminished considerably. During the leadthrough of contrasting X-ray,
sciagraphies for patients with the intestinal-gastric bleeding the symptom of "pushing" away of
barium mixture is determined.
           On occasion in the specialized departments for diagnostics of the gastroenteric bleeding
apply selective angiography of branches of abdominal aorta. At continuation of bleeding for
patients the hit of contrast is determined in the road clearance of gastroenteric highway.
           Differential diagnosis.
           Differential diagnostics of bleeding on the basis of ulcerous illness of stomach and
duodenum is conducted.
           1. with the diseases of stomach: erosive gastritis, syndrome of Menetrie, bleeding at
shrine of stomach, shrine of gullet, by the diverticulums of food highway, syndrome of Mulori-
Veis, syndrome of Zolinger - Ellison, polyposis of stomach .
           2. Bleeding of unulcerous character (diaphragmatic hernia, phlebeurysm gullet and
stomach at portal hypertension).
           1. At atherosclerosis of vessels of abdominal aorta.
           2. At innate angioectasy (illness of Randyu-Osler).
           3. At the diseases of blood and violation of the convolutional system of blood.
Medical tactic and choice of method of treatment.
Medical tactic depends on reason of bleeding, duration of bleeding and his dynamics, degree of
bleeding.
 All of patients with suspicion on the gastroenteric bleeding of must be hospitalized in a surgical
department, and at confirmation of diagnosis - in a reanimation (O.O. Shalimov, 1987).
 Conservative treatment of bleeding is rotined:
а) at a doubtful diagnosis;
b) at bleeding of the first degree, which is shut-down;
c) at the shut-down bleeding, when absent is given about possibility of its relapse;
d) in default of terms for implementation of operation;
e) at presence of heavy accompanying pathology.
Conservative treatment includes:
1. Bed rest, hunger.
2. Cannulation of two veins, one of which must be central.
3. Transfusion of mass of red corpuscles, plasma.
4. Introduction of hemostatics (fibrinogen, aminocaprony acid, cryoprecipitate, plasma, chloride
of calcium, vicasoly).
5. Intravenous introduction of inhibitirs of proteasis (contrical, trasilol).
6. Oppression of gastric secretion (to the atropine sulfate, blocks of H2-receptors).
7. Oppression of fibrinolytic activity (aminocaprony acid perorally).
8. Guided low blood pressure (arfonad, pentamin).
9. Proceeding in VCB is due to haemocorectors.
10. Local hypothermia (washing of stomach by cold water).
11. In case of stopping of bleeding is a diet of Meylengrakhta (sour cream, raw frappe eggs).
12. Local stop of bleeding. Through a nasogastric probe mixture is entered: to 4 ml
Noradrenalinum, 50 ml of chloride of sodium, 50 ml of aminocaprony acid, 200 grammes to
Thrombinum. Mechanism of action: Noradrenalinum exposes артеріовенозні shunts in a
submucous layer, results in the local draining of blood of mucus гемостазу. At the same time
Noradrenalinum activates the XII factor of hemopexis. Aminocaprony acid diminishes
fibrinolytic activity of blood. Thrombinum causes the local stop of bleeding.
         During the leadthrough of EFGDS it is possible natively to stop bleeding by electro-
coagulation, photocoagulation a laser, application of glue of KL-3.
 Methods of endoscopic stop of bleeding:
         1. Cryocautery.
         2. Diathermo-coagulation.
         3. Electro-coagulation.
         4.Laser coagulation.
 A cryocautery is local influence on the area of bleeding by a cold.
         To to, an ampoule is joined a probe which is brought to the area of bleeding from
chlorethil through the special reducer.
         Crioelectrocoagulation - by the special device a bleeding area is irrigated by the stream
of khradon at a temperature -280С before formation of “snow cap”.
 Diathermocoagulation. The special probe (mono- or bipolar electrode) is tricked into to the
    bleeding area and by the short (not more than 2-3 сек) including of current of high-purity
    coagulation fabrics to education white a scab.
         If directly coagulation a bleeding vessel is not succeeded, it is expedient to conduct
coagulation round it, on the stored fabrics, coagulation a vessel on a draught.
 Most effective is laser coagulation, where depending on power of radiant it is possible to
    regulate the depth of coagulation.
         To stop with bleeding these methods succeeded in 80-90 % cases. However, in 15-20% in
different terms after coagulation there are relapses of bleeding. For their prophylaxis utillize:
1) injection of bleeding area by different blood stop preparations (Noradrenalinum, 96% ethyl
    spirit, dicinoni, aminocaprony acid);

        Control of conservative treatment is conducted by measuring of pulse, arteriotony each
30 minutes, central of venous pressure - hourly. A blood test is hourly conducted a patient (red
corpuscles, haemoglobin, Ht). A patient is conduct sounding of stomach for control after
bleeding, systematic axsufflation of gastric maintenance, permanent cannulation of urinary
bladder and control after a diuresis (it must be selected urine not less than 30 ml/hour).
                                         Surgical treatment.
        Surgical practice at the gastroenteric bleeding to this time is a large problem. Utillize two
basic methods of treatment:
        1. Active tactic is operative treatment on height of bleeding.
        2. Temporizing tactic which foresees the stop of bleeding conservative facilities and in
future is the planned operative interference.
An absolute testimony to him is the stream bleeding.
De bene esse absolute indications is:
1. The recurrent bleeding is in anamnesis;
2. Relapse of bleeding during treatment or unefficiency of conservative treatment;
3. Localization of ulcer is in areas with increased blood flow, in the projection of main vessels;
4. Unfavorable endoscopy picture (deep ulcer, calosus ulcer with a trombosis vessel).
         From our point of view, most justified is actively temporizing tactic which includes
drawing on all complex of endoscopy and conservative measures. Operative interferences which
are executed at bleeding divide by urgent, which execute in the first 12-24 hours since a receipt,
early, - during 1-3 days, later - to 10-14 days and planned.
         Urgent operations are conducted patients with the intensive bleeding which is not
stopped.
         Early operations are executed at endoscope signs unreliable haemostasis (a group II-An is
after Forest), when a danger of relapse of bleeding is.
         The deferred operations are executed for patients with haemostasis signs stable (group
ІІІ after Forest).
         The planned operative interferences are rotined in default of danger of relapse of
bleeding: terms and volume of operation are determined character of disease which caused
bleeding.
         Preparation of patient to the operation lasts 1,5-2 years, on occasion massive bleeding not
conducted practically. The volume of preparation beforeoperation depends on the degree of
bleeding.
Operative treatment of the gastro-duodenal bleeding is conducted under intratracheal anesthesia.
Surgical access is overhead-middle laparotomy. Conduct the review of stomach and intestine for
an exposure in them of blood.
In default of information, which testify to the ulcer, conduct a longitudinal gastrotomy which
begins in the distance in a few centimetres from pylorus, audit stomach and duodenum.
After establishment of bleeding source, to the choice of optimum method of operation apply
exigent measures for providing local haemostasis. For this purpose it is necessary suture during a
gastrotomy, to bandage, coagulation bleeding vessels or proper area of mucus, to impose 8-
similar guy-sutures on an ulcer.
The volume of operative interference is determined the state of patient, bleeding weight,
concomitant diseases, anatomic localization and character of ulcer.
For extraordinarily heavy patients of palliative operations is justified:
1) sewing of bleeding vessel is from the side of mucus;
2) V-like carving of ulcer;
3) embolization of bleeding vessels;
4) sewing of wall of stomach through on the perimeter of ulcer with next imposition of serous-
muscular guy-sutures by Kartavin;
5) inseaming of bleeding gastric and duodenum ulcer.
         At a bleeding gastric ulcer the resection of stomach is rotined. In declining years with the
high risk of operation is carving of ulcer with a pyloroplasty and vagotomy or sewing of vessels
through the гастротомічний opening of combination with a pyloroplasty and barrel ваготомією.
         At the bleeding ulcers of duodenum depending on its localization, carving of ulcer can be
conducted on a front wall, selective or barrel vagotomy, pyloroplasty, at localization on a back
wall - duodenotomy, visual stop of bleeding (sewing of vessels, diathermocoagulation, stopping
medical glue), vagotomy and pyloroplasty.
         At the low ulcers of duodenum the visual stop of bleeding and resection of stomach is
rotined on an exception.
         At the combined gastric and duodenum ulcer vagotomy is rotined from
pyloroantrumectomy.
         Postoperative treatment.
         Basic principles:
         1.Proceeding in VCB.
       2. A fight is against postbleeding anaemia.
       3. Improvement of reologic properties of blood.
       4. Prophylaxis or treatment of hepatic-kidney insufficiency.
       5. Infusion therapy.
       6. Antiulcerous therapy which includes for itself block of gastric secretion.
       7. Decompression of stomach is to proceeding in a peristalsis and arcade of intestinal
       maintenance.
       8. Fight against paresis of intestine, leadthrough of cleansing enemas.
       9. Vitaminterapy.
       10. Symptomatic therapy.
       11. Antibiotic therapy is after indications.

         Under the perforation (by a breach) of gastric and duodenum ulcer understand the breach
of ulcer in a free abdominal region with a receipt for it of stomach-duodenal maintenance and
air. Among other complications of ulcerous illness of stomach and duodenum a perforation of
ulcer is an instant danger for a patient in connection with mushroom growth of the poured out
peritonitis.
   Principal reasons of origin of perforation of gastro-duodenal ulcers can be divided on: 1)
favourable; 2) caused.
 To favourable reasons of origin of perforation of gastro-duodenal ulcers take acuteening of
ulcerous illness, which is accompanied the making progress process of destruction and necrosis
of wall of stomach or duodenum.
 The physical loading serves as other factors which are instrumental in a perforation, full
stomach by a meal, abuse of alcohol, neurotic violations in an organism (stress), which result in
the increase of intra-abdominal, inwardly gastric pressure, cause the increase of secretion with
high acidity of gastric juice.
 Penetration in the ulcer of virulent infection, origin of local reaction which causes the
thrombosis of veins, behaves to the caused factors. Thrombosis, thrombophlebitis of veins of
stomach as a local reaction on an autoimmune process results in the origin of perforation.
 The perforation of gastro-duodenal ulcers results in the permanent entering abdominal region of
gastro-duodenal maintenance, which operates on a peritoneum as chemical, physical, and then
and bacterial irritant. At first six hours under the action of gastric juice there is inflammation. A
clinical picture and violation in an organism remind pathogenesis and clinic of shock, that
enabled to name this stage the stage of shock.
In future, as a result of adaptation to aggression, the cardinal signs of perforation disappear
paresis of nervous completions of peritoneum (6-12 h.). State sick improved, the period of
“imaginary prosperity comes”. With development of bacterial peritonitis, caused a streptococcus,
staphylococcus, by a collibacillus and others like that, an inflammatory process passes to the
third stage – stage of making progress peritonitis.
 In some cases the perforative opening of small sizes can through set time to be covered a fibrin,
stuffing-box. Thus a general inflammatory process is limited and acquires local character – there
is the covered perforative ulcer.
                                                 Classification
         Gastro-duodenal perforations can be classified:
1.By etiology:
   - as a result of ulcerous illness;
   are acute ulcers (hormonal, stress but other).
2. By localization:
   а) gastric ulcers (antrum department, pyloric channel, body, cardiac department, bottom);
   b) ulcers of duodenum (overhead-horizontal, descendens part).
  3. By clinical motion:
   а) period of shock;
  b) imaginary prosperity;
  c) period of peritonitis.
4. Clinical forms of perforation of ulcer:
   а) a perforation is in a free abdominal region;
   b) a perforation is covered;
   c) atypical perforations.

        Clinic. The perforation of gastric and duodenum ulcer conduces to the profluvium in the
free abdominal region of gastro-duodenal maintenance which operates on a peritoneum as
physical, chemical and bacterial irritant.
        Divided all of symptoms of perforative ulcer of A. Mondor (1938) into three groups:
1. Basic is pain, tension of muscles of abdominal wall, ulcerous anamnesis;
2. Side - functional, physical;
3. General.
        First period - period of primary shock - lasts 3-6 hours. His duration depends on the size
of opening which appeared, degree of filling of stomach to the moment of perforation of ulcer.
        The first symptom of perforation is pain, extraordinarily acute, permanent, “knife-like”
which arises up suddenly. Patients characterize pain as “blow of knife”, “was a guardian boiling
water”. Pain is so strong, that patients often remain tied down to the that place, where they were,
when a perforation came.
        At first pain arises up in a epigastric area or in Rt subchondric, spreads on the Rt half of
stomach and quickly takes all of stomach, in accordance with distribution of the outpoured liquid
and exsudate from subhepatic of space on the Rt lateral channel of stomach in a Rt iliac fossula
and other departments of peritoneal cavity. During the perforation of ulcers which are localized
on the front wall of body of stomach, maintenance which flows out accumulates under the
counter-clockwise dome of diaphragm and spreads downward along a colon. Pain in these cases
from a epigastric area spreads on the counter-clockwise half of stomach, and then on all of
stomach.
        Irradiation of pain under to the Rt or counter-clockwise shoulder-blade, in supraclavicular
areas arises up as a result of irritation of completions of diaphragmatic nerve is a sign of Elekera
(Oelecker).
        Vomit or urges on vomit is a nonpermanent symptom. Vomit can be preceded the
perforation of ulcer.
         Expression persons sick at first after a perforation fRtened, they are covered a death-
damp, pale.
        Positions sick forcedly - they motionlessly lie on the back or, more frequent, on a Rt side
with the brought knees to the stomach. At the least motions of patients a stomach-ache increases.
        The temperature of body is mionectic or normal.
        Pulse at first good filling, the slow to 50-60 b/min. (vagal pulse) or moderato frequent
(80 b/min.), arteriotony is mionectic. A breathing type is thoracal, breathing is superficial,
frequent.
        A tongue and mucus shells of cavity of mouth is moist. A stomach is pulled in, has a
boat-like form through acute tension of muscles of abdominal wall. Protective tension of muscles
arises up as a result of reflex - transmission of irritation from a peritoneum for innervation it to
the sensible fibres of intercostal and lumbar nerves through a spinal cord on the proper
intercostal motoriuss and observed in 95-98% patients with the perforation of ulcer.
        For youths of thin people direct muscles of stomach well viasulisation as long billows,
part in transversal direction tendon membranes. Hereupon thin people often have transversal
folds of skin higher belly-button, which are located accordingly the tenderly bridges of direct
muscles of stomach is a sign of Dzbanovskiy-Chugaev’s. Permanent tonic tension of muscles of
abdominal wall is characterized vivid expression is a “abdomen as board”. Such tension of
muscles of stomach, which is during the perforation of ulcer, is not observed not at which other
acute disease of organs of abdominal region.
        Palpation of stomach is acutely sickly. The signs of irritation of peritoneum are
determined: Blyumberg-Schotkin,s, Rozdolskiy,s.
Free gas in a peritoneal cavity is a characteristic sign of perforation of organ which contains gas.
Going out through the perforative opening, gas accumulates under a diaphragm in stand-up
position. For the exposure of free gas in an abdominal region conduct percusion of liver in
recumbency of patient. In place of the ordinary dulling above this area there will be tympanic
percusion sound (the Spizharnogo sign).
        In a peritoneal cavity can be found out a free liquid at cpercusion (dulling of
перкуторного sound is in the lateral departments of stomach. Can be hearkened to peristaltic
noises, but often become hyposthenic. At dactylar rectal and vaginal researches it is possible to
find out pain of pelvic peritoneum in the case of folding-in in the small pelvis of liquid and
exsudate is the Kulenkompf,s sign(Kulenkamff).
        The second period is a period of “imaginary prosperity” (in 6-12 hours since a
perforation). As a result of adaptation to aggression, breeding of muriatic acid in a peritoneal
cavity by an exsudate, the acutely expressed symptoms are smoothed out, the feel of patients is
improved, stomach-aches diminish.
                Treachery of this period consists in that the improvement of the state of patients
can enter in an error both sick and doctor. Persons sick acquires a normal color. Breathing is
free, but there is a speed-up. The temperature of body is normal or subfebril. Pulse a moderato
speed-up (70-80 b/minute), arteriotony is normal. Patients are euphoric. However, at the analysis
of clinical data it is possible to find out growth of signs of peritonitis    (acceleration of pulse,
fervescence, enteroplegia, leycocytosis). Patients grumble about nausea, vomit, dryness in a
company, delay of gases.
        Third period - the period of peritonitis begins in 12 hours from the moment of
perforation. State sick heavy. An abdominal pain can become moderate. There is multiple vomit.
        Temperature of body of 38-40С. A pulse is a speed-up (110-120 b/minute) considerably,
weak filling. An arteriotony is mionectic. Breathing is superficial, frequent.
        Through dehydration and intoxication the lines of person are acuteened, eyes lose
brilliance. A skin is dry. A tongue and mucus shells of cavity of mouth is dry. A stomach is
exaggerated as a result of enteroplegia, an abdominal wall extension and resistent (elastic
tension), sickly at palpation and cpercusion. Symptoms of irritation of parietal peritoneum, as a
rule, acutely positive. Not hearkened to the peristalsis. A free liquid appears in a peritoneal
cavity.
        As a result of dehydration which comes through vomit, depositing of liquid in an intestine
and in a peritoneal cavity, a diuresis diminishes.
        Given laboratory inspection: high leycocytosis with the change increase of indexes of
haemoglobin and Ht (as a result of dehydration of organism).
        There are other variants of motion of perforative ulcer:
        1. A perforation - variant of clinical motion of perforation of ulcer is covered in a free
abdominal region, which opening, formed in an organ is at, after a perforation covered tapes of
fibrin, nearby organ (by a liver, omentum but other), sometimes closed from within the fold of
mucus shell. The more frequent covered perforation is observed at localization of ulcer on the
front wall of 12-falling bowel.
        At the beginning of complication the typical signs of perforation of ulcer appear in a free
abdominal region - suddenly there is acute pain in a epigastric area, “board-like” tension of
muscles of front abdominal wall of stomach. Then these phenomena diminish gradually.
        Characteristic proof tension of muscles of abdominal wall in the Rt overhead quadrant of
abdomen at the general satisfactory state of patient is a symptom of Ratnera-Vikkera. A
diagnosis is confirmed at a X-ray inspection at which it is possible to find out gas under a
diaphragm.
        2. Perforation of ulcer of back wall of stomach. The table of contents of stomach is
outpoured in a omentum bag. Acute pain which arises up in a epigastric area is not such acute, as
at the hit of maintenance in a free abdominal region. At the objective inspection of patient in a
epigastric area it is possible to find out pain and tension of muscles of abdominal wall. A free
liquid is not in a peritoneal cavity. Hepatic dullness is stored, at a roentgenologic inspection free
gas can not appear in a peritoneal cavity.
        For confirmation of diagnosis under control X-ray give a patient to have a drink a
contrast. Thus there is an output of contrast outside a stomach.
 Sometimes there is combination of perforation and acute gastric bleeding. Certain a diagnostic
value has a FGDS.
                                       Differential diagnosis.
        Differential diagnostics of perforative ulcers is conducted:
1. With the diseases of stomach (acuteening of ulcerous illness of stomach, acute phlegmon of
stomach, perforation of malignant tumours of stomach).
2. With the diseases of gall-bladder, pancreas (acute cholecystitis, hepatic colic, acute
pancreatitis).
3. With the diseases of intestine (acute appendicitis, acute intestinal impassability).
4. With the diseases of the сardiac-vessels system (thrombosis and embolism of vessels of
mesentery, aneurism of abdominal aorta, heart attack of myocardium).
5. With the diseases of the respiratory system (basale pneumonia, pleurisy).
6. With the diseases of a kidney (nephrocolic).

                                             Treatment
        The diagnosis of perforative of gastro-duodenal ulcer (or suspicion on this pathology) is
set by a show to exigent hospitalization of patients in surgical permanent establishment. On the
before hospital stage introduction of analgetic is categorically forbidden, as it can entail the
change of clinical picture and complicate diagnostics. In the cases when it is needed to
differentiate the perforation of ulcer with a acute cholecystitis, pancreatitis, kidney colic, at a
stable hemodynamics, introduction of preparations of spasmolytic action is assumed (Papaverini
2% - 2,0; Nospanum 2,0 and other). After shows cardiac facilities are entered. By a patient with
a grave condition, it follows to conduct measures an unstable hemodynamics for its stabilizing
(polyhybrid, dexametasoni).
        A presence of the diagnosed perforative gastric or duodenum ulcer is an absolute show to
operative interference. Unique contra-indication in such cases there is the agony state of patients.
        Brief intensive preoperative preparation is rotined at the grave condition of patients with
the displays of decompensation vitally of important organs and systems, that more frequent is as
a result of the poured out peritonitis, and must include the followings components:
        1. 5% solution of glucose, 0,9% solution of NaCl, 3% solution of K+.
        2. 10% solution of albumin, plasma.
        3. Polyhybrid, reopolyglucini.
        4. Desintoxication preparations.
        5. Intravenous introduction of antibiotics (cyfran).
        6. Cardiac (strophanthin 0,05% - 0,5).
        7. After the shows of prednisoloni.
        8. Stimulation of diuresis (lasix).
        Interferences begin after stabilizing of haemodynamic indexes.
        Basic access during an operation concerning perforative of gastro-duodenal ulcers is
overhead middle laparotomy. Other types of accesses, in particular pararectalis, apply after
individual shows.
        At the section of front abdominal wall, after the section of aponevrosis, thrusting out of
peritoneum (as a sail) appears quite often, that predefined by the presence of free gas in a
peritoneal cavity. In the moment of section of peritoneum with the characteristic hissing the two-
bit of gas can be selected. In a peritoneal cavity in a that or other amount find out a turbid liquid
from addition bile, mucus or pieces of meal.
        If the perforative opening is located on the front wall of stomach or duodenum, to find
him easily. As a rule, he has a characteristic roundish form. (Round opening often there is
hyperemia of serose, stratification of fibrin. The area of ulcer palpation as infiltrate of different
closeness with deepening from the side of mucus shell (by the crater of ulcer).
        In the cases of perforation of the low located ulcers of duodenum, highly located ulcers of
small steepness of stomach, ulcers of back surface of stomach and duodenum, and also at the
covered perforations there can be complications in intraoperative diagnostics. In such cases it
follows to inspect all of departments of stomach and duodenum, divide accretion of them with
other organs, to expose a omentum bag and to examine the back wall of stomach. Last it follows
to do and during the perforation of ulcer of front wall of stomach, as there can be a perforation of
“mirror” ulcers (on a front and back wall).
        After finding of the perforative opening and his previous suture and delete of stomach-
duodenal maintenance from a peritoneal cavity a question decides about the choice of volume of
operative interference. At his decision follow the followings rules:
        1. If from the moment of perforation not more than 6 hours passed and the signs of
peritonitis absent, a radical operation is conducted: at a gastric ulcer is his resection, at the ulcer
of duodenum is selective proximal vagotomy, with carving of ulcer and draining operation, or,
after shows, resection of stomach.
        2. If from the moment of perforation passed from 6 to 12 hours, there are the phenomena
of diffuse peritonitis, carving of ulcer is conducted with suture, truncus vagotomy and draining
operation.
        3. If after a perforation more than 12 hours passed and there are the phenomena of the
poured out or general peritonitis - suture of ulcer is conducted.

                                       Conservative treatment
        Conservative treatment of perforative ulcers after the method of Teylora can be applied in
exceptional cases - at the square refusal of patient from an operation, in default of surgeon. In
these cases treatment is directed on preoperation preparation of patient. A method includes
nasogastric intubation of stomach, permanent axsufflation of gastric maintenance, introduction
of matters which reduce a gastric secretion, introduction intramuscular, intravenously not less
3th antibiotics of wide spectrum of action, leadthrough of infusion therapy and X-ray inspection
of abdominal region. An axsufflation is closed since gastric maintenance lost a greenish color.
Before the delete of probe it is necessary to enter a contrast and X-ray to get reliable information
about absence of folding-in of contrasting matter for the contours of stomach and duodenum.




       5.2. Theoretical questions are to employment:
1. Etiology and pathogenesis of the ulcerous bleeding.
2. Methods inspections sick with the ulcerous bleeding.
3. Classification of the ulcerous bleeding.
4. Clinic of the ulcerous bleeding.
5. Differential diagnostics of the ulcerous bleeding.
6. Features of clinical motion of the active bleeding .
7. Features of clinical motion of the ulcerous bleeding which was halted.
8. A choice of method of stop of bleeding is depending on the degree of its activity
9. Conservative therapy of the ulcerous bleeding
10. Methods endoscopic haemostasis and testimony to their application
11. Methods of operative interferences are at the ulcerous bleeding
12. A choice of method of operative interference is depending on the state sick, intensity of
bleeding, degree of bleeding, localization of ulcer
13. Features of technique of operative interferences are at the ulcerous bleeding
14. Complication in an early postoperative period at implementation of operative interferences
concerning the ulcerous bleeding.
15. Treatment of complications in an early postoperative period at implementation of operative
interferences concerning the ulcerous bleeding
16. Features conducts sick with the ulcerous bleeding in an early and late postoperative period.
17. Anatomy information is about a stomach and duodenum.
18. Methods inspections sick with a perforative ulcer.
19. Classification of perforative ulcer.
20. Etiology and pathogenesis of perforative ulcer.
21. Clinic of typical perforative ulcer.
22. Differential diagnostics of perforative ulcer.
23. Features of motion of the covered perforative ulcer.
24. Features of motion of perforative ulcer are in a omenutm bag.
25. Features of motion of perforative ulcer are in retroperitoneal space.
26. A choice of volume of operative interference is at a perforative ulcer.
27. Technique of sewing together of perforative ulcer.
28. A technique of execution of a perforative ulcer.
29. Choice of method of implementation of vagotomy.
30. Testimony and technique of execution of selective vagotomy.
31. Testimony and technique of execution of selective proximal vagotomy.
32. A testimony and technique of execution of resection of stomach is at a perforative ulcer.
33. Laparoskopy technologies are in surgical treatment of perforative ulcer.
34. Complication in an early postoperative period at implementation of operative interferences
concerning a perforative ulcer.
35. Features conducts sick with a perforative ulcer in an early and late postoperative period.
36. Complication in a late postoperative period at implementation of operative interferences
concerning a perforative ulcer.
37. Treatment of complications in a late postoperative period at implementation of operative
interferences concerning a perforative ulcer.
38. Etiology and pathogenesis of the ulcerous bleeding.
39. Methods inspections sick with the ulcerous bleeding.
40. Classification of the ulcerous bleeding.
41. Clinic of the ulcerous bleeding.
42. Differential diagnostics of the ulcerous bleeding.
43. Features of clinical motion of the active bleeding .
44. Features of clinical motion of the ulcerous bleeding which was halted.
45. A choice of method of stop of bleeding is depending on the degree of its activity.
46. Conservative therapy of the ulcerous bleeding.
47. Methods endoscopic haemostasis and testimony to their application.
48. Methods of operative interferences are at the ulcerous bleeding.
49. A choice of method of operative interference is depending on the state sick, intensity of
bleeding, degree of bleeding, localization of ulcer.
50. Features of technique of operative interferences are at the ulcerous bleeding.
51. Complication in an early postoperative period at implementation of operative interferences
concerning the ulcerous bleeding.
52. Treatment of complications in an early postoperative period at implementation of operative
interferences concerning the ulcerous bleeding.
53. Features conducts sick with the ulcerous bleeding in an early and late postoperative period.
        5.3. Practical works (task) which are executed on employment:
1) To collect anamnesis, conduct a review, palpation, percussion, auscultation for a patient with
bleeding or perforative gastric or duodenum ulcer;
2) To choose the most characteristic signs of bleeding or perforative gastric or duodenum ulcers
  from information of anamnesis ;
3) Correctly to estimate information of research
4) To discover and correctly estimate the degree of expressed (negative, poorly positive,
positive, acutely positive) of the followings signs: Schotkin-Blyumberg,s, Mondor,s;
5) To conduct differential diagnostics with other acute diseases of organs of abdominal region,
other organs and systems;
6) To determine a testimony to conservative treatment, operative interferences (depending on
complications of disease)
7) To make an individual troubleshooting routine for a concrete patient with bleeding or
perforative gastric or duodenum ulcer ;
8) To ground and formulate the previous diagnosis of basic disease, complications and
concomitant pathology;
9) To use deontologic principles of socializing with a patient;

        5.4. A questions for self-control:
      1. What is it found out at questioning of patient with bleeding or perforative gastric or
duodenum ulcer?
      2. Why is it important to find out all complaints, that in a presence for a patient with
bleeding or perforative gastric or duodenum ulcer?
      3. Why is it important to know a date and time of beginning of disease for a patient with a
perforative gastric or duodenum ulcer?
      4. Why is it important to know what previous treatment conducted a patient with bleeding
or perforative gastric or duodenum ulcer?
      5. What is it found out at the review of patient and his belly at suspicion on bleeding or
perforative gastric or duodenum ulcer?
      6. Why is the origin of delay of participation of areas of front abdominal wall possible in
breathing at a acute inflammatory abdominal syndrome, in particular, on a perforative gastric or
duodenum ulcer?
      7. What changes can it find out at palpation of wall of belly at a perforative gastric or
duodenum ulcer?
      8. What changes can it find out at dactylar research of vagina and rectum at a perforative
gastric or duodenum ulcer?
      9. Are there features of inspection of patient with suspicion on the perforative ulcer of
stomach or duodenum?
      10. What is based on the ground of previous diagnosis of disease on bleeding or
perforative gastric or duodenum ulcer?
      11. What is based on the ground of clinic of typical and atypical perforation gastro of
duodenal ulcer and differential diagnostics?
      12. What principles is the list of diseases formed after for the leadthrough of differential
diagnosis at suspicion on bleeding or perforative gastric or duodenum ulcer?
      13. Why in a clinical diagnosis on bleeding or is it important to represent a perforative
gastric or duodenum ulcer not only nosology form of disease but also his motion and
complication ?
      14. What is it important to define at forming of medical tactic for patients with bleeding or
perforative gastric or duodenum and development of complications ulcer?
       5.5. Tasks for self-control:


1. The Pt, 48 years old, delivered in a clinic in 3 hours after the perforation of gastric ulcer.
During an operation in a Rt lateral channel found out the two-bit of transparent exsudate. The
loops of small bowel are insignificantly bloodshot. On the small steepness of stomach in an
antrum department perforative opening 0,2х0,4 cm in a diameter with hard edges. Bulb of
duodenum the cicatrical is deformed. What operation does need to be executed?
   A. Vagotomy with carving of ulcer and pyloroplasty by Finey.
   B. Vagotomy with carving of ulcer and pyloroplasty by Dzhad.
   C. Resection of stomach.
   D. Gastroenteroanastomosis.
   E. Resection of duodenum.

2. The patient, 50 years old, grumbles about the expressed general weakness, dizziness, black
liquid emptying. It is ill for a day long after the use of spicy food and alcohol. Objectively: the
state is heavy. A skin is pale, moisture. Pulse - 120 b/min. BP - 90/60 mm.Hg. A tongue is
assessed, dry. An abdomen is soft, moderato sickly in an epigastrium. A peristalsis is increased.
What to most reliable diagnosis?
   A. Gastrointestinal bleeding.
   B. Acute pancreatitis.
   C. Nonspecific ulcerous colitis.
   D. Apendicitis.
   E. Poisoning by alcohol.

3. For a patient, 36 years old, driver on speciality, hour ago there was acute pain
in a epigastric area. Does not mark the dyspepsia phenomena. Pulse –
56 b/min. A tongue is dry. Position is forced. An abdomen is pulled in with tension of muscles.
Hepatic dullness is not determined. Positive signs of irritation of parietal peritoneum. What most
credible diagnosis?
   A. Perforative gastric or duodenal ulcers
   B. Acute gastritis
   C. Acute cholecystitis
   D. Acute intestinal obstruction
   E. Acute pancreatitis

4. The Pt., 35 years old, delivered with complaints about a general weakness, dizziness, temporal
loss of consciousness. It was known from information of anamnesis, that during three years
periodically disturbs pain in a epigastric area, especially in a night-time, heartburn. For medical
help did not apply, did not inspect. During two weeks before a receipt marks strengthening of
pain which independently passed two days ago. A strong weakness, nausea, dizziness, appeared
in the day of receipt, twice there were the black, tarry emptying. According to accompanying –
lost consciousness twice. Common analysis of blood: Hg- 96 gr/l. Most reliable previous
diagnosis?
   A. Bleeding ulcer of duodenum.
   B. Cancer of stomach.
   C. Acute pancreatitis.
   D. Heart attack of myocardium.
   E. Bleeding from esophagus.
         5.6. Tests for self-control:

1. Complications of perforative ulcer are:                   9. The complications of ulcer disease belong:
A. Peritonitis.                                              A. Carcinoma.
B. Acute cholecistitis.                                      B. Perforation.
C. Colitis.                                                  C. Bleeding.
D. Pancreonecrosis.                                          D. Penetration.
E. Hemoperitoneum.                                           E. Apendicitis.
2. At a roentgenologic inspection in stand-up position       10. Which factors are promoting the origin of ulcer
for patients with a perforative ulcer gas appears:           disease?
    A. Under a pancreas.                                     A. Aggressive properties of acid-peptic factor.
    B. Under a diaphragm.                                    B. Hypersecretion of HCl.
    C. Under a stomach.                                      C. Mechanical damage of mucous layer.
    D. Under a kidney.                                       D. Influence of Helicobacter pylori.
                                                             E. Excrement stone.
3. During examination а patient with perforative ulcer it    11. Melena – is:
is possible to mark that:                                        A. Liquid black emptying
A. Tension muscles of abdominal wall.                            B. Black designed emptying
B. The Lt half of abdomen retract during the breathing.          C. Foamy emptying of sad-coloured
C. The Rt half of abdomen stick out during the
breathing.
D. Patient wants to lie down on the Lt side with legs
falled.
E. Patient wants to lie down on the back with legs falled.
4. The Rozdolskiy’s sign is:                                 12. The Blumberg’s sign is:
A. Tension of muscle of abdominal wall.                      A. Shift of pain from the epigastria in a Rt iliac area.
B. At percussion there is unpainful in a Rt iliac area.      B. After gradual pressing by fingers on anterior wall from
C. Increase of pain during the palpation in a Rt iliac       the place of pain the hand is taken away. Decrease of pain
area.                                                        is considered as a positive sign in that place..
D. After gradual pressing by fingers on anterior wall        C. Disappearance of pain during the palpation in a Rt iliac
from the place of pain the hand is taken away.               area.
Strengthening of pain is considered as a positive            D. After gradual pressing by fingers on anterior wall from
symptom in that place.                                       the place of pain the hand is taken away. Strengthening of
E. At percussion of abdominal wall there is painfulness.     pain is considered as a positive sign in that place.
                                                             E. After gradual pressing by fingers on anterior wall from
                                                             the place of pain the hand is taken away. Strengthening of
                                                             pain is considered as a negative sign in that place.

5. Pain at the ulcer of stomach is localized in:             13. At bleeding from the ulcer of stomach vomit is more
A. Lt iliac area.                                            frequent:
B. Rt iliac area.                                                A. By red blood.
C. Lt subcostal area.                                            B. By chole.
D. Rt subcostal area.                                            C. By the color of «coffee-grounds».
E. Epigastric area.

6. At a perforative ulcer the period of primary shock        14. The Rt.gastric artery is the branch of:
lasts:                                                       A. A. mesenterica inferior.
    A. 3-6 hours.                                            B. V. mesenterica superior.
    B. 6-12 hours.                                           C. A. ileocolica.
    C. 6-18 hours.                                           D. Truncus caeliacus.
                                                             E. V. ileocolica.

7. At a perforative ulcer symptoms of irritation of          5. The signs of peritoneal irritation are:
peritoneum are in the first period:                          A. The Sitkovskiy’s sign.
   A. Positive.                                              B. The Voskresenskiy,s sign.
   B. Negative.                                              C. The Rozdolskiy’s sign.
   C. Possibly first and second.                             D. The Obrazcov’s sign.
                                                             E. The Blumberg’s sign.
8. What haemostatic preparations apply at a bleeding          16. The basic signs of perforative ulcer during palpation in
ulcer:                                                        the epigastric area are:
   A. Vikasoli                                                A. Decrease of pain during the palpation in a Rt iliac area.
   B. Aminocaproni acid                                       B. Positive signs of peritoneal irritation.
   C. Dicinoni                                                C. Shift of pain from the epigastric in a Rt iliac area.
   D. Heparinum                                               D. Tension of muscle of abdominal wall.
   E. Fragmin                                                 E. Disappearance of pain during the palpation in a Rt iliac
                                                              area.
17. Surgical therapy for peptic ulcer disease (PUD) has       18. The operation for duodenal ulcer with the lowest risk of
decreased with the advent of pharmacologic agents that        recurrence is
control and decrease gastric acid secretion. However,         A. Highly selective vagotomy
surgery is still necessary under several conditions. All of   B. Nissen fundoplication
the following are indications for surgical intervention in    C. Vagotomy and antrectomy
the management of peptic ulcer disease EXCEPT                 D. Vagotomy and pyloroplasty
     A. Gastric outlet obstruction
     B. Continuation bleeding
     C. Night pain
     D. Perforation of an ulcer




         6. Literature

1. Hospital surgery / Edited by L. Kovalchuk, V. Sayenko, G. Knysov, M. Nychytailo . –
   Ternopil: Ukrmedknyga, 2004. – 472 p.
2. Textbook of surgery (third edition) / Edited by S. Das. – Calcutta: 2001. – 1324 p.
3. S-4439. Liechty R.D., Soper R.T. Fundamentals of surgery 6-th ed. - St. Louis ect. Mosby
   1989.
4. W-287. Melaschie G.R. Oxford handbook of «limed .suigery. repr., Oxford ect. 1992.
5. Ed. Swartz. Surgery. 5-th ed.
6. D.C. Sabiston. Basic Surgery.
7. Handbook of Surgery (Ed. by I.R. Sehroek 8-th ed.)

				
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