stomach ulcer- a chronic disease in which the formation of ulcerative defects of the gastric mucosa occurs. Most often the disease affects men from 20 to 50 years. The disease is characterized by a chronic course with frequent relapses, which usually occur in spring and autumn.
The bacterium Helicobacter pylori plays a significant role in the occurrence of gastric ulcer, the vital activity of which leads to an increase in the acidity of gastric juice. Treatment of stomach ulcers is carried out by a gastroenterologist.
Constant stress provokes disruption of the nervous system, leading to spasms of the muscles and blood vessels of the gastrointestinal tract. The nutrition of the stomach is disturbed, the gastric juice begins to have a detrimental effect on the mucous membrane, which leads to the formation of an ulcer.
Causes of stomach ulcers
The main reason for the development of the disease is considered to be an imbalance between the protective mechanisms of the stomach and aggression factors, i.e. The mucus secreted by the stomach cannot cope with enzymes and hydrochloric acid.
The following factors can lead to such an imbalance and the development of stomach ulcers:
- the presence of chronic diseases of the gastrointestinal tract (gastritis, pancreatitis);
- malnutrition;
- long-term use of drugs that have ulcer-forming properties;
- alcohol abuse and smoking;
- stress;
- genetic predisposition.
Symptoms of a stomach ulcer
Symptoms of a stomach ulcer are:
- strong pain;
- hungry pains;
- night pains;
- vomiting sour;
- heartburn.
The main conspicuous symptom of an ulcer is persistent pain. This means that the patient feels them for a long time, depending on his patience - a week, a month, six months. If an unexamined patient suffers pain for a long time, then he may notice such a sign as the seasonality of pain - their appearance in the spring and autumn months (winter and summer pass in their absence).
Ulcer pain is more often localized in the epigastric region, in the middle of the distance between the navel and the end of the sternum; with gastric ulcer - in the midline or to the left of it; with a duodenal ulcer - 1-2 cm to the right of the midline. The cause of pain is a periodic spasm of the pylorus and irritation of the ulcerated wall of the organ with hydrochloric acid.
Pain can be of different intensity, which depends both on the patience of the patient and on the depth of the ulcer. Ceteris paribus, pain in duodenal ulcers is stronger than in gastric ulcers. More often pains, in comparison, for example, with colic, are much weaker, their intensity is small or medium, the nature of the pain is aching.
Pain is associated with food intake. When the disease is localized in the stomach, pain occurs after eating - the sooner, the “higher” the ulcer (i.e., closer to the esophagus); on an empty stomach the pain subsides. With duodenal ulcers, the so-called hungry and night pains are typical, which, on the contrary, decrease or disappear immediately after eating, and after 2-3 hours they resume again.
In most patients with peptic ulcer, pain is relieved after taking baking soda (“soda test” - take baking soda powder on the tip of a knife, pour it into half a glass of boiled water and let the patient drink during pain).
If the pain instantly, like angina pectoris from nitroglycerin, disappears, then most likely it is the “ulcerative” patient in front of you. The appearance or intensification of pain is preceded by a “sin” the day before or the day before yesterday. Remember if there was a plentiful "libation", spicy food, unusual food. The pains are more intense in bad weather, when a strong wind blows and the rain pours like buckets.
They say there is a connection between geomagnetic and solar activity and the exacerbation of the disease. Often, patients feel that their ulcer has “opened up” and got sick after a quarrel, scandal, trouble at work, a funeral, etc. It is interesting that excessively strong positive emotions can also provoke pain. Often, pain appears or becomes more severe after treating a cold with aspirin, after prescribing, for example, Brufen (or its analogues) for joint pain.
As already mentioned, long-term use of hormones (prednisolone and its analogues), for example, for the treatment of rheumatism or severe bronchial asthma, naturally leads to an acute course of inflammation or an exacerbation of a chronic one, especially if drugs from the group of gastric protectors were not taken prophylactically.
With exacerbation and especially with perforation, the rhythm of pain changes - they become constant, painful. Patients are especially concerned about pain in ulcers penetrating the pancreas. When penetrating into the liver, sometimes the pain decreases when the patient is positioned on the left side. During the period of exacerbation, approximately 30-40% of patients experience vomiting, and the contents of the vomit are sour in taste.
Vomiting is more typical for stomach ulcers and with the development of ulcerative stenosis (narrowing of the stomach with scars); in the latter case, vomiting is frequent, occurs easily and effortlessly, bringing great relief. With stenosis, vomiting occurs with stagnant gastric contents, with a bad smell. Often in the vomit there is food eaten the day before.
There are also cases of ulcers with a painless, asymptomatic course. True, when feeling the abdomen in such patients, pain is still noted in the "ulcer points" of the epigastric region.
Sometimes the first symptom of a chronic ulcer is perforation or bleeding; then the person is in a peak situation. Therefore, you should not wait for the deployment of all the described symptoms. In modern life, the disease is often diagnosed with minor pain and heartburn in the absence of a vivid clinical picture.
For ulcers that occur with excessively high acidity, constipation is characteristic, often with intestinal colic.
Detailed descriptions of stomach ulcer symptoms
"Portrait of an ulcer" with a lesion of the stomach
Ulcer patients often experience a feeling of internal tension and increased irritability. This is not a cause, but a consequence of an ulcer, the result of an incorrect receptor activity of the nervous system as a whole.
Often, already by their changed mood, ulcers correctly judge the exacerbation of the disease. When observing "ulcerative" patients, it is necessary to take into account their appearance.
Typically, a person with a stomach ulcer is a middle-aged or elderly man; thin, with a displeased expression, often frowns, extremely picky about food. He experiences exacerbations tragically; very suspicious.
Treatment of stomach ulcer
In the treatment of peptic ulcer, an important place is given to diet.
The basic principle of therapeutic nutrition:
Medical treatment of stomach ulcers
Drug treatment includes several groups of drugs:
Surgical treatment of stomach ulcers
With multiple, often recurrent ulcers, as well as in the event of complications, surgical treatment is indicated: resection of the stomach and vagotomy - cutting the nerves that stimulate the secretion of acid in the stomach.
Peptic ulcer today is successfully treated. If you follow a diet, give up bad habits, timely therapeutic measures, you can avoid complications of the disease. They are, after all, the cause of death.
Instructions for drugs used in the treatment
Which doctors to contact
Diagnosis of a stomach ulcer
To date, the most effective diagnostic method is FGDS - fibrogastroduodenoscopy. Visual examination of the gastric mucosa through a fiber optic probe makes it possible to determine the presence of an ulcer, its localization, and take a scraping of the mucous membrane for analysis.
In connection with the establishment of the role of Helicobacter pylori in the development of the ulcerative process, tests for antibodies to this microorganism in the patient's blood and in mucosal scrapings were introduced into the diagnostic program.
To choose the right treatment tactics, it is necessary to correctly determine the acidity of gastric juice. For this purpose, pH-metry of the contents of the stomach, taken through a tube, is carried out.
Nutrition and diet for stomach ulcers
Compliance with the correct diet is a prerequisite for effective treatment of stomach ulcers. From the diet it is necessary to exclude:
- alcohol;
- fatty food;
- spicy and spicy dishes;
- carbonated drinks;
- coffee;
- chocolate.
Useful products are:
- cereals;
- White rice;
- dairy products.
You need to eat warm food and in small portions so that there is no irritation of the intestines and stomach. A common folk remedy - water with soda - only temporarily relieves pain, since soda is an alkali and neutralizes the acid of gastric juice, which ceases to irritate the ulcer and the pain subsides for a while.
An excellent folk remedy is cranberries, whose juice is not inferior to antibiotics in antibacterial properties. Two glasses a day will protect you from the spread of the disease. Especially cranberry juice is useful for women. In addition, sea buckthorn oil, honey, aloe juice, fresh cabbage juice, carrot juice are good at restoring the gastric mucosa and healing wounds.
Folk remedies for the treatment of stomach ulcers
Important: the use of traditional medicine must be agreed with the attending physician.
Honey and lemon
Prepare lemon juice from 2 lemons, add half a kilo of honey and half a liter of olive oil. Mix thoroughly and store in a cool place with a lid. Before taking, it is desirable to mix the mixture. Take half an hour before meals, a tablespoon 3 times a day. The course of treatment is a month. It is desirable to conduct such courses 2-3 times a year, for prevention. It is recommended that in parallel with this treatment, eat 5-6 pieces of walnuts.
Sea buckthorn juice
cabbage juice
It is very useful to drink cabbage juice. Juice from fresh cabbage leaves heals even better than any drugs. It is advisable to drink a glass of juice 4 times a day. But you can also use fresh tomato juice, sea buckthorn juice or sophorin. Before eating, it does not hurt to eat a piece of aloe leaf. Course of treatment 6 weeks It is also useful to drink a tablespoon of sunflower oil every morning before meals until the bottle is over. Store the oil itself in a dark place.
Oak bark
You need to pour 4 tbsp. oak bark 1 liter of boiling water and boil for about 20-30 minutes, then cool and take a couple of times a day for 1st.l.
Aloe tincture
Aloe leaf tincture treats stomach ulcers very well. It is also used for prevention and chronic disease. You will need 250 grams of aloe leaves. Before cutting, the flower is not watered for 2 weeks. In this case, the plant should be 3-5 years old by age. After cutting, the leaves should be put in a cool dark place for a while.
Pass cut 250 grams of leaves through a meat grinder, add 250 grams of honey, mix and put on gas. Stirring constantly, heat the mixture to 50-60 degrees. After reaching this temperature, add half a liter of red natural wine. Mix everything and put in a dark place for a week. Take one tablespoon 3 times a day, one hour before meals. The course of treatment is 21 days. In the first 7 days, it is better to use a teaspoon to adapt the body.
potato juice
You need to grate the potatoes and squeeze the juice out of it. Add water in a ratio of 1:1 and drink in the morning on an empty stomach half an hour before breakfast.
Recipe for an ulcer
There is one very useful and tasty folk recipe for stomach ulcers. Take 300 grams of flower honey, walnuts and butter. Put everything in an enamel pan, bake in the oven at 100 degrees for twenty minutes, then stir. Take 3 times a day for a tablespoon half an hour before meals and do not need to drink anything. The ulcer will heal very quickly, the operation is no longer needed. This tool has been proven.
Perforated stomach ulcer
A perforated ulcer is a severe complication of gastric and duodenal ulcer that can cause peritonitis. Most often, this condition develops in spring and autumn during the period of exacerbation.
Causes of ulcer perforation
The development of perforation contributes to the use of alcohol, physical and emotional overstrain, as well as malnutrition, especially during seasonal exacerbations. Sometimes this condition can occur after a gastric sounding procedure. During crises and wars, when psycho-emotional stress increases and nutrition worsens, the frequency of development of ulcer perforation increases by 2 times.
Perforation, i.e. the appearance of a through defect in the wall of the stomach or intestines with the release of contents into the abdominal cavity, especially characteristic of the elderly. In young people, this complication is most often localized in the duodenum.
Symptoms of a perforated ulcer
At the beginning, a person feels acute severe pain, nausea and an urge to vomit appear. Characterized by pallor, cold sweat, severe weakness and dizziness. The patient lies motionless, pressing his legs to his stomach.
After about 5-6 hours, an apparent improvement occurs - the acute symptoms of perforation stop, but it is during this period that peritonitis may occur, which is characterized by:
- bloating;
- temperature rise;
- tachycardia.
Symptoms of a perforated stomach ulcer may be similar to those of other acute diseases of the internal organs, renal colic or appendicitis, so if such symptoms appear, you need to call an ambulance. When the diagnosis of perforation is confirmed, the patient is hospitalized.
Important: when symptoms appear, it is impossible to hesitate to call a doctor, since with the development of peritonitis there is a threat to the life of the patient.
Treatment of perforated stomach ulcer
Treatment of a perforated ulcer is carried out in a hospital with the help of surgical intervention in order to eliminate the defect in the patient's stomach cavity. Timely access to a doctor, a timely diagnosis and an operation, as well as the correct postoperative treatment of the patient, are the key to recovery.
Postoperative treatment and diet for perforated gastric ulcer
In the postoperative period of treatment, the patient needs long-term treatment with antiulcer drugs. Bed rest is prescribed for the first 10 days. A fundamental factor for a quick recovery is a therapeutic postoperative diet, which requires strict adherence to the first months after surgery. The diet after surgery on a perforated ulcer is designed to eliminate inflammation and promote recovery processes in the stomach. Mandatory is the restriction on consumption, salt, fluids and simple carbohydrates.
On the 2-3rd day after the operation, the patient can be given mineral water without gas, weak tea and slightly sweetened fruit jelly. After a few more days, you can drink a decoction of rose hips, eat 1-3 soft-boiled eggs, well-boiled and mashed rice or buckwheat porridge, mashed vegetable soups. 8-10 days after the operation, you can add mashed carrots, potatoes, pumpkins and zucchini to the diet. You can eat fish and meat cutlets, steamed and without oil.
Bread can be eaten only after a month, in limited quantities, only yesterday's baking. Kefir and sour cream can be eaten 2 months after the operation. From the menu of the patient it is necessary to exclude dishes from the liver, lung, kidneys, baking.
Also, you can not eat spicy, smoked and salty dishes, marinades, canned food and sausage. Jam, honey, chocolate, coffee and cocoa are contraindicated. Until complete recovery, it is necessary to abandon dishes from legumes, mushrooms, cabbage, onions, sorrel, garlic, radishes, spinach and ice cream.
Alcohol and carbonated drinks are prohibited. And only when the patient's condition improves, after 2-4 months, you can gradually expand the diet.
Prognosis for gastric ulcer
The prognosis of the disease is mostly positive, treatment started on time leads to full recovery. Only in some cases there are a number of serious complications, such as profuse bleeding and perforation, these conditions are very dangerous because they can lead to peritonitis.
Prevention of stomach ulcers
- sleep 6-8 hours;
- refuse fatty, smoked, fried foods;
- during pain in the stomach, it is necessary to be examined;
- treat bad teeth so that food can be chewed well;
- avoid stress, because after a nervous strain, pain in the stomach intensifies;
- do not take very hot or very cold food;
- Do not smoke;
- do not abuse alcohol.
Questions and answers on the topic "Stomach ulcer"
Hello! My husband has loss of appetite, vomiting and fever. But there is no pain. Can you tell me if this is an ulcer?
The main symptom of a stomach ulcer is persistent pain. You need a face-to-face consultation with a therapist.
Hello. I began to have pain in the left hypochondrium, the third week has already gone. Now also pains have gone under the left scapula. I don’t complain about the stomach, I eat normally without pain before and after eating. I sleep without pain, the pain begins only with physical activity. load. It might have something to do with the stomach.
The left hypochondrium contains the spleen, stomach, pancreas, intestinal loops (as, indeed, everywhere in the abdomen) and the left side of the diaphragm. Thus, pain in the left hypochondrium can be caused by damage and disease of these organs. Also, pain syndrome can be associated with pathology of the heart. You need an internal consultation with a doctor for examination.
I am 35 and two ulcers were found in me: in the stomach and 12 duodenal ulcer. They said it was from stress. Is it dangerous or not? Thank you.
Due to an untreated ulcer, perforation occurs, as a result of which through holes are formed in the stomach, and all the food entering it enters the abdominal cavity. The consequence of this phenomenon is the development of peritonitis and the death of a person within three days, if he does not receive urgent medical care. The disease is also dangerous due to internal bleeding that occurs due to the fact that erosive formations expose the wall of the blood vessel, and hydrochloric acid corrodes it. For this reason, blood loss occurs, the consequences of which can be very serious. Peptic ulcer disease is also dangerous because, over time, pathology can also cover neighboring organs, such as the pancreas. And although the ulcer remains closed, acute pancreatitis develops, the consequences of which are even more dangerous than the erosive damage to the organ.
Recently, she began to feel heaviness and pain in the stomach with attacks, then pain in the intestines during defecation. If you eat something sparing (fresh vegetables, oatmeal with yogurt), then there are no pains, they occur after spicy and fatty foods. It became less desirable to eat at a time, it just does not climb, with severe pain it is impossible to force yourself to eat. There are no night pains, there was a feeling of nausea, but did not vomit. Could it be a stomach or duodenal ulcer? Is it possible to get by with just proper nutrition, without a visit to the doctor?
It can be peptic ulcer and other diseases of the gastrointestinal tract (hungry pains are typical for the duodenum). It is better to be examined by a gastroenterologist so as not to miss anything serious - it is easier to be treated in the early stages of diseases.
I have a stomach ulcer. And I almost always smell an unpleasant smell from the oral cavity. After the course of treatment, this feeling goes away, but not for long. How can you get rid of this? And is it possible at all? Thanks in advance.
First of all, it is necessary to exclude diseases of the upper respiratory tract and dental diseases. If the problem persists, it is necessary to work further with a gastroenterologist.
After inpatient treatment of gastric and duodenal ulcers (he was admitted to the hospital with bleeding in the stomach), my dad was prescribed to take control at home 2 times a day without instructions during, before or after meals. Do not call the doctor. Please tell me the specifics of taking this drug.
It has been established that neither time of day nor food intake affect the activity of the drug, so you can take it at your convenience. Health to you!
My father has been eating for the 2nd month, and he immediately vomits. He was prescribed pills, but they do not help him. I just don't remember the name. Now they took the tests again, a piece of the stomach for analysis. Please tell me what it could be.
The occurrence of vomiting after eating can be observed with stenosis (narrowing) of the pylorus, in which food cannot pass from the stomach to the intestines. Pyloric stenosis may be due to peptic ulcer disease or even cancer. It is for this reason (to determine the exact cause of the disease) that a tissue fragment was taken from your father for analysis.
I have read a lot of literature about stomach ulcers, but nowhere does it indicate that diarrhea can also be one of the symptoms. The point is that my husband has an ulcer and it is accompanied by terrible diarrhea. Food does not stay in the stomach at all. Bowel movements occur after each meal and even more often. Approximately 5-6 times a day. He was found to have the H-pylori bacterium. Antibiotics drank for 2 weeks - did not help. They scheduled a gastroscopy. He is 33 years old. The question is, can there be severe diarrhea with a stomach ulcer?
Diarrhea (diarrhea) is indeed not a classic symptom of an ulcer, which is why it is rarely listed in the list of symptoms of this disease. In your husband's case, it is likely that the occurrence of diarrhea is due to increased irritability of the digestive tract, as is observed in irritable bowel syndrome (ie, the coexistence of two diseases is possible). The lack of effect from a course of antibiotics should not discourage you - the effect of treatment will become noticeable a little later. on the other hand, persistent diarrhea may indicate a malfunction of the pylorus and too rapid passage of food into the intestines (this is a complication of peptic ulcer). Now you should undergo a gastroscopy, which should determine the condition of the ulcer and the presence of possible complications, perhaps during the examination the exact cause of diarrhea will be established.
A peptic ulcer can be detected by X-ray or endoscopic method.
X-ray examination
A direct symptom ("niche") is characteristic - a shadow of a contrasting mass that filled the ulcer crater. The silhouette of the ulcer can be seen in profile (contour "niche") or in full face against the background of mucosal folds ("relief-niche"). Small "niches" are radiologically indistinguishable. The shape of the contour "niche" can be round, oval, slit-like, linear, pointed or irregular. The contours of small ulcers are usually even and clear. In large ulcers, the outlines become uneven due to the development of granulation tissue, accumulation of mucus, and blood clots. At the base of the "niche" small indentations are visible, corresponding to edema and infiltration of the mucous membrane at the edges of the ulcer. The relief "niche" looks like a persistent round or oval accumulation of a contrasting mass on the inner surface of the stomach or duodenum. With a chronic ulcer, the relief "niche" may have an irregular shape, uneven outlines. Sometimes there is a convergence of the folds of the mucous membrane to the ulcer. Indirect radiological signs of an ulcer include the presence of fluid in the stomach on an empty stomach, accelerated progression of the contrast mass in the ulcer zone, and regional spasm. In the stomach and bulb, spasm usually occurs at the level of the ulcer, but on the opposite side. There, a retraction of the contour of the organ wall with even outlines is formed - a symptom of the "pointing finger". Often observed duodenogastric reflux.
FEGDS
FEGDS is a more informative method (an ulcer is found in 98% of cases), which allows not only to detect an ulcer and control its healing, but also to conduct a histological assessment of changes in the gastric mucosa, to exclude malignancy. An ulcer in the acute stage is most often rounded. The bottom of the ulcer is covered with a fibrinous coating and is often colored yellow. The mucous membrane around the ulcer is hyperemic, edematous. The edges of the ulcer are usually high, even, there is an inflammatory shaft around the ulcer. A healing ulcer is characterized by a decrease in hyperemia, the inflammatory shaft is smoothed out, the ulcer becomes less deep, the bottom is cleared and covered with granulations. According to the results of a biopsy of the edges and bottom of the ulcer, the healing process is confirmed. Changes in the form of leukocyte infiltration persist for a long time after the restoration of the integrity of the mucous membrane.
Version: Directory of Diseases MedElement
Gastric ulcer (K25)
Gastroenterology
general information
Short description
Stomach ulcer(GU) is a multifactorial chronic disease accompanied by the formation of ulcers in the stomach with possible progression and development of complications.
The first morphological stage of peptic ulcer is erosion Erosion - superficial defect of the mucous membrane or epidermis
, which is a shallow defect (damage) of the mucous membrane within the boundaries of the epithelium and is formed during necrosis of the mucous membrane area.
Erosions, as a rule, are multiple and localized mainly along the lesser curvature of the body and the pyloric part of the stomach, less often in the duodenum. Erosion can have a different shape and size - from 1-2 mm to several centimeters. The bottom of the defect is covered with fibrinous plaque, the edges are soft, even and do not differ from the surrounding mucous membrane in appearance.
Healing of erosion occurs by epithelization (complete regeneration) in 3-4 days without scar formation, with an unfavorable outcome, a transition to an acute ulcer is possible.
acute ulcer is a deep defect of the mucous membrane, which penetrates to the proper muscular plate of the mucous membrane and deeper. The reasons for the formation of an acute ulcer are similar to those for erosions. Acute ulcers are more often solitary; have a round or oval shape; on the section they look like a pyramid. Size of acute ulcers An ulcer is a defect in the skin or mucous membrane and underlying tissues, the healing processes of which (development of granulations, epithelialization) are impaired or significantly slowed down.
- from several mm to several cm. Localized on the lesser curvature. The bottom of the ulcer is covered with fibrinous plaque, it has smooth edges, does not rise above the surrounding mucous membrane and does not differ from it in color. Often the bottom of the ulcer has a dirty gray or black color due to the admixture of hematin hydrochloride.
Microscopically: weakly or moderately expressed inflammatory process in the edges of the ulcer; after rejection of necrotic masses at the bottom of the ulcer - thrombosed or gaping vessels. When an acute ulcer heals, a scar is formed within 7-14 days (incomplete regeneration). With a rare adverse outcome, a transition to a chronic ulcer is possible.
For chronic ulcer characterized by pronounced inflammation and proliferation of scar (connective) tissue in the area of the bottom, walls and edges of the ulcer. The ulcer has a round or oval (rarely linear, slit-like or irregular) shape. Its size and depth may vary. The edges of the ulcer are dense (callous ulcer), even; undermined in its proximal section and gently sloping in the distal.
Morphology of a chronic ulcer during an exacerbation: the size and depth of the ulcer increase.
Three layers are distinguished at the bottom of the ulcer:
- upper layer- purulent-necrotic zone;
- middle layer- granulation tissue;
- bottom layer- scar tissue penetrating into the muscle membrane.
Purulent-necrotic zone decreases during remission. Granulation tissue, growing, matures and turns into coarse fibrous connective (scar) tissue. In the area of the bottom and edges of the ulcer, the processes of sclerosis intensify; the bottom of the ulcer is epithelized.
Scarring of the ulcer does not lead to a cure for peptic ulcer disease, since an aggravation of the disease can occur at any time.
Classification
There is no generally accepted classification of peptic ulcer disease.
From the point of view of nosological independence, the following types of disease are distinguished:
- peptic ulcer associated with H. pylori;
- peptic ulcer disease not associated with H. pylori;
Symptomatic gastroduodenal ulcers.
Depending on the localization, there are:
- gastric ulcers (cardiac and subcardial regions, stomach body, antrum, pyloric canal);
- ulcers of the duodenum (bulb or postbulbar region);
- combined ulcers of the stomach and duodenum.
Ulcers can be located on the lesser or greater curvature, the anterior and posterior walls of the stomach and duodenum (duodenum).
According to the number of ulcers It is customary to distinguish between single ulcers and multiple ulcers.
Depending on the size of the ulcer exist:
- small ulcers (up to 0.5 cm in diameter);
- medium (0.6-2 cm);
- large (2-3 cm);
- giant (more than 3cm).
When formulating diets, it is noted disease stage:
- exacerbation;
- scarring (with endoscopically confirmed stage of "red" and "white" scar);
- remission.
The presence of cicatricial and ulcerative deformity of the stomach and duodenum is also reflected.
The disease may have acute course(for newly diagnosed peptic ulcer) and chronic course with repeated exacerbations.
Periods of exacerbations in patients may be rare(1 time in 2-3 years) or frequent(2 times a year or more).
Depending on the timing of scarring, it is customary to single out hard-to-heal (long-term non-healing) ulcers, the scarring time of which exceeds 12 weeks.
When formulating a diagnosis, indicate complications of peptic ulcer:
- bleeding;
- perforation;
- penetration;
- perigastritis;
- periduodenitis;
- cicatricial-ulcerative stenosis of the pylorus.
Also indicate anamnestic complications and surgery for peptic ulcer.
Etiology and pathogenesis
The most common cause of YABZh is the bacterium H. pylori (75-80%).
The second most common cause is the use of non-steroidal anti-inflammatory drugs (NSAIDs).
Rare causes include Zollinger-Ellison syndrome, liver cirrhosis, collagenosis, HIV infection; diseases of the lungs, heart, kidneys and stress ulcers, which are combined into a group of so-called symptomatic ulcers.
An important factor in the development of gastric ulcer is hereditary predisposition. The family history of peptic ulcer disease in children is about 15-40%.
Pathogenesis is a consequence of an imbalance between the factors of "aggression" and "protection" of the gastric mucosa. Factors of "aggression" include hydrochloric acid, pepsin, impaired evacuation of gastric contents, duodenogastric reflux Duodenogastric reflux is the reflux of the contents of the duodenum into the stomach.
.
In the formation of chronic ulcers in the stomach, a decrease in the resistance of the mucous membrane, a weakening of its resistance to the damaging effects of gastric juice, is of primary importance. This occurs with the development of atrophic (autoimmune) gastritis, with a long-term course of gastritis associated with H.pylori, with prolonged exposure to chemical and certain medicinal substances. For example, when taking NSAIDs, there is a violation of the production of prostaglandins, which leads to a decrease in mucus production and suppression of the regeneration of the epithelium of the gastric mucosa.
Mucosal resistance sharply decreases at the site of local ischemia Ischemia is a decrease in blood supply to a part of the body, organ or tissue due to a weakening or cessation of arterial blood flow.
, which may be the result of hemorrhage, thrombosis or vasculitis against the background of an immunopathological process.
With reduced mucosal resistance, the normal and even somewhat reduced aggressiveness of the gastric secretion becomes sufficient for the formation of ulcers.
The bulk of stomach ulcers appear in the area located on the lesser curvature of the stomach between the body and the antrum. It is called the place of least resistance (locus minoris resistentiae).
Epidemiology
Age: Predominantly mature and advanced age
Sex ratio (m/f): 1.5
Peptic ulcer disease affects from 5 to 14% of the population in different age and social groups.
According to some authors, H. pylori infection (as the main potential cause of GU) is much higher and ranges from 25 to 80% in various countries. The level of infection correlates primarily with the socioeconomic level. Among urban residents, the disease is registered 2-3 times more often than among rural residents. Men under 50 get sick more often than women. GU is a rarer form compared to duodenal ulcer.
In the structure of ulcerative lesions of the gastrointestinal tract in children, Istomach ulcers account for about 13% and occur in about 2 out of 10,000 children. Peptic ulcer of the duodenum occurs 8 times more often. The disease affects children aged 7 years. Boys and girls get sick equally often.
Factors and risk groups
The main factors contributing to the development of gastric ulcer:
- H. pylori infection;
- heredity;
- smoking;
- gastrinoma (Zollinger-Ellison syndrome) - excessive production of gastrin and histamine (carcinoid syndrome);
- hypercalcemia;
- overcrowding;
- low socio-economic level;
- professional contact with gastric and duodenal contents (health workers).
Clinical picture
Clinical Criteria for Diagnosis
Epigastric pain associated with eating, dyspepsia
Symptoms, course
The clinical picture appears pain syndrome and dyspeptic syndrome Dyspeptic syndrome - a digestive disorder, usually manifested by pain or discomfort in the lower chest or abdomen, which can occur after eating and is sometimes accompanied by nausea or vomiting
.
Usually the disease proceeds with periods of exacerbation and remission.
The main symptom of an exacerbation of peptic ulcer is pain in the epigastric region to the left of the midline (with ulcers of the body of the stomach) or to the right of it (with ulcers of the pyloric canal and duodenal bulb). Pain may radiate Irradiation - the spread of pain outside the affected area or organ.
in the left half of the chest and the left shoulder blade (more often with ulcers of the subcardial region), the right hypochondrium (with postbulbar ulcers), the thoracic or lumbar spine.
Pain during exacerbation of peptic ulcer is usually associated with food intake. They can occur immediately after a meal (with ulcers of the cardiac and subcardial sections of the stomach), 0.5-1 hour after a meal (with ulcers of the body of the stomach).
For ulcers of the pyloric canal and duodenal bulb, late pains are typical (2-3 hours after eating), "hungry" pains (occur on an empty stomach and are stopped by eating), as well as night pains.
Pain decreases and disappears after taking antacids, antisecretory and antispasmodic drugs, and applying heat.
In a number of patients, at the peak of pain, vomiting of acidic gastric contents occurs, which brings relief (due to this fact, patients can induce vomiting artificially). Frequent complaints of patients with exacerbation of peptic ulcer - nausea, belching, constipation.
The course of the disease has a number of features in women, in adolescence and adolescence, as well as in senile and old age.
Clinic of peptic ulcer in atypical course or atypical forms:
1. Pain is often localized mainly in the right hypochondrium or in the right iliac region.
2. Atypical localization of pain in the region of the heart ("heart mask") or in the lumbar region ("radiculitis mask") is possible.
3. The presence of "silent" ulcers, which have only dyspeptic manifestations in the absence of pain. "Silent" ulcers may present with gastric bleeding or perforation. Often they lead to the development of cicatricial pyloric stenosis, and patients seek medical help only if symptoms of the stenosis itself appear.
In children
The clinical picture of GU in children differs from that in adults in some details. The most pronounced clinical features occur in children with localization of the ulcer in the cardial or subcardial part of the stomach.
Among the features of the manifestations of ulcers of the upper part of the stomach, a weak severity of the pain syndrome, atypical localization and irradiation of pain are noted. Children often complain of a burning sensation and pressure under the xiphoid process, behind the sternum, or to the left of it. The pain may radiate to the region of the heart, left shoulder, under the left shoulder blade; appears 20-30 minutes after eating and decreases when taking antisecretory agents.
For patients with mediagastric ulcers, a fuzzy pain syndrome is characteristic: pains are pulling, arching, do not go away after eating. Pain can radiate to the left half of the chest, lumbar region, right and left hypochondria. In some patients with mediogastric peptic ulcer, there is a decrease in appetite and weight loss, which is not typical for pyloroduodenal ulcers. The stool is often unstable. Often the disease proceeds latently or atypically with a predominance of neurovegetative changes in the clinical picture.
Examination of the patient can reveal signs of hypovitaminosis, tongue furring; palpation of the abdomen causes pain in the epigastrium Epigastrium - the region of the abdomen, bounded from above by the diaphragm, from below by a horizontal plane passing through a straight line connecting the lowest points of the tenth ribs.
and mesogastric Mesogastrium (stomach) - the region of the abdomen located between the line connecting the lowest points of the X ribs and the line connecting the anterior superior iliac spines.
.
Diagnostics
Diagnosis of peptic ulcer is based on a combination of clinical examination data, the results of instrumental, morphological and laboratory research methods.
Instrumental diagnostics. Diagnosis of the presence of an ulcer
Required Research
Of primary importance is endoscopy, which allows you to clarify the localization of the ulcer and determine the stage of the disease. The sensitivity of the method is about 95%. An ulcer is a defect in the mucous membrane, reaching the muscular and even serous layer. Chronic ulcers may be round, triangular, funnel-shaped, or irregular in shape. The edges and bottom of the ulcer may be thickened with connective tissue (callous ulcer). When a chronic ulcer heals, scarring occurs, often with deformation of the stomach.
If EGDS is not possible, fluoroscopy of the stomach, which allows you to detect an ulcer in about 70% of cases. The diagnostic accuracy is improved by the double contrast method. The ulcer crater (niche) looks like a depression on the contour of the stomach wall or a persistent contrast spot. The folds of the stomach converge to the base of the ulcer, surrounded by a wide inflammatory shaft (Hampton's line). The ulcer crater is smooth, rounded or oval in shape.
X-ray examination is more often used to identify complications (cicatricial deformities, penetration).
Diagnosis of H. pylori(helicobacteriosis), as the main cause of GU, is of great importance.
Invasive methods:
- biopsy stain according to Giemsa, Warthin-Starry;
- CLO-test - determination of urease in the mucosal biopsy;
- biopsy culture.
Non-invasive methods:
- determination of antigen in the stool (chromatography with monoclonal antibodies);
- breath test with urea labeled with carbon isotope (C13-14);
- serological methods (determination of antibodies to H.pylori).
Bismuth preparations, proton pump inhibitors and others suppress the activity of H. pylori, which leads, for example, to false-negative results of a urease test, histological examination, and determination of antigen in feces. Thus, diagnostic methods should be applied on average 4 weeks after the end of antibiotic therapy or 2 weeks after the end of other antiulcer therapy (PPI). It is also possible to increase the reliability of studies by multiplying them - for example, multiple biopsies from more than 2 sites of the stomach increase the specificity of this diagnostic method.
Additional Research
Spend daily pH-metry, the study of intragastric proteolytic activity of the stomach. To assess the motor function of the stomach, ultrasound, electrogastrographic, x-ray studies, and antroduodenal manometry are used.
Ultrasound of the abdominal organs is performed to diagnose concomitant pathology of the hepatobiliary system and pancreas.
Laboratory diagnostics
Required Research: general blood and urine analysis, coprogram Coprogram - recording the results of a study of feces.
, fecal occult blood test, tests for Helicobacter pylori infection, determination of blood group and Rh factor
Additional Research(performed to diagnose the so-called "endocrine and symptomatic" ulcers): determination of the level of parathyroid hormone, alkaline phosphatase, liver tests, creatinine.
Determination of calcium and phosphorus in urine and blood is also recommended.
Although endocrine gastric ulcers in Zollinger-Ellison syndrome Zollinger-Ellison syndrome (syn. gastrinoma) - a combination of peptic ulcers of the stomach and duodenum with adenoma of the pancreatic islets, developing from acidophilic insulocytes (alpha cells)
are many times less common than duodenal ulcers or gastrojejunal ulcers, the determination of gastrin levels should be considered mandatory in treatment-resistant GU. In doubtful cases, provocative tests with intravenous calcium (5 mg / kg per hour for 3 hours) or secretin (3 units / kg per hour) are used. With an increase in the content of gastrin in the blood serum by 2-3 times compared with the basal level, the test is considered positive.
Indications for determining the level of gastrin in relation to YABZH:
- peptic ulcers in combination with diarrhea;
- recurrent postoperative peptic ulceration;
- multiple ulceration Ulceration - the process of ulceration, that is, the formation of an ulcer (ulcers)
;
- family history of peptic ulceration;
- peptic ulcers in combination with hypercalcemia or other manifestations of multiple endocrine neoplasia Multiple endocrine neoplasia (MEN) is a group of hereditary autosomal dominant syndromes caused by tumors or hyperplasia of several endocrine glands.
Type I (Wermer syndrome Wermer's syndrome (multiple endocrine neoplasia type I, MEN-I) is a hereditary combination of endocrine adenomatosis and peptic ulcers of the small intestine. Includes a combination of hormonally active tumors originating from endocrine cells and hormonally inactive tumors originating from other (non-endocrine) cells in the body
);
X-ray or endoscopic signs of hypertrophy of the folds of the gastric mucosa.
In patients over 60 years of age, ulcers can form during circulatory decompensation, against the background of hypertension and atherosclerotic lesions of the abdominal aorta and its visceral branches; in this regard, for this group of patients, it is recommended to determine the laboratory parameters corresponding to the listed changes.
Differential Diagnosis
First of all, it is necessary to differentiate peptic ulcer disease as such from symptomatic gastric and duodenal ulcers, the pathogenesis of which is associated with certain underlying diseases or with specific etiological factors (for example, with NSAIDs).
Symptomatic gastroduodenal ulcers(especially medicinal ones) often develop acutely, sometimes manifesting as sudden gastrointestinal bleeding or perforation of an ulcer, and can occur with atypical clinical manifestations (a blurred picture of exacerbation, lack of seasonality and periodicity).
Gastroduodenal ulcers in Zollinger-Ellison syndrome, unlike the usual peptic ulcer, they have a very severe course; they are characterized by multiple localization (often even in the jejunum) and persistent diarrhea. When examining such patients, a sharply increased level of gastric acid secretion is noted (especially in basal conditions), an increased content of gastrin in the blood serum (3-4 times compared with the norm).
To recognize the Zollinger-Ellison syndrome, provocative tests (with secretin, glucagon), ultrasound examination of the pancreas are used.
Gastroduodenal ulcers in patients with hyperparathyroidism differ from peptic ulcer severe course with frequent relapses, a tendency to bleeding and perforation, the presence of signs of increased function of the parathyroid glands (muscle weakness, bone pain, thirst, polyuria). The diagnosis is established on the basis of determining the concentration of calcium and phosphorus, an elevated level of parathyroid hormone in the blood serum, signs of hyperparathyroid osteodystrophy, characteristic symptoms of kidney damage and neurological disorders.
When ulcerative lesions are found in the stomach, it is necessary to make a differential diagnosis between benign ulcers, malignancy of the ulcer and primary ulcerative form of gastric cancer. The very large size of the ulcer (especially in young patients), the localization of the ulcer on the greater curvature of the stomach, the presence of an increase in ESR and histamine-resistant achlorhydria speak in favor of the malignant nature of the lesion.
In children
Since there are no specific symptoms in the clinical picture of gastric ulcer, in children it is necessary to carry out differential diagnosis with other diseases of the digestive tract, which are manifested by similar pain and dyspeptic syndromes.
Esophagitis, chronic gastroduodenitis (CGD), duodenal ulcer are excluded by endoscopic and morphological studies.
To exclude acute cholecystitis and exacerbation of chronic cholecystitis, the clinic, indicators of inflammation activity, ultrasound data, analysis of the composition of bile are taken into account.
Acute pancreatitis and exacerbation of chronic pancreatitis, along with clinical manifestations, are differentiated on the basis of the appearance of steatorrhea in the coprogram, an increase in amylase in the urine and pancreatic enzymes in the blood, and ultrasound data of the pancreas.
If an ulcer defect of the gastric mucosa is detected, differential diagnosis is carried out with symptomatic ulcers, among which the most common in children (much more often than gastric ulcer) are acute ulcers:
Stress ulcers that occur with burns, after injuries, with frostbite;
- allergic ulcers, mainly developing with food allergies;
- medical ulcers resulting from the use of drugs that violate the barrier functions of the mucous membrane (non-steroidal and steroidal anti-inflammatory drugs, cytostatics, etc.)
Acute ulceration of the mucous membrane of the digestive tract does not have typical clinical manifestations. They develop very dynamically and can both heal quickly and unexpectedly lead to severe complications: bleeding, perforation.
During endoscopy, acute ulcers range in size from several millimeters to several centimeters, round or oval, the edges of the ulcers are edematous, hyperemic, the bottom is lined with fibrin. After healing of an acute ulcer, scars often do not remain.
Complications
The prognosis for a Helicobacter-associated process is largely determined by the success of H. pylori eradication. H. pylori eradication is the name of standard treatment regimens aimed at the complete destruction of Helicobacter pylori in the gastric mucosa in order to provide favorable conditions for the healing of ulcers and other mucosal lesions.
, as a result of which a relapse-free course of the disease is possible in most patients.
In adults, PUD is complicated by bleeding in 15–20% of cases, perforation/penetration in 5–15%, and pyloric stenosis in 2%.
The incidence of gastric cancer, as one of the complications of gastric ulcer, is 3-6 times higher in patients infected with H. pylori.
H. pylori infection has been associated with several other diseases (so-called extraintestinal lesions), such as coronary heart disease, the risk of which increases by 1-20%.
H. pylori infection may present with idiopathic chronic urticaria, rosacea, and alopecia areata Alopecia - persistent or temporary, complete or partial loss (absence) of hair.
.
Approximately 4% of patients with peptic ulcer childhood complications such as bleeding, perforation, penetration, and occasionally malignancy develop.
Bleeding manifested by bloody vomiting, tarry stools and symptoms of acute vascular insufficiency. Often, with the development of bleeding, pain disappears (Bergman's symptom). With heavy bleeding, vomiting of "coffee grounds" is characteristic. The color of vomit is formed as a result of the conversion of hemoglobin to hematin, which has a black color, under the influence of hydrochloric acid. In the vomit, scarlet blood can also be noted. Black tarry stool appears on the 2nd day of heavy bleeding. In the case of moderate bleeding, the color of the stool does not change, but occult blood can be detected in the feces using the Gregersen reaction. With significant blood loss, weakness, pallor, dizziness, nausea, cold, sticky sweat, arterial hypotension occur. Hypotension - reduced hydrostatic pressure in vessels, hollow organs or body cavities.
, tachycardia, possible fainting. In the blood, the hematocrit decreases and later - the content of erythrocytes and hemoglobin. The source of bleeding is determined by endoscopy of the stomach.
Perforation gastric ulcer is characterized by a sudden sharp dagger pain in the epigastrium, vomiting does not bring relief. There is a board-like tension of the muscles of the anterior abdominal wall, symptoms of peritoneal irritation increase. The general condition of the patient quickly worsens, the body temperature rises, consciousness is disturbed. The most significant method of diagnosis is a survey X-ray examination of the abdominal cavity. It helps to detect the presence of free gas in the abdominal cavity.
penetration- the spread of an ulcer outside the wall of the stomach into adjacent tissues and organs, more often into the lesser omentum and the body of the pancreas. With penetration, the pain syndrome intensifies. The pain is constant (regardless of food intake) and does not decrease after taking antacids. Possible increase in body temperature. In the general blood test, leukocytosis and an increase in ESR are increasing. On palpation in the area of the pathological focus, severe pain occurs, sometimes it is possible to palpate the inflammatory infiltrate Infiltrate - a tissue area characterized by an accumulation of cellular elements that are usually not characteristic of it, an increased volume and increased density.
. A typical sign of penetration during radiopaque examination of the stomach is the appearance of an additional shadow of barium next to the silhouette of the organ.
Malignization- a rare complication of stomach ulcers. Most often there is a malignancy of subcardiac ulcers. The clinical picture of peptic ulcer in the early stages does not change significantly. In the case of a neglected disease, patients may experience increased pain, weight loss, the appearance of hematological changes (anemization, increased ESR). The diagnosis is established by morphological examination of the biopsy.
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Treatment
Non-drug treatment
In addition to prescribing medications, the treatment of PUD should also include measures such as dietary nutrition, cessation of smoking and alcohol consumption, refusal to take ulcerogenic drugs (primarily NSAIDs).
Diet food should be frequent, fractional, mechanically and chemically sparing. In the bulk of cases, the appointment of diet No. 1 according to M.I. Pevzner. Physiologically defective diets No. 1a and 16 should be prescribed only with pronounced symptoms of exacerbation and for a very short time.
Physiotherapy procedures(heaters, poultices, paraffin and ozocerite applications, electrophoresis with 5% novocaine solution, microwave therapy) are additional to pharmacotherapy and are recommended for patients only in the phase of subsiding exacerbation of peptic ulcer in the absence of signs of peptic ulcer bleeding. Procedures are not carried out until the full confirmation of the benign nature of the lesions.
H. pylori eradication with the help of any one drug is not effective enough, so it must be carried out using a combination
Several antisecretory agents. One or another scheme is considered effective if it allows to achieve eradication in more than 80-90% of cases. Most H. pylori therapy regimens include proton pump inhibitors (abbr. PPI, PPI). These drugs, by increasing the pH of gastric contents, create unfavorable conditions for the life of H. pylori and increase the effectiveness of many anti-Helicobacter drugs.
Based on this information, the recommendations of the last conciliation meeting "Maastricht-III"(Florence, 2005) provide as first line therapy a single triple eradication regimen, including PPI (in standard doses 2 times a day), clarithromycin (at a dose of 500 mg 2 times a day) and amoxicillin (at a dose of 1000 mg 2 times a day). In addition, these recommendations contain an important clarification that this regimen is prescribed if the proportion of H. pylori strains resistant to clarithromycin in this region does not exceed 20%.
The protocol of eradication therapy implies mandatory monitoring of effectiveness, which is carried out 4-6 weeks after its completion (during this period, the patient does not take any antibacterial drugs and PPIs).
If H. pylori is detected in the mucosa, a second course of eradication therapy is indicated using second-line therapy, followed by monitoring of its effectiveness also after 4 weeks. Only strict adherence to such a protocol makes it possible to properly sanitize the gastric mucosa and prevent the risk of recurrence of ulcers.
As second line therapy a 4-drug regimen is used, including PPIs (at a standard dose 2 times a day), bismuth preparations at a usual dosage (for example, colloidal bismuth subcitrate 0.24 g 2 times a day), metronidazole (0.5 g 3 times a day). day) and tetracycline (in a daily dose of 2 g). The scheme of quadruple therapy retains its effectiveness in cases of resistance of H. pylori strains to metronidazole.
In case of ineffectiveness of first and second line eradication schemes, the Maastricht-III consensus offers several options for further therapy. Since H. pylori strains do not develop resistance to amoxicillin during its use, it is possible to prescribe its high doses (0.75 g 4 times a day, for 14 days) in combination with high (4-fold) doses of PPIs.
Another option may be to replace metronidazole in the quadrotherapy regimen with furazolidone (100-200 mg 2 times a day). An alternative is the combination of a PPI with amoxicillin and rifabutin (at a dose of 300 mg/day) or levofloxacin (at a dose of 500 mg/day). The best way to overcome resistance remains the selection of antibiotics, taking into account the determination of the individual sensitivity of this strain of H. pylori.
Taking into account resistance to antibiotics and other factors, they were developed and adopted by the X Congress of NOGR on March 5, 2010 " Standards for the diagnosis and treatment of acid-dependent and Helicobacter pylori-associated diseases(4th Moscow agreement)" which include the following treatment.
First line
Option 1
Three-component therapy, including the following drugs, which are taken for 10-14 days:
One of the "standard dose" PPIs twice a day +
Amoxicillin (500 mg 4 times a day or 1000 mg 2 times a day) +
Clarithromycin (500 mg twice daily) or josamycin (1000 mg twice daily) or nifuratel (400 mg twice daily).
Option 2
Quadruple therapy, including, in addition to the drugs of Option 1, a bismuth drug. Duration also 10-14 days:
Indications for surgical treatment of peptic ulcer are currently complicated forms of the disease (perforation and penetration of the ulcer, the development of cicatricial and ulcerative pyloric stenosis, malignancy of the ulcer). If all the necessary protocols of conservative treatment are followed, cases of its ineffectiveness (as an indication for surgery) can be minimized.
In children
Treatment of peptic ulcer in children, as well as in adults, should be comprehensive, including regimen, dietary nutrition, drug and non-drug therapy, as well as prevention of recurrence and complications.
Non-drug treatment
During periods of intense pain, bed rest is recommended. The diet should be mechanically, chemically and thermally gentle on the gastric mucosa. Spicy seasonings are excluded from the diet, the consumption of table salt and foods rich in cholesterol is limited. Eating should be done 4-5 times a day. With exacerbation, which is accompanied by severe pain in the abdomen, it is advisable to prescribe diet No. 1, followed by a transition to diet No. 5.
Medical treatment
Drug treatment is prescribed depending on the leading pathogenetic factor.
In forms of the disease associated with H. pylori, therapy begins with a 10-14-day 3-component eradication course (for example, omeprazole + clarithromycin + metronidazole) followed by a 3-4-week course of antisecretory drugs, usually inhibitors of H +, K + -ATPase (omeprazole, rabeprazole, esomeprazole).
4-6 weeks after the completion of the eradication course, its effectiveness is monitored (helix breath test). In case of treatment failure, after 4 months, a second course is carried out - quadruple therapy of the second line (inhibitors of H +, K + -ATPase + De-Nol + 2 antibacterial drugs).
With H.pylori-negative gastric ulcer against the background of atrophic gastritis, film-forming cytoprotectors are prescribed - sucralfate (venter, antepsin, alsukral), colloidal bismuth subcitrate (de-nol).
With duodenogastric reflux, prokinetics are used - domperidone (motilium).
In the treatment of gastric ulcer associated with long-term use of NSAIDs, synthetic prostaglandins - misoprostol (arboprostil, enprostil, Cytotec, Cytotect) are recommended. Assign tablets of 0.2 mg 3 times a day orally during meals and at bedtime.
In the case of a bleeding stomach ulcer, EGDS and endoscopic hemostasis (diathermo or laser coagulation) are performed. Parenteral administration of hemostatic drugs (vikasol, calcium, adroxon), as well as H2-histamine receptor blockers, is necessary. Inside prescribe aminocaproic acid with thrombin and adroxon. With significant blood loss, transfusion of high-molecular blood substitutes, plasma is used, and in critical conditions - blood transfusion.
With adequate treatment in children, healing of stomach ulcers occurs within 20-23 days. At the 2-3rd week of therapy, a control endoscopic examination is performed. In the absence of positive dynamics or slow healing, daralgin is additionally prescribed. This drug stimulates regeneration processes, improves microcirculation in the gastric mucosa and has an anti-stress effect.
In the process of endoscopy, local laser therapy, ulcer irrigation with solcoseryl, and fibrin glue applications are also used.
Physiotherapy is of secondary importance in the treatment of gastric ulcer. Electrosleep, electrophoresis with bromine on the collar zone and with novocaine on the epigastric region, EHF-therapy are prescribed. At the beginning of convalescence after an exacerbation, DMV-, SMV-therapy, laser therapy are used on the most painful point of the epigastrium, a little later - ozokerite, paraffin on the epigastric region.
Surgery
Surgical treatment of gastric ulcer in children is necessary in the development of such complications of gastric ulcer as incessant massive bleeding, perforation, ulcer penetration, malignancy.
Forecast
In adultsthe prognosis is largely determined by the success of eradication of H. pylori infection, which leads to a relapse-free course of the disease in most patients.
In children: P The prognosis is favorable subject to timely diagnosis, adequate treatment and subsequent rational management.
Hospitalization
Primary diagnosis of peptic ulcer should be carried out in a hospital only in children. In adults, this diagnosis can be outpatient.
All patients are hospitalized if complications are suspected.
Prevention
Prevention of gastric ulcer involves limiting the impact of trigger Trigger - trigger, provocative substance or factor
factors, carrying out epidemiological measures aimed at preventing infection with H. pylori.
The basics of anti-relapse prevention are adherence to a rational diet, limitation of stressful effects, preventive therapy "on demand": when the first clinical symptoms of an exacerbation appear, one of the antisecretory drugs is taken for 1-2 weeks at a full daily dose, and then for another 1-2 weeks at a half dose.
In forms of gastric ulcer associated with H.pylori, control of H.pylori infection is mandatory and, if reinfection is detected, eradication.
Dispensary observation is carried out for life. In the first year after an exacerbation, examination and endoscopy with a urease test are carried out 4 times a year, from the second year - 2 times a year.
Information
Sources and literature
- Ivashkin V.T., Lapina T.L. Gastroenterology. National leadership. Scientific and practical edition, 2008
- McNally Peter R. Secrets of gastroenterology / translation from English. edited by prof. Aprosina Z.G., Binom, 2005
- General and emergency surgery. Guide / ed. Paterson-Brown S., trans. from English. ed. Gostishcheva V.K., M: GEOTAR-Media, 2010
- Roitberg G.E., Strutynsky A.V. Internal illnesses. The digestive system. Study guide, 2nd edition, 2011
- "International clinical guidelines for the management of patients with non-variceal bleeding from the upper gastrointestinal tract", Journal of Emergency Medicine, No. 5 (18), 2008
- "Endoscopic hemorrhage arrest in Dieulafoy's disease" Shavaleev R.R., Kornilaev P.G., Ganiev R.F., journal "Surgery", No. 2, 2009
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The article presents the results of endoscopic studies of the stomach and duodenum in patients with surgical peptic ulcer. The authors of the article discuss in detail the mechanisms of the pathogenesis of the disease, the role of H. pylori infection, the requirements for performing a rapid urease test, the principles of classification of the disease by domestic and foreign authors. The most common surgical and therapeutic classifications of the disease are considered. The indications for endoscopic examination are presented, the features of the endoscopic picture in the benign course of the disease and in the presence of complications are discussed. All the most common complications are illustrated by endophoto. The stages of the course of the disease are discussed separately, the features of the endoscopic picture, the characteristics of ulcerative defects, the perifocal zone, and concomitant changes in the gastric mucosa and duodenum are considered. The article is illustrated with endoscopic photographs reflecting the stages of the process.
stages of peptic ulcer disease
classification of peptic ulcer
pathogenesis of peptic ulcer
endoscopy
peptic ulcer of the stomach and duodenum
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3. Ivashkin V.T. Sheptulin A.A. Diseases of the esophagus and stomach. Moscow. - 2002.
4. V. T. Ivashkin, F. I. Komarov, and S. I. Rapoport, ed. A short guide to gastroenterology. - M .: LLC Publishing House M-Vesti, 2001.
5. Pimanov S.I. Esophagitis, gastritis, peptic ulcer. - N. Novgorod, 2000.
7. Chernyshev V.N., Belokonev V.I., Aleksandrov I.K. Introduction to surgery of gastroduodenal ulcers. - Samara: SGMU, 1993. - 214 p.
8. Shapovalyants S.G., Chernyakevich S.A., Mikhalev I.A., Babkova I.V., Storozhuk G.N., Mayat E.K., Chernyakevich P.L. Efficacy of parenteral rabeprazole in patients with acute ulcerative gastroduodenal bleeding with a high risk of recurrence after endoscopic hemostasis. - 2014. - No. 3.
9. Shahrokhi N, Keshavarzi Z, Khaksari M. J Pharm Bioallied Sci. 2015 Jan-Mar;7(1):56-9. doi: 10.4103/0975-7406.148739. Ulcer healing activity of Mumijo aqueous extract against acetic acid induced gastric ulcer in rats.
10. Tsukanov VV, Shtygasheva OV, Vasyutin AV, Amel "chugova OS, Butorin NN, Ageeva ES. Bull Exp Biol Med. 2015 Feb 26. Parameters of Proliferation and Apoptosis of Epithelial Cells in the Gastric Mucosa in Indigenous and Non-Indigenous Residents of Khakassia with Helicobacter pylori Positive Duodenal Ulcer Disease.
Peptic ulcer of the stomach and duodenum (PU) is a heterogeneous disease with multifactorial etiology and complex pathogenesis. The pathological process is based on inflammation of the mucous membrane of the gastroduodenal zone with the formation of a local lesion, the morphological equivalent of which is a defect in the mucous and submucosal layer with an outcome in a connective tissue scar.
PU is a chronic relapsing disease with alternating periods of exacerbation and remission. In a modern clinic, duodenal localization of ulcers, occurring 8-10 times more often, dominates over localization in the stomach. Typical for PUD are seasonal periods of increased pain and dyspeptic disorders. The possibility of an asymptomatic course of ulcer should also be taken into account. The frequency of such cases according to the literature can reach 30% (Minushkin O.N., 1995).
The factors of aggression include: increased exposure to the acido-peptic factor associated with an increase in the production of hydrochloric acid and pepsin; violation of the motor-evacuation function of the stomach and duodenum (delay or acceleration of the evacuation of acidic contents from the stomach, duodenogastric reflux).
Protective factors are: the resistance of the mucous membrane to the action of aggressive factors; production of gastric mucus; adequate bicarbonate production; active regeneration of the surface epithelium of the mucous membrane; sufficient blood supply to the mucosa; normal content of prostaglandins in the wall of the mucous membrane; immune protection.
Great importance at present in the pathogenesis of PU, especially duodenal ulcers, is attached to the infectious agent - Helicobacter pylori (HP). On the one hand, the microorganism in the course of its life, forming ammonia from urea, alkalizes the antrum of the stomach, which leads to hypersecretion of gastrin, constant stimulation of parietal cells and hyperproduction of HCl, on the other hand, a number of its strains secrete cytotoxins that damage the mucous membrane. All this leads to the development of antral gastritis, gastric metaplasia of the duodenal epithelium, HP migration to the duodenum, the development of duodenitis and, ultimately, can be realized in PU (Pimanov S.I., 2000).
Along with HP infection, an important role in the pathogenesis of PU is given to hereditary predisposition to the disease and the use of non-steroidal anti-inflammatory drugs (NSAIDs).
In foreign literature, the term "chronic peptic ulcer of the stomach or duodenum" is accepted. This name reflects the main pathogenetic signs of the disease - the appearance of an ulcer in the stomach or duodenum, as a result of the peptic effect of digestive enzymes on these organs. In Russia, the term "peptic ulcer" dominates, and the presence of a detailed classification of the disease is necessary in connection with the traditions of the Russian therapeutic school and the requirements of the examination of working capacity (Minushkin O.N., 1995).
The most common classification of peptic ulcer is the Johnson classification.
Classification A.G. Johnson (1990)
- Chronic type I ulcers - lesser curvature ulcers
- Chronic type II ulcers - combined with duodenal ulcer, including with a healed duodenal ulcer
- Chronic ulcers type III - prepyloric ulcers
- Chronic type IV ulcers - acute superficial ulcers
- Chronic type V ulcers - due to Zollinger-Elisson syndrome
Classification of chronic stomach ulcers
(V.N. Chernyshev, V.I. Belokonev, I.K. Aleksandrov, 1993)
Type I - single or multiple ulcers, located from the proximal (antral) part of the pyloric part of the stomach to the cardia;
Type II - single or multiple ulcers of any part of the stomach in combination with an ulcer or erosions of the duodenum or with a healed ulcer of the duodenum;
Type III - ulcers of the pyloric ring or supra-pyloric zone (no further than 3 cm from the pyloric sphincter);
Type IV - multiple ulcers, subject to a combination of an ulcer of the pylorus and the supra-pyloric zone with ulceration of any overlying part of the stomach;
Type V - secondary ulcers of any part of the stomach, developed due to various local causes of non-ulcer etiology.
Classification of gastroduodenal ulcers according to ICD-10
1. Gastric ulcer (gastric ulcer) (Code K 25), including peptic ulcer of the pyloric and other parts of the stomach.
2. Duodenal ulcer (duodenal ulcer), including peptic ulcer of all parts of the duodenum (Code K 26).
3. Gastrojejunal ulcer, including peptic ulcer (Code K 28) of the anastomosis of the stomach, adductor and efferent loops of the small intestine, fistula with the exception of the primary ulcer of the small intestine.
From the point of view of surgical practice, the complicated course of peptic ulcer is of clinical importance - acute gastroduodenal bleeding; penetration of the ulcer into neighboring organs; ulcer perforation; pyloroduodenal cicatricial stenosis (compensated, subcompensated, decompensated); perivisceritis (perigastritis, periduodenitis); degeneration of an ulcer into cancer.
Fig.5. Bleeding
Endoscopic semiotics of peptic ulcer
Gastric ulcers in most cases are located along its lesser curvature in the prepyloric and pyloric sections. Less commonly, they are found in the cardiac and subcardial regions. More than 90% of gastric ulcers are located on the border between the zones of the gastric and pyloric glands, usually on the side of the pyloric glands. This corresponds to the section of the stomach wall, limited by the anterior and posterior oblique fibers and the circular layer of the muscular membrane of the stomach wall, where during its movements there is the greatest stretching of the wall.
Duodenal ulcers are usually located in the area of the transition of the gastric mucosa to the duodenal mucosa at the place where the pyloric sphincter is separated from the circular muscles of the duodenum by the connective tissue layer. Here, too, the greatest stretching is noted during peristaltic activity. The size of gastroduodenal ulcers can vary from a few mm to 50-60 mm in diameter or more. The depth of the ulcers can also be different - from 5 to 20 mm. Ulcers may be round, oval, or irregular in shape. The edge of the ulcer, facing the entrance to the stomach, is usually undermined, and the mucous membrane hangs over the ulcer. The opposite edge of the bowl seems to be gentle. The folds of the mucous membrane along the periphery of the ulcer are thickened and converge towards its edges. The serous membrane in the area of the ulcer is sharply thickened.
Testing for Helicobacter pylori infection
According to the recommendation of the Russian Gastroenterological Association, all patients with gastric or duodenal ulcers, including patients with ulcers caused by NSAIDs, should be examined for the presence of HP. A diagnostic test should be performed before starting treatment.
When performing FGDS, it is advisable to take a biopsy with a urease test (Kist M., 1996). With its negative values, it is recommended to conduct a morphological study with the sampling of at least two biopsies of the mucous membrane of the body and one from the antrum of the stomach. In addition, this test can only be used in patients who have been off antimicrobials for at least four weeks and antisecretory drugs for at least one week.
The characteristics of the ulcerative defect - the size, shape, depth of the ulcer, the presence and extent of infiltration and hyperemia around the defect, to a certain extent, depend on the stage of development of the ulcerative process.
Stages of development of the ulcerative process (Vasilenko V.Kh. 1987)
I - acute stage. An ulcer at this stage during endoscopic examination is a defect in the mucous membrane of various sizes, shapes and depths. Most often it has a round or oval shape, its edges with clear boundaries, hyperemic, edematous. In some cases, the edge facing the cardia is somewhat undermined, while the distal edge is flatter and smoother (Fig. 6, 7). The mucous membrane of the stomach or duodenal bulb is edematous, hyperemic, its folds are thickened and poorly straightened by air, there are often small-pointed erosions covered with white bloom and often merging into vast fields. Deep ulcerative defects often have a funnel-shaped appearance. The bottom of the ulcer is usually covered with fibrinous overlays of grayish-white and yellowish color, the presence of dark inclusions in the bottom of the ulcer indicates bleeding.
Figure 6. Endophoto. duodenal ulcer. Acute stage
II - stage of subsiding of inflammatory phenomena. The ulcerative defect in this stage is characterized by a decrease in hyperemia and edema of the mucous membrane and the inflammatory shaft in the periulcerous zone, gradually becomes flatter, may be irregular in shape due to the emerging convergence of the mucosal folds to the edges of the defect. The bottom of the defect is gradually cleared of fibrinous plaque, while granulation tissue may be detected, the ulcer takes on a peculiar appearance, which is described as “pepper and salt” or “salami”. However, a similar picture is observed at the beginning of ulcer formation. At various stages of healing, the ulcer changes shape to slit-like, linear, or divides into several fragments.
Fig.7. Endophoto. Ulcer in the corner of the stomach. Acute stage
Fig.8. Endophoto. Post-ulcer duodenal scar
III - stage of scarring - the ulcer acquires a slit-like shape with slight infiltration and hyperemia around it; on the mucous membrane at a distance from the ulcer there may be areas of slight hyperemia, edema and single erosions.
IV - scar stage The post-ulcer scar looks like a hyperemic area of the mucous membrane with a linear or stellate retraction of the wall (the stage of the "red" scar). In the future, during endoscopic examination at the site of the former ulcer, various violations of the relief of the mucous membrane are determined: deformations, scars, narrowing. Most often, linear and star-shaped scars are formed. With the healing of deep chronic ulcers or with frequent relapses, gross deformities of the organ and stenosis may develop (Fig. 8). Often, a chronic ulcer can heal without visible scarring. A mature scar acquires a whitish appearance due to the replacement of granulation tissue with connective tissue and the absence of active inflammation (the “white” scar stage). Scars and deformation of the wall of the stomach and duodenum, resulting from frequent exacerbations of chronic ulcers, serve as reliable endoscopic criteria for PUD.
The results of our own research show that the endoscopic method allows for dynamic monitoring of the process of scarring of the ulcer. On average, healing of a stomach ulcer before the formation of a "red" scar occurs in 6-7 weeks, and of a duodenal ulcer in 3-4 weeks. The formation of a full-fledged scar usually ends in 2-3 months (the “white” scar phase). It should be borne in mind that acute superficial ulcers can heal within 7-14 days without the formation of a visible scar.
Erosions of the mucosa (a superficial defect that extends no deeper than the muscular layer of the mucosa and heals without scarring) are often found in PU and are diagnosed only endoscopically.
Erosions of the distal stomach and duodenal bulb occur in 30-50% of patients with pyloroduodenal ulcers, and in approximately 75% of patients with exacerbation of PU, only erosive lesions of this zone are found.
Reviewers:
Korotkevich A.G., Doctor of Medical Sciences, Professor of the Department of Surgery, Urology and Endoscopy, NGIUV, Novokuznetsk;
Uryadov S.E., Doctor of Medical Sciences, Professor of the Department of Surgery of the National Educational Institution of Higher Professional Education MI REAVIZ, Head of the Endoscopy Department of the State Healthcare Institution “SGKB No. 8”, Saratov.
Bibliographic link
Blashentseva S.A., Supilnikov A.A., Ilyina E.A. ENDOSCOPIC ASPECTS OF DIAGNOSTICS OF GASTRIC ULCER IN SURGICAL PATIENTS // Modern problems of science and education. - 2015. - No. 3.;URL: http://science-education.ru/ru/article/view?id=18709 (date of access: 01/27/2020). We bring to your attention the journals published by the publishing house "Academy of Natural History"
Peptic ulcer of the stomach and duodenum is characterized by the formation of a peptic ulcer in the walls of the stomach or duodenum, which eats through the mucous layer and deeper muscle layers.
A peptic ulcer most commonly presents with pain or discomfort in the upper abdomen (epigastrium). Sometimes the pain can be localized in the upper third of the right and left hypochondrium. Occasionally, pain can radiate to the back, but this is a rare and not very characteristic symptom. If left untreated, symptoms may appear for several weeks and then be replaced by an asymptomatic period, sometimes lasting several months.
Most often, the pain of a duodenal ulcer appears 2 to 5 hours after eating, and also at night (usually between 11 pm and 2 am).
With a stomach ulcer, pain usually occurs during meals. There may be other symptoms: the appearance of belching after eating, the early appearance of a feeling of satiety, heaviness in the epigastrium, intolerance to fatty foods, nausea, and sometimes vomiting.
The asymptomatic course is most typical for the elderly and patients who have been receiving NSAID painkillers for a long time (the most commonly used group of painkillers).
Complications of peptic ulcer develop regardless of whether it is asymptomatic or accompanied by typical complaints.
Main complications:
- Bleeding from a peptic ulcer - is manifested by nausea, vomiting of the color of coffee grounds or chalky (black feces, its staining occurs due to contact of blood with hydrochloric acid in the stomach).
- Pyloric stenosis (reduction of the lumen of the outlet between the stomach and duodenum due to scarring of ulcers) - is manifested by a feeling of early satiety, fullness after a small amount of food, nausea, sometimes vomiting, weight loss.
- Ulcer penetration - penetration, “germination” of an ulcer into other organs (large intestine loops, pancreas, abdominal vessels, etc.). Most often it is manifested by a change in the nature of complaints, an increase in pain, the appearance of an unusual irradiation of pain (for example, in the back). New symptoms depend on which organ was involved. At the same time, antacids (medicines used to relieve pain and get rid of heartburn) stop helping or reduce pain slightly.
- Perforation - an ulcer completely eats through the wall, and the contents of the stomach or duodenum begin to enter the abdominal cavity. It is characterized by the appearance of a sharp, dagger pain in the epigastrium, and then pain throughout the abdomen.
- Malignancy - the degeneration of an ulcer into a malignant tumor - cancer.
Figures and facts
- About 70% of peptic ulcer cases are asymptomatic and are detected with the development of complications - bleeding, perforation or ulcer penetration. Between 43% and 87% of those hospitalized with bleeding ulcers did not report any pain or digestive problems before.
- Up to 60% of ulcers heal on their own.
- Epigastric pain during or after eating is the most common symptom of peptic ulcer disease. Approximately 80% of patients with confirmed peptic ulcer noted epigastric pain associated with eating.
- Helicobacter pylori infection is the most common chronic infection in humans. It infects up to 50% of the population. In some developing countries, this figure reaches 94%.
- Between 5% and 30% of ulcers may recur in the first year after treatment.
When to See a Doctor
- The appearance of black feces. However, you should be aware that the use of certain foods and drugs also causes darkening of the stool, which is in no way associated with bleeding: prunes, pomegranate and black currants, blueberries and dark grapes, liver, beets. Iron preparations, bismuth preparations, activated charcoal and some other drugs also stain the feces dark.
- Pain in the abdomen during or after eating.
- Sudden sharp dagger pain in the epigastrium, then spreading to the entire abdomen, requires an ambulance call and urgent medical attention. In general, the appearance of acute pain in any part of the abdomen is a reason to urgently seek medical help.
- Unexplained weight loss is a formidable symptom, not necessarily associated with peptic ulcer disease. It can be caused by another, no less serious condition.
- The appearance of belching, nausea, feeling of early satiety during meals.
- Vomiting with an admixture of blood also requires an immediate call to an ambulance.
Diagnosis of the disease
For peptic ulcer, a change in laboratory blood parameters is uncharacteristic. Sometimes a decrease in the number of red blood cells and hemoglobin in the general blood test can be determined - anemia. It is also possible to detect occult blood in the stool.
The most accurate method for diagnosing peptic ulcer is EGDS (esophagogastroduodenoscopy) - examination of the esophagus, stomach, duodenum using a special tube with a camera.
In some cases, during the EGDS, a piece of the ulcer (biopsy) is taken to exclude its malignancy - degeneration into a cancerous tumor.
Sometimes a barium x-ray is done. The patient drinks a mug of a special contrast agent, and then a series of images is taken to monitor the passage of the contrast agent through the gastrointestinal tract and look for defects in the organ wall.
Also, all patients with peptic ulcer disease are mandatory examined for the presence of the Helicobacter pylori bacterium, which lives in the pyloric section of the stomach and contributes to the destruction of the mucosa and the formation of an ulcer. For the diagnosis of Helicobacter pylori infection, different methods are used: the determination of DNA in feces, the respiratory urease test, the determination of antibodies in the blood, the determination of DNA in a biopsy sample taken during gastroscopy.
In the case of multiple ulcers, an additional examination is performed to rule out other conditions that may be the cause (for example, gastrinoma - a tumor of the pancreas - stimulates the secretion of gastric juice).
Treatment of the disease
Treatment of uncomplicated peptic ulcer disease is conservative, that is, without surgical intervention. Medicines are used that reduce the acidity of gastric juice and reduce the amount of hydrochloric acid. The course of treatment can last up to 12 weeks. You should not interrupt the course of treatment yourself, even if all symptoms have disappeared.
In some cases, for example, if the peptic ulcer is caused by taking NSAIDs and it is necessary to continue taking them, drugs that reduce secretion may be prescribed indefinitely.
If a Helicobacter pylori infection is found that accompanies an ulcer, treatment with antibiotics is prescribed, usually two at the same time. The period of admission is usually two weeks with mandatory control four weeks after the end of treatment - either a urease breath test or a stool test is used for this. The determination of antibodies in the blood is indicative and meaningless for the control of cure.
In addition to medication, patients are advised to limit their intake of alcohol, carbonated drinks, and stop smoking. The doctor also gives recommendations on nutrition during the period of exacerbation and after recovery.
Emergency surgical treatment is indicated for patients with ulcer perforation, with penetration, with gastrointestinal bleeding.
With frequently recurring episodes of peptic ulcer even against the background of drug treatment, or with malignancy of the ulcer, planned surgical treatment is indicated.
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