1. Complications of the ulcer disease of the stomach and duodenum (perforation, penetration, malignization)

2. Complication ulcer disease
Stenosis(10%)
Bleeding (20%)
Perforation (10%)
Malignization (0,3-15%)
Penetration (5%)

3. Classification of the ulcer perforations (B.D.Komarov, V.S.Savelev)
Localization
Clinic currency
А) in the stomach
By small curvature
Anterior wall
Posterior wall
Cardial zone
Pyloric zone
B) In the duodenum
А) perforation into the free space, into the abdominal cavity
B) Hidden perforation
C) Perforation with the atypic currency

4. Main signs of the perforation of the ulcer (Mondor’s triad)
1. Dagger pain
2. Board abdomen
3. Presence of the ulcer anamnesis
The board abdomen defines at the palpation

5. Ways of the spreading of pain at the prforation of the UDS and duodenum
Epigastria
Right lateral channel
Right iliac area
Pelvis
Left iliac area 1 2
At the ulcer perforation the clinic of the spreading of the pain is similar with the clinic of acute appendicitis (Cocher-Volkovich symptome). 3 5 4

6. Free gas under the dome of the diaphragm (Spijarskiy symptome )
Overview X--ray

7. Differential diagnostis
Acute appendicitis - laparosopy
Acute cholecystitis – US, X-ray
Acute oancreatitis – US, diastasa
Intensification of the UDS an duodenum – X-ray, EGDFS
Acute mesenterial thrombosis - laparoscopy
Acute inferct - ECG

8. Choose of the method of the operation at the perforation of the ulcer
Stage of the fermentative desinteration
Stage of the festering peritonitis
Radical operation
Palliative operation
Resection
TV+ antrumectоmy
Sewing of the prforative ulcer
TV+ pyloroplastic

9. Sewing of the perforative ulcer

10. Resection of the stomach – radical operation at the perforations of stomach an duodenum

11. Stages of sewing – the first prick

12. Stages of the operation- tampon to the perforated ulcer

13. Penetration – passing of the ulcer onto the nearest organs
Pancreas
Liver
Gall bladder

14. Stages of the penetration
1 stage (39-51%) – defeat with the ulcer process all layers of the stomach or duodenum
2 stage (25-30%) – fibrous connection with the nearest organs
3 stage (22-29%) – the fundus of the ulcer is the parenchima of the nearest organ

15. Symptoms of the penetration of the ulcer
Constant pain in the epigastria with the increasing
Irradiation of the pain depend on the organ, in which the penetration was: to the lumbar area (pancreas), to the scapula (liver), to the neck (gall bladder)
Not effective conservative therapy
At the penetration into the hollow organ the fistula appears.

16. Method of sewing of the cult at the penetration

17. Malignization – regeneration of the ulcer into the cancer
The ulcer of stomach maligns in 20% cases
The ulcer of the duodenum maligns in 0,3% cases
States at which the risk of malignization is high:
diameter of ulcer more than 1,5 sm,
At the localization of ulcer in the stomach,
At the patients elder than 40 years,
Not effective conservative therapy during 4-6 months.

18. ULCUS-TUMOR

19. Signs of the malignization at X-ray
Defect of filling,
Convergention of the pleats
Absence of the peristaltic around the ulcer
Defect of filling
(finger pressing in)

20. Gastrectomy