Peptic ulcer(PU) is a chronic recurrent disease, which is based on inflammation of the mucous membrane of the stomach and duodenum and the formation of ulcers, in most cases caused by Helicobacter pyloricus. Mostly young men (25-40 years old) suffer from peptic ulcer disease; women suffer from it less often. The male to female ratio is 4:1.
YaB classification:
By localization:
· Stomach ulcer.
· Ulcer of the 12th intestine.
By flow phase:
· Exacerbations.
· Incomplete remission (faded exacerbation).
· Remission.
According to the morphological course:
· Acute ulcer.
· The ulcer is active.
· The ulcer is cicatricial.
· Chronic ulcer.
· Post-ulcer deformity (scar).
· Duodenitis.
· Duodenogastric reflux.
With the flow:
· Latent.
· Light.
· Medium-heavy.
· Heavy.
By complication:
· Bleeding.
· Perforation (perforation).
· Penetration (into other organs).
· Pyloric stenosis (narrowing).
· Malignancy (malignant degeneration).
· Reactive hepatitis.
· Reactive pancreatitis (inflammation of the pancreas).
Etiology: The causes of ulcers have not yet been fully elucidated. A number of factors that contribute to the development of the disease are taken into account:
Psycho-emotional stress;
Closed injury skulls;
Dietary disorders;
Drinking alcohol and smoking;
Effect of drugs (salicylates);
Infection of the stomach with Helicobacter pylori and candida;
Chronic disorder of duodenal patency.
Contributing factors are:
Presence of blood group I.
Congenital alpha-trypsin deficiency and hyperproduction of hydrochloric acid.
Pathogenesis: During the development of the disease, several pathogenetic levels are distinguished.
Level 1 – under the influence of etiological factors, disintegration (disruption) of the processes of excitation and inhibition occurs in the cerebral cortex.
Level 2 – dysfunction of the hypothalamus occurs.
Level 3 - dysfunction of the autonomic nervous system in the case of increased tone of the parasympathetic nervous system - gastric peristalsis increases, the secretion of hydrochloric acid increases, the dystrophic process of the 12-gut develops, the secretion of enzymes decreases in it and conditions for development arise ulcers of the 12th intestine . When the tone of the sympathetic nervous system is predominant, the tone of the stomach decreases, evacuation slows down, the production of hydrochloric acid and gastrin increases, and the contents of the 12-piece intestine are thrown into the stomach and conditions are created for the development of stomach ulcers .
Level 4 – dysfunction of the endocrine system occurs, which is manifested in an increase in the activity of hormones that suppress or inhibit gastric secretion.
Level 5 – as a result of the preponderance of aggression factors over protective factors, they develop ulcers of the stomach and 12 intestines .
Pathological anatomy:
There may be one or several ulcers. There are simple and callous ulcers.
Simple ulcer - has thickening of edges and scars, inflammatory changes around.
Callous ulcer – has soft edges without pronounced cicatricial changes.
Ulcer - more often it has a round shape, its dimensions can vary, in the stomach it is usually 0.5-2 cm, in the 12-piece intestine - from a few millimeters to 1 cm. Ulcers of the 12th intestine occur 7 times more often than gastric ulcers. An ulcer differs from erosion in that it affects not only the mucous and submucosal layers, but also the deeper layers of the stomach wall. It can penetrate neighboring organs, and then it is called - penetration. If the ulcer opens directly into the abdominal cavity, it is called - perforated or perforated. The bottom of the ulcer is made of necrotic or granulation tissue; during the period of scarring, its surface is covered with a film consisting of necrotic tissue, leukocytes and erythrocytes. When the ulcer heals, a scar is formed. With multiple ulcers, scars deform the stomach and colon, which leads to the development of stenosis (narrowing) of the pylorus. If there is a large blood vessel at the bottom of the ulcer, damage to its wall leads to bleeding.
Clinic: Main symptom pain – localized in the epigastric or pyloroduodenal region. The pain is characterized by frequency, it is associated with food intake, and can occur 30 minutes -1 hour after eating ( early pain) or 2-3 hours after eating ( late pain), there may be night pain, which is intense and disappears after eating. Rich, coarse, salty foods cause especially pronounced pain, while liquid and mushy foods are easily tolerated. The pain is clearly localized. During the period of exacerbation of the disease, pain is sharply expressed, patients take a comfortable position (legs brought to the stomach). The earliest symptom of peptic ulcer disease is heartburn – its mechanism is associated with the reflux of gastric contents into the esophagus due to weakness of the cardiac sphincter. Belching, nausea, vomiting – associated with pain syndromes of increasing pyloric stenosis. Constipation- due to spasm of the large intestine and due to food (poor in fiber), appetite is usually preserved. ANS disorders – cyanosis of the extremities and wetness of the palms, increased sweating, the tongue is coated with a whitish coating at the root, the abdomen is bloated, and upon palpation there is pain depending on the location.
Course of the disease: In mild form: relapses 1-3 years. In case of moderate severity: relapses 2 times a year, may become complicated. In severe cases: relapses more than 2 times a year, frequent complications.
Complications:
· Bleeding – occurs as a result of a violation of the integrity of the vessels at the bottom of the ulcer. Symptoms depend on the amount of blood loss. With massive bleeding, signs of vascular insufficiency (pallor skin, dizziness, fainting, decreased blood pressure, tachycardia, vomiting in the form of coffee grounds, melena - this late symptom bleeding).
· Ulcer perforation – maybe into the free abdominal cavity, maybe covered or behind the abdominal tissue. It usually develops acutely and is characterized by two main symptoms: sharp “dagger” pain and “board-like” tension in the muscles of the anterior abdominal wall with the subsequent development of other symptoms of peritonitis. Positive Shchetkin-Blumberg symptom (sharp pain when pressed and suddenly released). Flatulence gradually increases, stool retention, and gases do not pass away. Facial features become sharper, the tongue is dry and covered with a white coating. Patients lie on their sides motionless with their legs brought up to their stomach. Characteristic symptom- disappearance of “baked dullness” during percussion, due to the entry of gas into the abdominal cavity under the diaphragm and an increase in body temperature.
· Penetration – Most often, ulcers of the 12th intestine penetrate into the omentum, pancreas, liver, colon, and mesentery. Clinic: the picture of the peptic ulcer changes, the pain becomes persistent, constant, signs of involvement of the pancreas, liver, and biliary tract in the pathological process (jaundice, girdle pain, etc.) are added.
· Pyloric stenosis – is the result of scarring of an ulcer, which is located in the pyloric part of the stomach; as a result of stenosis, an obstacle arises for the passage of food from the stomach into the 12-gut. Clinic: feeling of expansion in the epigastric region, vomiting containing remnants of food eaten the day before, weight loss, belching with a smell rotten egg. Upon examination, peristalsis is visible in the epigastric region. On palpation of the abdomen there is bloating. X-ray examination reveals a slowdown in evacuation contrast agent from the stomach and expansion of the stomach.
· Ulcer malignancy – the pain becomes constant and is not associated with food intake. The patient loses appetite, loses weight, vomits more frequently, and body temperature rises to low-grade fever. Diagnostics: FGDS (biopsy), signs of cell degeneration.
FGDS (fibrogastroduodenoscopy) - an ulcerative defect of the corresponding localization is observed. During the process of scarring, a regenerating epithelium is determined at the site of the ulcer, and a large scar is subsequently formed.
X-ray of the stomach - the symptom of a “niche” is determined - this is an additional shadow to the shadow of the stomach.
Laboratory research – UAC, OAM, feces for occult blood.
Instrumental research – Ultrasound examination of the abdominal organs (pancreas, liver, gallbladder).
Treatment: There are 2 types.
1. Conservative treatment - for uncomplicated peptic ulcer disease. In the hospital when a peptic ulcer is detected and exacerbation for 7-10 days. Further - ambulatory treatment. Restricted mode motor activity. Diet No. 1a in the first week, and then Diet No. 1. Small meals with limited salt and spices.
Drug treatment:
Antacids ( low acidity) almagel, phosphalugel, de-nol, vikalin;
Cholinomimetics (drugs that interfere with the flow of nerve impulses from nerve centers to the stomach) - atropine, platifilin, metacin.
Drugs that suppress the secretion of hydrochloric acid (cinitidine); promotes epithelization of ulcers (gastrocypin);
Drugs that normalize gastric motility (cerucal, papaverine, no-shpa).
Physiotherapeutic treatment: paraffin treatment, electrophoresis, etc.
A drug that heals ulcers is solcoseryl.
2. Surgical treatment – in case of complications (bleeding, perforation, penetration, malignancy).
· In case of complications, special measures are taken:
1. In case of bleeding, ingestion of food, water and medications is prohibited. An ice pack is applied to the abdomen, 10% calcium chloride solution 10 ml, or 1% vikasol solution 1 ml is injected intravenously; delivered to the surgical department
2. In case of perforation, pain relief is not performed until examined by a surgeon. For perforation with a decrease in blood pressure - cordiamine 2 ml or mesaton 1% -1 ml. Hospitalization in the surgical department.
3. In case of penetration - hospitalization in the surgical department.
4. In case of malignancy – oncologist consultation.
After a period of exacerbation it is indicated Spa treatment using slightly alkaline mineral waters, mud therapy, diet.
Prevention: primary and secondary.
Primary – balanced diet from childhood, organization of work and rest, fight against smoking and alcoholism, creation of a favorable psychological climate in the family, at work, physical education, early diagnosis, treatment of pre-ulcerative condition (chronic gastritis).
Secondary – preventing exacerbation of the disease. Two types of therapy: 1) Continuous (maintenance) therapy. For several months or years with an antisecretory drug (ranitidine, famotidine, quamatel). 2) Therapy on demand - when symptoms characteristic of an exacerbation of peptic ulcer disease appear. Dispensary observation is carried out for 5 years, after the next exacerbation. "D" observation includes preventive treatment in spring and autumn. Full examination.
CHRONIC CHOLECYSTITIS
This chronic inflammation gallbladder, combined with motor-tonic disorders (dyskinesias) of the biliary tract and changes in the physicochemical properties and biochemical composition of bile (dyscholia). The duration of the disease is more than 6 months; women get sick 3-4 times more often than men.
Etiology:
1. Bacterial infection– the source of infection can be diseases of the nasopharynx, oral cavity, reproductive system, and infectious diseases of the intestines. The infection enters the gallbladder through hematogenous and lymphogenous routes. Pathogens: Escherichia coli, enterococci, streptococci, staphylococci.
3. Duodenal reflux (reverse reflux).
4. Allergies – food and bacterial allergens can cause the development of chronic cholecystitis.
5. Chronic inflammatory disease of the digestive system - chronic hepatitis, liver cirrhosis, enterocolitis, pancreatitis are often complicated by chronic cholecystitis.
6. Acute cholecystitis.
Predisposing factors: bile stagnation, obesity, pregnancy, diabetes mellitus, psycho-emotional stress, eating disorders, abuse or insufficient dietary fiber (vegetables and fruits). Congenital anomalies of the biliary tract, intestinal dysbiosis.
Pathogenesis: It is important that the infection penetrates the wall of the gallbladder, which will lead to inflammation and the development of chronic cholecystitis, contributes to the development of biliary dyskinesia and bile stagnation.
Classification:
2. According to clinical factors - divided by:
1. Chronicle acalculous cholecystitis (not calculous).
2. Chronicle calculous cholecystitis.
3. By type of dyskinesia - hyperkinetic (increased motor function), hypokinetic (decreased motor function).
4. According to the phase of the disease - exacerbation phase, subsiding inflammation phase, remission phase.
5. Complications - reactive pancreatitis, reactive hepatitis, chronic duodenitis.
Clinic:
1. Pain - This is the most constant and characteristic sign. The pain is localized in the right hypochondrium and is associated with eating large amounts of fatty and fried foods, as well as spicy, hot or cold foods or alcohol. Pain can occur after physical activity or psycho-emotional stress. Chronic cholecystitis accompanied by biliary dyskinesia. With biliary dyskinesia, the pain is constant, aching in nature. With the hyperkinetic type, the pain is paroxysmal in nature.
2. Dyspeptic syndrome – nausea, vomiting, belching, feeling of bitterness in the mouth, diarrhea, constipation.
3. Temperature increased - during exacerbations of chronic cholecystitis.
4. Psycho-emotional disorders – weakness, fatigue, irritability.
5. Skin – sometimes the sclera and skin are subicteric (slightly noticeable color).
6. Palpation of the abdomen - Local pain is determined at the point of the gallbladder.
Kera point – the intersection of the rectus abdominis muscle and the right lower rib.
Ortner's sign - When you tap the edge of your palm on the right costal arch, pain appears.
Mussi-Georgievsky point – pain on palpation between the legs of the sternocleidomastoid muscle on the right (phrenicus symptom).
Diagnostics: Duodenal sounding– in the 2nd portion there is a large number of leukocytes, this portion is cloudy with mucus.
Ultrasound of the gallbladder– detect thickening and compaction of the gallbladder wall, signs of dyskinesia.
UAC– moderate leukocytosis, increased ESR.
Treatment: Hospitalization during an exacerbation. During an exacerbation period, it is prescribed for 7-10 days. bed rest, fasting diet on the 1st-2nd day. As the exacerbation subsides, diet No. 5 is administered to relieve pain. atropine solution, no-shpa, analgin.
At calculous cholecystitis– for severe pain, narcotic analgesics (promedol).
Antibacterial therapy: doxycillin, erythromycin, biseptol, kefzol.
Detoxification therapy: rosehip decoction, mineral water, intravenous hemodez, glucose 5%, saline. rr.
Choleretic drugs: allohol, festal, can be of plant origin - corn silk, holosas, holagol.
Drugs that stimulate bile secretion: xylitol, sorbitol, magnesium sulfate.
Physiotherapeutic treatment: dubazh.
Spa treatment.
Prevention: Primary – prevention of the onset of the disease, diet, avoiding alcohol abuse, treating chronic foci of infection in the body.
Secondary – “D” accounting, prevention of exacerbations.
CHRONIC ENTERITIS
Chronic enteritis - uh it is a polyetiological disease small intestine. Characterized by the development of inflammatory-dystrophic processes, impaired absorption and digestive function small intestine.
Etiology:
1. Past acute intestinal infections, salmonellosis, dysentery, staphylococcal infections.
2. Nutritional factors: nutritional disorders - dry food, overeating, predominance of carbohydrate-free foods without vitamins, abuse of spices and spicy foods.
3. Allergies - the presence of food allergies, the most common food allergens are cow's milk, chocolate, fish eggs.
4. The effect of toxic and medicinal substances is the interaction of salts heavy metals, long-term use of certain medications (glucocorticoids, cytostatics, some antibiotics).
5. Ionizing radiation- exposure to ionizing radiation.
6. Gastrointestinal diseases - peptic ulcer of the stomach or 12p of the intestine, chronic hepatitis, cholecystitis, cirrhosis of the liver, lead to the development of secondary enteritis.
Clinic: The main symptom is stool upset. Diarrhea is typical up to 4-20 times a day, the stool is liquid or mushy, light yellow in color, contains pieces of undigested food, muscle fibers, and fat. Before defecation, there is pain in the abdomen, around the navel. Flatulence. Objectively: the tongue is coated with a grayish-white coating, bloating, rumbling upon palpation of the small intestine or retraction of the abdomen (with diarrhea).
Diagnostics:
Biochemical blood test (BAC)- dysproteinemia (violation of the ratio of proteins in the blood).
Coprogram- there are pieces of undigested food, mucus, and fat in the stool.
Bacterioscopic examination of stool- dysbacteriosis.
Treatment: Therapeutic nutrition - diet No. 4 (frequent meals 5-6 times a day with the exception of spicy, fried, spices, alcohol, everything is steamed and pureed).
Antibacterial drugs taking into account sensitivity to microorganisms (biseptol, furazolidone, metronidazole, etc.).
Astringent and enveloping drugs (bismuth nitrate).
Adsorbents (activated carbon).
Drugs that improve absorption in the intestine (acedin-pepsin).
Correction of protein metabolism disorders: intravenous administration of protein preparations (casein hydrolyzate, polyamine).
Correction of vitamin deficiency: vitamins B1, B6, C and PP.
Physiotherapy, spa treatment.
Prevention: is the same.
Stomach ulcer And ulcer duodenum as independent diseases, they usually develop as a result of an imbalance between the activity of gastric juice and the protective capabilities of the mucous membrane.
Stomach ulcer- one of the most common diseases of the digestive system. More than 50% of patients in the gastroenterology department in a city hospital are patients with stomach ulcer or duodenal ulcer.
Ulcers come in different sizes and have rounded or slit-shaped, can be superficial or deep, penetrating to the muscular wall of the stomach and deeper. Healing of ulcers occurs by overgrowing with connective tissue with the formation of a scar.
The course of peptic ulcer disease is very diverse: it can drag on for years with exacerbations ranging from once every few years to annually after a number of months. As a rule, it occurs in young and middle age, rarely debuting after 60 years.
"Senile" stomach ulcers are prone to bleeding, with long periods of scarring and relapses, usually large in size (more than 2 cm). More often they are not manifestations peptic ulcer, and secondary in chronic lung diseases, coronary heart disease or obliterating atherosclerosis large vessels of the abdominal cavity as a result of circulatory disorders in the gastric mucosa.
Symptoms of a stomach ulcer
Detailed signs of peptic ulcer disease depend on the location ulcerative defect.
Subcardial gastric ulcer
- more often in people over 50 years of age. Pain occurs after eating almost immediately near the xiphoid process (where the sternum ends), sometimes radiating to the heart area, so an electrocardiogram is required. It is desirable to combine two types of examination - X-ray and gastroscopy due to the difficulty of examining this area of the stomach due to its anatomical location.
It is with this localization that the ulcer is often complicated by bleeding, penetration (penetration of a stomach or duodenal ulcer into adjacent organs, penetration of ulcers is observed in 10-15% of patients with peptic ulcer, more often in men aged 40 years with a long history of ulcers), resistance to scarring, i.e. difficult to treat with medication. If the ulcerative defect persists within 3 months, then surgical intervention is resorted to.
Ulcer of the angle and body of the stomach -- the most common location for gastric ulcers. Pain occurs 10-30 minutes after eating in the epigastric region, sometimes radiating to the back, left half of the chest, behind the sternum, in left hypochondrium. Heartburn, belching, nausea are common, and sometimes patients themselves induce vomiting to feel better. Question about surgical treatment placed when the ulcer recurs 2 or more times a year, complications - perforation, massive bleeding, signs of malignancy - degeneration of the ulcer into cancer.
Ulcers of the antrum of the stomach
-- predominate in at a young age. I am concerned about “hunger” pains, i.e. 2-3 hours after eating, heartburn, sometimes vomiting sour contents. The course is favorable, one of the shortest terms for scarring of the ulcer.
Pyloric ulcer - the narrowest part of the stomach when it passes into duodenum. Sharp pain in the epigastric region at any time of the day, sometimes constant, can be accompanied by persistent vomiting, which leads to weight loss with simultaneous restriction in food. Complications: bleeding, penetration, perforation, narrowing of the pyloric canal itself with disruption of the passage of food from the stomach to duodenum, which determines the surgical method of treatment.
Duodenal ulcers are most often localized in its bulb (90% of cases). Accompanied by heartburn, “hunger” pain 1-3 hours after eating or at night, usually on the right and above the navel, less often in the right hypochondrium. At extra-bulb ulcers of the duodenum pain appears on an empty stomach and subsides after eating after 20-30 minutes.
Combined ulcers of the stomach and duodenum account for approximately 20% of all lesions. Moreover, patients first develop an ulcerative defect duodenum, and many years later he joins stomach ulcer, which dominates in the future.
Multiple ulcers of the stomach and duodenum -- more often the consequences of taking medications of an ulcerogenic nature (i.e., causing ulcers), stressful situations.
It must be remembered that taking various medications (aspirin, steroid hormones, anti-inflammatory drugs such as voltaren, methindol, ortofen) often causes the formation of ulcers.
Complications of gastric ulcer
Stomach bleeding
Bleeding complicates the course of the disease, regardless of its duration. Sometimes it is the first manifestation of the so-called “dumb”, i.e. asymptomatic ulcers.
At heavy bleeding vomiting with dark blood or “coffee grounds” appears, pale skin, dizziness, even fainting of varying duration. Over the next few days, low blood pressure and loose black stools are usually observed. Hemoglobin may remain within normal limits. Massive bleeding can only be stopped in a hospital setting; very rarely it is so colossal that death occurs within a few minutes.
Not strong stomach bleeding can stop on their own, the state of health is not disturbed, its only sign is the color of the stool black.
Perforation or perforation of an ulcer is a violation of the integrity of the wall of the stomach or duodenum. As a result, the contents from the cavity of these organs leak into the abdominal cavity and cause peritonitis. It often develops after drinking alcohol, filling the stomach with food, excessive physical stress, or injury. Sometimes ulcer perforation is the first manifestation of peptic ulcer disease, especially at a young age.
The pain is very strong, sharp, “dagger-like”, accompanied by signs of collapse: cold sticky sweat, pale skin, cold extremities, thirst and dry mouth. Vomiting is rare. Arterial pressure goes down. After a few hours, flatulence develops - bloating of the abdomen due to the failure of gases to pass away. After 2-5 hours, an imaginary improvement in well-being occurs: pain subsides, tense abdominal muscles relax. The appearance of well-being can last up to a day. During this time, the patient develops peritonitis and his condition begins to deteriorate rapidly.
You should consult a doctor in the first hours of the disease. Perforation of an ulcer into the abdominal cavity without surgical assistance ends within 3-4 days from the moment of its occurrence with the death of the patient due to diffuse purulent peritonitis.
Penetration of stomach ulcer
Penetration of an ulcer is the same perforation of an ulcer, but not into the abdominal cavity, but into the nearby pancreas, omentum, intestinal loops, etc., when, as a result of inflammation, fusion of the wall of the stomach or duodenum with surrounding organs has occurred. More common in men.
Characteristic symptoms: nocturnal pain attacks in the epigastric region, often the pain radiates to the back. Despite the most vigorous therapy, the pain does not stop. Treatment is surgical.
Narrowing (stenosis) of the pylorus
Obstruction of the pyloric part of the stomach, or pyloric stenosis. It occurs as a result of scarring of an ulcer located in the pyloric canal or the initial part of the duodenum. Deformation and narrowing of the lumen after scarring of the ulcer lead to difficulty or complete cessation of evacuation of food from the stomach.
A slight degree of narrowing of the pylorus is manifested by episodes of vomiting of eaten food, heaviness in the stomach for several hours after eating. As stenosis progresses, some food is constantly retained in the stomach cavity and overstretched, a putrid odor appears from the mouth, and patients complain of gurgling in the stomach (the so-called “splashing symptom”). Over time, all types of metabolism (fats, proteins, carbohydrates, salts) are disrupted, which leads to exhaustion.
Subphrenic abscess
A rare complication of peptic ulcer disease, difficult to diagnose. It is an accumulation of pus between the diaphragm and the organs adjacent to it. Develops as a result of perforation of an ulcer or the spread of infection during an exacerbation of peptic ulcer disease. lymphatic system stomach and duodenum. The main symptoms are pain in the right hypochondrium and above, often radiating to the right shoulder, elevated temperature. There is lethargy, general weakness, and loss of appetite. The number of leukocytes in the blood increases. If the abscess is not opened and the pus is not evacuated, then after 20-30 days it develops sepsis.
Examination methods for stomach ulcers
Explore gastric acidity pH-metry methods and determination of the amount of hydrochloric acid in portions of gastric contents, taken by the probe. More often with peptic ulcers, acidity is increased.
Stool examination for occult blood allows you to identify bleeding and requires special preparation: do not eat meat, fish and products made from them for three days, if your gums are bleeding, do not brush your teeth, do not take iron-containing medications.
At x-ray examination with an open ulcer, the symptom of a “niche” or “depot” of the contrast agent is determined, as well as violations contractile function stomach in the form of pyloric spasm, disturbances of gastric tone and peristalsis.
Gastroscopy as a more accurate research method confirms the presence of an ulcer, its size, depth, helps to distinguish an ulcer from cancer, its degeneration into cancer, i.e. malignancy.
Treatment of stomach ulcers
1. Painkillers for stomach ulcers
In case of severe pain syndrome, drugs from the group are prescribed anticholinergics ( atropine, platiphylline, metacin in tablets and injections) or antispasmodics ( no-shpa, papaverine). It should be remembered that anticholinergics are contraindicated in old age with glaucoma, prostate adenoma.
2. Drugs that reduce gastric acidity
Drugs antacid action, i.e. neutralizing hydrochloric acid produced by the gastric mucosa, and antisecretory action, i.e. suppressing the secretion of hydrochloric acid, indicated for duodenal ulcer in almost all cases, and also stomach at normal and increased acidity.
Soluble antacids, For example, soda And magnesium oxide , give a quick effect of neutralizing hydrochloric acid, but short-lived, moreover long-term use soda leads to disruption of electrolyte balance in the body.
From insoluble antacids(they are not absorbed into the blood, but only envelop the gastric mucosa) the most popular Almagel, phosphalugel, which take 1-2 dessert spoons 1-1.5 hours after meals. Their long-term use is undesirable chronic renal failure.
Among the means suppresses the secretion of hydrochloric acid, recently M-anticholinergic has been widely used gastrocepin 1 tab. 2 times a day, as well as a group histamine H2 receptor blockers.
Assign last group medications should be taken after determining the acidity of gastric juice during stimulation histamine.
- The first generation of the group of H2 receptor blockers includes cimetidine (belomet, tagomet) taken during exacerbation, 1 tablet. 3 times after meals and at night.
- To the second generation - drugs ranitidine (Zantac, Ranisan) with taking 1 tablet. 2 times a day or 2 tablets. for the night.
- Third generation -- famotidine derivatives , 1-2 tab. once a day. Doses are prescribed individually by the attending physician.
After scarring of the ulcer with high or normal acidity, to prevent exacerbation, one of the drugs from this group is recommended in maintenance doses at night for several months to a year.
3. Antibiotics against Helicobacter pylori
One of the reasons for the development of gastric and duodenal ulcers is considered bacteria living in the pylorus of the stomach Helicobacter pylori(pronounced Helicobacter pylori, or Helicobacter pylori).
Medicines for Helicobacter pylori constitutes a group of numerous medications that suppress bacteria that are found on the gastric mucosa and in some cases contribute to the formation of ulcers. Treatment is carried out in courses of up to 2 weeks trichopolum, oxacillin, furagin , each drug individually or in combination, de-nolom course up to 4 weeks.
Bismuth Afternoon snack: milk.
Dinner: pureed buckwheat porridge with milk, soft-boiled egg, tea with milk.
At night: milk.
Sample diet menu No. 1 (mashed)
1st breakfast: soft-boiled egg, pureed rice porridge with milk, tea with milk.
2nd breakfast: baked apple with sugar.
Lunch: pureed oat milk soup, steamed meatballs with carrot puree, fruit mousse.
Afternoon snack: rose hip decoction, crackers.
Dinner: boiled fish, baked in milk sauce, mashed potatoes, tea with milk.
At night: milk.
Approximate menu of diet No. 1 (unprocessed)
1st breakfast: soft-boiled egg, crumbly buckwheat porridge, tea with milk.
2nd breakfast: fresh non-sour cottage cheese, rosehip decoction.
Lunch: vegetarian potato soup, boiled meat, baked with bechamel, boiled carrots, boiled dried fruit compote.
Afternoon snack: decoction of wheat bran with sugar and crackers.
Dinner: boiled fish, baked with milk sauce, carrot-apple roll, tea with milk.
At night: milk.
Meals are fractional, frequent, in small portions 5-6 times a day. Meat and fish broths, any canned food, smoked meats, marinades and pickles, carbonated fruit waters, coffee, cocoa and strong tea are excluded from food. confectionery, soft bread and black. Soups are better pureed vegetarian or dairy. Boiled meat and fish in the form of steam cutlets and meatballs, minced meat.
After 1-2 weeks, with a decrease in pain and the beginning of scarring of the ulcer, preserved teeth, meat and fish can be consumed in pieces, but well-cooked. Other dishes recommended include soft-boiled eggs, mashed stewed vegetables, sweet berry jelly, baked or grated raw sweet apples, stale white bread or dry biscuits, pureed liquid porridge, milk, cream, butter.
After scarring of the ulcer, even if the patient feels well, he must continue to follow a diet, eat 4-5 times a day, and do not consume canned food, smoked meats, spices, marinades and pickles. Soups should be prepared using weak meat and fish broths from low-fat varieties. Avoid smoking and alcohol completely.
Gastrointestinal diseases rank first among the most common diseases of modern city dwellers. The reason for this is stress, irregular eating, poor diet, as well as a love of “junk” food. Ulcers of the stomach and duodenum are ranked immediately after in prevalence. Both diseases will not allow themselves to be missed - each causes excruciating pain, which is unlikely to be tolerated. How to distinguish them from each other if the symptoms of ulcers are the same?
Peptic ulcer disease most often becomes a consequence regular stress. Psychological overload irritates the nervous system, this causes spasms in the muscles and blood vessels of the gastrointestinal tract, which leads to malnutrition of the stomach. Gastric juice and pepsin begin to corrode the gastrointestinal mucosa, resulting in the formation of wounds on it.
The disease can also be triggered by alcohol and smoking, frequent consumption of fatty, fried, spicy, salty and smoked foods, lack of vegetables and fruits, metabolic disorders, poisoning and infectious diseases.
Damage to the duodenum is four times more common than gastric ulcers. Most often it affects men.
Both diseases require immediate treatment, as they pose a deadly threat.- untreated ulcers can degenerate into cancerous tumors, or open, leading to heavy internal bleeding.
Ulcerative lesions of the stomach and duodenum differ in the location of the open lesions, but the main symptoms are exactly the same. These include “hunger pains,” aching and burning pains in the abdomen, vomiting (often with blood), disorders or constipation, the presence of blood during bowel movements, weight loss, constant dizziness, weakness and deterioration in performance.
However, there is also specific sign, which will reliably help distinguish a duodenal ulcer from a gastric ulcer. Localization of pain: in the first case, the pain will be reflected in the lower abdomen under the navel or in the lower back, in the second - in the upper abdomen.
In addition, with a stomach ulcer, pain appears immediately or an hour after eating, lasting for about 2-3 hours. And for disease of the duodenum severe pain they suffer not after eating, but before, which is especially noticeable in the morning.
Diagnosis and treatment
If you suspect a peptic ulcer, you must consult a doctor, undergo examinations and a course of treatment. Accurate diagnosis Only an ultrasound examination of the abdominal organs and esophagogastroduodenoscopy (examination of the digestive tract using a gastroscopic tube that transmits an image to a monitor) will help.
Peptic ulcer of the stomach and duodenum is a fairly common disease and has been known since ancient times, the clinical manifestations of which have been well studied. It has a chronic, wave-like course with periods of exacerbation and remission and people long time may not seek help in a timely manner at all, without experiencing any symptoms. And this can ultimately lead to severe consequences, as well as to numerous complications of peptic ulcer. Therefore, it is so important to identify a stomach ulcer in time and begin to treat it.
What is the most common complaint?
The main characteristic complaint is pain in the upper abdomen (between the costal arch and the navel) without clear localization. They can be sharp, cutting, quite intense, aching, pressing. The most interesting thing is that depending on the type of pain, the doctor can guess where the ulcer is located.
So, we can highlight the following types pain:
- early - appear immediately after eating and disappear after 2 hours as food is pushed into the duodenum. This nature of the symptom suggests that the ulcer is localized in the upper sections of the stomach (cardiac section).
- late - do not appear immediately after eating, but only 2 hours later. These symptoms indicate a problem in the lower parts of the stomach.
- hungry or nocturnal, arising on empty stomach and more often at night, passing some time after eating, they speak of an ulcer of the duodenum.
Knowing the nature of the pain, the doctor can guess the approximate location of the disease.
Although there are cases when the disease occurs without a painful attack and the problem is found only when complications arise (bleeding, perforation). This is possible when people, for example, take non-steroidal anti-inflammatory drugs such as diclofenac, aspirin, nimesulide, ketorolac, etc. for a long time. These drugs suppress pain receptors and the disease may be asymptomatic. Plus, this group of people includes older people, whose pain receptors acquire qualitative and quantitative changes with age and become less susceptible to pain. In such cases, the disease first manifests itself with its complications.
Along with pain, a symptom of the disease is attacks of nausea and vomiting with sour contents, which bring relief. This is why some patients induce vomiting on their own to relieve their suffering, which is not correct. Some patients complain of sour heartburn, which is associated with the reverse reflux of gastric contents into the esophagus due to weakness of the cardiac (lower, where it passes into the stomach) sphincter of the esophagus and reverse peristalsis.
When acute pain Some patients experience general weakness, decreased appetite, and patients may specifically refuse to eat, which leads to their exhaustion and a more severe course of the disease. If the pain is aching and not very pronounced, then the appetite may be normal or even increased.
50% of patients experience constipation, which is caused by impaired intestinal motility and food digestion processes.
How to distinguish a stomach ulcer from a duodenal ulcer?
Correctly distinguishing a stomach ulcer from a duodenal ulcer, as well as from another disease, will not help to analyze the symptoms, but only to conduct a full examination. A gastroenterologist specifically deals with this disease.
What is included in the examination plan?
1.Correct collected history diseases (history).
The slightest information about symptoms, complaints, and the presence of other ailments is asked. For example, here are some questions your doctor might ask you:
- When did the pain start?
- Where exactly does it hurt?
- What kind of pain is this - aching, sharp, burning?
- Does it hurt more or less after eating?
- What time of day does it hurt more often?
- Do you drink alcohol or smoke?
- Are you often stressed?
- Do you take anti-inflammatory drugs such as diclofenac, ketorolac, nimesulide, aspirin, etc.?
- Have you had any cases of peptic ulcers in your family?
- Have you ever had a fibrogastroduodenoscopy performed before? If so, when?
- Are you taking any medications?
- How did your illness begin?
- Do you have any other health problems?
After collecting your medical and life history, the doctor examines your body and Special attention pays attention to feeling (palpation) of the abdomen in order to detect the place where the symptoms will be the most painful.
Pain will be felt in the upper abdomen, between the costal arch and the navel (in the epigastrium), and in some cases, with the development of complications (perforation), the abdominal muscles will tense during palpation and, along with acute, dagger-like pain, it will be hard as a board. The tongue is also examined - it may be covered with a dirty gray coating.
3.Instrumental and laboratory methods examinations.
- General blood analysis.
Very important in diagnosis. Since the disease can be accompanied by bleeding, this will certainly affect the blood. In case of acute blood loss, the level of hemoglobin and red blood cells will quickly decrease in the analysis, in case chronic blood loss the analysis will note a gradual decrease in these indicators. There may be an increase in white blood cells with the development of inflammation of the mucous membrane.
- Fecal occult blood test.
Necessary when not obvious signs blood loss, but there is anemia. Helps in diagnosing anemia unknown etiology in order to identify hidden blood loss from the gastrointestinal tract.
And if with a stomach ulcer the patient may vomit with pure blood or vomit “the color of coffee grounds,” then with bleeding from an ulcer of the duodenum, the blood mostly enters the intestines and then the stool will be black.
- Fibrogastroduodenoscopy with biopsy.
This is the most informative diagnostic method. Today this is a completely common examination method. In this case, the doctor visually sees through a fiberscope (thin probe) the wall of the stomach and duodenum and the source of the disease, its location, from which a piece of the mucous membrane is taken for examination (biopsy). Using a biopsy, it is subsequently possible to distinguish an ulcer from an oncological process and identify Helicobacter pylori.
- Ultrasonography abdominal organs.
Helps identify another cause of pain, if any. In ultrasound, the doctor sees the liver, gallbladder, and pancreas. The stomach and duodenum cannot be clearly assessed.
DefinitionPeptic ulcer of the stomach and duodenum (PU) chronic illness gastrointestinal tract, the main manifestation of which is the formation of a fairly persistent ulcerative defect in the stomach and/or duodenum (duodenum).
IN international classification diseases (ICD-10) PUD corresponds to the name peptic ulcer disease (peptic ulcer disease). Peptic ulcer is a chronic and recurrent disease, prone to progression and involvement in the pathological process, except for the stomach, other digestive organs and the whole body. Inadequate treatment of ulcer leads to complications that threaten the patient’s life.
Epidemiology
Data regarding the prevalence of ulcer disease are varied, which is associated not only with regional and ethnic characteristics, but also with the diagnostic methods that are used.
According to E.M. Lukyanova et al (2000) the prevalence of PU in children in Ukraine is 0.4%. According to Yu.V. Belousova (2000) Approximately one in 1000 Ukrainian children suffers from BU. According to N.P. Shabalov (1999) the prevalence of PU in the Russian Federation is 3.4% among city residents and 1.9% in rural areas. In the structure of pathology of the digestive organs, the share of ulcers accounts for from 1.7 to 16%. The most common ulcer in children is duodenal disease in 82-87% of cases. The prevalence of gastric ulcer is 11-13%, combined gastric and duodenal ulcer is 4-6%.
Up to 6-10 years of age, PU affects boys and girls with approximately the same frequency, and after 10 years of age, boys get sick much more often. This fact is probably explained by the antiulcerogenic effect of estrogens. It should be emphasized that recently there has been a significant rejuvenation of ulcers. Often this disease is diagnosed at the age of 5-6 years.
Etiology and pathogenesis of ulcer
Over the past decades, we can observe fundamental changes in the point of view on the etiology and pathogenesis of ulcers. The “no acid, no ulcer” paradigm has been replaced by the belief “no Helicobacter pylori (HP) - no ulcer.” HP infection is associated with the development and recurrence of ulcer in more than 90% of cases, and chronic gastritis in 75-85% of cases. So according to (Borody, TJ, George, LL, Brandl, S, 1991) 95% duodenal ulcer in the United States, Europe and Australia are associated with HP. Despite the obvious maximalism of this point of view, it should still be considered proven that the vast majority of cases of ulcer are Helicobacter-associated. At the same time, it is indisputable that the ulcerogenicity of HP depends on a significant number of endogenous and exogenous risk factors. Considering high level infection of individual HP populations, one would expect significantly higher rates of PU incidence.
Thus, PU is a polyetiological, genetically and pathogenetically heterogeneous disease. Among the unfavorable premorbid factors that increase the risk of developing ulcers, heredity plays an important role. It is likely that it is not the disease itself that is inherited, but only the tendency to it. Without a certain hereditary tendency, it is difficult to imagine the occurrence of ulcers. Moreover, it should be noted that children with a burdened heredity are characterized by the so-called advance syndrome: that is, they, as a rule, begin to suffer from ulcers earlier than their parents and close relatives.
Genetic factors that contribute to the occurrence of ulcers:
- high level of maximum secretion of hydrochloric acid;
- an increase in the number of parietal cells and their increased sensitivity to gastrin;
- trypsin inhibitor deficiency;
- fucomucoprotein deficiency;
- increased pepsinogen content in blood serum and urine;
- excess gastrin production in response to stimulation;
- gastroduodenal dysmotility - prolonged retention of food in the stomach;
- increased pepsinogen formation;
- insufficiency of secretory Ig A and prostaglandin production;
- serological blood markers: reduce the resistance of the gastric mucosa blood group 0(1), positive Rh factor;
- hereditary histocompatibility markers for duodenal ulcer - HLA B5 (in the Ukrainian population - B15, in the Russian population - B14);
- congenital antitrypsin deficiency;
- absence of secretion of ABO system factors with gastric juice (the risk of ulcer increases 2.5 times).
In an extremely simplified form, we can present the pathological chain of occurrence of ulcers as follows:
1. In the presence of a number of the above risk factors, oral infection of HP occurs with food, during endoscopic manipulations, and probing. Penetrating through the protective layers of mucus, the bacterium attaches to epithelial cells, penetrates the crypt and glands of the stomach, destroys the protective layer of mucus and provides access for gastric juice to the tissues. The main virulence factor for HP is the enzyme urease, which breaks down urea present in the interstitial fluid and gastric secretions. The hydrolysis of urea produces carbon dioxide and ammonia. Ammonia damages the epithelium and alkalizes the environment around the HP, thereby creating optimal conditions for it. Alkalinization of the epithelium leads to increased secretion of gastrin, increased aggressive properties of gastric juice and damage to the gastric mucosa (GM).
The above-mentioned events upset the balance between protective factors that ensure the integrity of the coolant and activate ulcerogenic factors of aggression. The relationship between the factors of defense and aggression is illustrated by the well-known scheme of Neck.
According to C. Goodwin (1990), antral HP gastritis and gastric metaplasia in the duodenum are the first stage of development of duodenal ulcer.
The second stage is a violation of the negative mechanism feedback gastrin secretion, which leads to hypergastrinemia and hyperproduction of HCl.
The third stage is colonization of metaplastic epithelium, duodenitis, destruction of the protective layer of mucin, ulcer. The fourth stage is characterized by alternating processes of ulceration and reparative regeneration, which leads to the formation of new areas of metaplasia.
Symptomatic ulcers (US) should be distinguished from peptic ulcers.
- Stressful SAs in physical and mental trauma, burns, frostbite, traumatic brain injuries - Cushing ulcers, in burns - Curling ulcers, shock. Such symptomatic ulcers are characterized by perforation and bleeding without pain.
- Drug-induced ulcers of ulcers are a complication of therapy with NSAIDs, corticosteroids, cytostatics, and reserpine.
- Hepatogenic side effects in liver cirrhosis, chronic hepatitis with disturbances of blood flow in the portal vein.
- Pancreatogenic side effects due to impaired flow of bicarbonates into the intestine with a simultaneous increase in the release of kinins and gastrin.
- Endocrine SAEs in hyperparathyroidism (observed in 10%).
- Ulcers due to Zollinger-Ellison syndrome, a gastrin-producing tumor in the pancreas.
Classification
In domestic pediatric practice, the classification of ulcers according to A.V. Mazurins is most often used. et al. (1984), with additions on the etiological factor.
1. Clinical and endoscopic stage: acute ulcer; the beginning of epithelization; healing of an ulcerative defect of the mucous membrane with existing gastroduodenitis; clinical and endoscopic remission.2. Phases: exacerbation; incomplete clinical remission; clinical remission.
3. Localization: stomach; duodenum (bulb; bulbous section); dual localization.
4. Form: without complications; with complications (bleeding, penetration, perforation, pylorus stenosis, perivisceritis).
5. Functional characteristics: acidity of gastric contents and motility (increased, decreased, normal).
6. Etiological characteristics: Helicobacter pylori associated; Helicobacter pylori non-associated.
Clinical manifestations of ulcer
Clinical manifestations of ulcer in children depend on the age of the patient, the location of the ulcer, the stage of the disease, and the individual and gender characteristics of the child. It should be noted that some classic manifestations of ulcers, which are encountered in therapeutic practice, are almost never encountered by pediatricians. In general, the younger the child’s age, the more atypical the course of PU. Clinical manifestations of ulcer can be conditionally divided into clinical syndromes (Yu.V. Belousov).
1. Pain syndrome is the leading clinical syndrome. During an exacerbation of duodenal ulcer, patients complain of pain in the epigastrium and pyloroduodenal area. The nature of the pain is paroxysmal or aching. Pain occurs on an empty stomach or 2-3 hours after eating (so-called late pain). Almost half of patients complain of night pain.
We observed the classic Moyningan rhythm: “hunger > pain > food intake > relief” relatively rarely, mainly in older children. Irradiation of pain to the back or lower back is characteristic of complications from the pancreas. Palpation during the period of exacerbation of ulcer is dominated by pain in the epigastrium, where a positive Mendelian sign and local muscle tension are often detected. Slightly less frequently, these symptoms are found in the pyloroduodenal zone. Skin hyperesthesia in the Zakharyin-Ged zones is almost never detected in pediatric practice.
2. Dyspeptic syndrome includes heartburn (leading symptom), nausea, belching, sour, vomiting. To a certain extent, the tendency to constipation, which is often observed in patients with hyperacidity of gastric juice during the period of exacerbation of the disease, can also be attributed to the dyspeptic syndrome.
Pain and dyspeptic syndromes are seasonal (intensify in autumn and spring).
3. Syndrome of nonspecific intoxication and neurocirculatory dystonia: emotional lability, astheno-neurotic syndrome, autonomic disorders, headache, sleep disturbances, sweating. Appetite in children with ulcers, as a rule, does not suffer and even increases, which may be a manifestation of hyperacidity and the equivalent of hunger pains.
The above clinical manifestations are characteristic of the period of exacerbation of the disease. With the beginning of epithelization of the ulcerative defect, as a rule, the intensity of the pain decreases, which acquires a slightly intense aching character, and the irradiation of pain disappears. Vomiting gradually disappears and the intensity of heartburn decreases, although late pain persists for a long time. With superficial palpation, pain significantly decreases or disappears, although local muscle tension may persist. During the healing stage and during the period of remission of the ulcer, the child stops complaining of abdominal pain, but there is still moderate pain in the gastroduodenal zone with deep palpation.
In no case should we forget that there is often no correspondence between the subjective improvement in the patient’s well-being and the clinical and endoscopic picture.
It should be emphasized that the absence of pain or dyspeptic syndrome does not indicate healing of the ulcer - endoscopic control is required!!!
In clinical practice, we have observed absolutely “silent” ulcerative lesions of the digestive tract.
Clinical features of ulcers of atypical localizations
Stomach ulcer
Girls are more likely to suffer from gastric ulcers; the heredity factor is less pronounced. The pain is usually aching, early (especially when the ulcer is localized in the antrum of the stomach), and is localized under the xiphoid process. Night pain is rare. Localization of palpation pain and local muscle tension mainly in the upper half of the abdomen, behind the sternum. Dyspeptic symptoms are typical: nausea, belching of air, heartburn, bitterness in the mouth. Decreased appetite up to anorexia. Flatulence. Seasonality is less pronounced than with duodenal ulcer.
Peptic ulcer of the duodenum (postbulbar localization)
Characterized by a severe, relapsing course, resistance to therapy. Complications (especially bleeding) are common. Severe pain syndrome – intense hunger and night pain. Night pain often causes the child to wake up. The main localization of pain is the upper right quadrant of the abdomen. Often irradiates to the back, to the spine. Dyspeptic symptoms are pronounced: heartburn, bitterness in the mouth, lightheadedness. Palpation almost always reveals local muscle tension, epigastric pain, and a positive Mendelian sign.
Combined peptic ulcer of the stomach and duodenum
As a rule, a severe course of the disease is observed. The main clinical signs are similar to duodenal ulcer.
Clinical manifestations of complicated ulcer
A complicated course of ulcer is observed in 10-15% of cases, twice as often in boys.
Bleeding- the most common complication of ulcer (80% of complications). Clinical signs of acute bleeding in PU: vomiting" coffee grounds", vascular collapse and signs of anemia in the body - pallor, general weakness. Often, as bleeding develops, a weakening of the pain syndrome is observed, which can lull the doctor’s vigilance.
Perforation.(7-8%); Perforation of an ulcer usually begins with an attack of acute “dagger pain”, which is accompanied by acute abdomen, tension in the epigastric region, abdominal wall, symptoms of peritoneal irritation. Note the weakening or absence of peristalsis. The clinic data is confirmed by an x-ray examination - the presence of free gas under the liver during an x-ray examination of the abdominal organs.
Penetration. (1-1,5 %). Ulcers of the duodenum penetrate into the head of the pancreas, liver, bile ducts, hepatoduodenal ligament. Gastric ulcers penetrate into the lesser omentum and the body of the pancreas. Main clinical manifestations – sharp pains pain that radiates to the back, vomiting that does not bring relief, and heartburn. Penetration is characterized by constant pain and loss of a clear connection with food intake. A characteristic radiological symptom of penetration is an additional shadow of a contrast agent next to the examined organ.
Deformity and pyloroduodenal stenosis.(10-12%). Patients feel fullness of the stomach, nausea, and belching. In severe cases, vomiting of stagnant stomach contents is observed. The patient can provoke vomiting himself to obtain a feeling of relief. The patient is losing weight. In typical cases, hourglass-type peristalsis and a splashing phenomenon during palpation in the epigastric zone are observed.
According to N.P. Shabalova (1999) distinguishes:
1. Inflammatory-spastic (functional stenosis), which is unstable and appears against the background of exacerbation of ulcerative disease.
2. Cicatricial stenosis, which forms slowly, gradually, but is permanent.
Peptic ulcer of the stomach and duodenum
Paraclinical methods of examination for ulcerative disease
1. Laboratory research.
1.1 Mandatory (on modern stage development of gastroenterology):General clinical blood test.
General clinical urine analysis.
Analysis of stool for worm eggs.
Coprocytogram.
Total protein into protein fractions of blood.
Histological (cytological) examination during endoscopy.
Tests for HP: rapid urease, bacteriological, respiratory urease test, serological (IFA), ELISA analysis of the concentration of HP antigen in stool, polymerase chain reaction (PCR).
Intragastric pH-metry.
1.2. According to indications:2. Instrumental studies and diagnostic criteria:Fecal occult blood test (Gregersen test).
Blood test for hormone levels to detect hypergastrinemia, hypersomatotropinemia.
Immunogram.
Study of gastric secretion:Fractional study of gastric juice (detection of hyperacidity, increased proteolytic activity).
Fibroesophagogastroduodenoscopy (FGDS) with targeted biopsy, diagnosis of HP infection is carried out for diagnostic purposes and 3-4 weeks after the start of treatment with complete epithelization of the ulcer.
Endoscopic criteria for ulcer stages
Exacerbation phase.
a) Stage I - acute ulcer. Against the background of pronounced inflammatory changes in the coolant and duodenum - a round-shaped defect (defects), surrounded by an inflammatory shaft; pronounced swelling. The bottom of the ulcer is layered with fibrin.
B) Stage II - the beginning of epithelization. Hyperemia decreases, the inflammatory shaft is smoothed out, the edges of the defect become uneven, the bottom of the ulcer begins to clear of fibrin, and convergence of folds towards the ulcer is noted.
Phase of incomplete remission.V) Stage III- healing of ulcers. At the site of reparation there are remains of granulations, red scars of various shapes, with or without deformation. Signs of gastroduodenitis activity remain.
Remission
Complete epithelization of the ulcerative defect (or “quiet” scar), there are no signs of concomitant gastroduodenitis.
When performing a targeted biopsy, rapid diagnosis of HP is performed; histological and microbiological diagnosis of HP; histological (cytological) verification of the diagnosis, differential diagnosis with acute ulcers.
X-ray examination is currently of an auxiliary nature. It is used primarily for the diagnosis of motor-evacuation disorders, duodenostasis, cicatricial and ulcerative deformities of the stomach and duodenum. WITH diagnostic purpose with absolute contraindications to endoscopy. X-ray criteria for ulcers: “niche” symptom, convergence of folds, etc. are rare in children.
Ultrasound examination of the abdominal organs
The study is carried out once to screen for the diagnosis of concomitant pathology.
Treatment of ulcer
The scope of treatment depends on the location of the ulcer (stomach or duodenum), phase of the disease, severity, presence of complications, connection with HP, leading pathogenetic mechanisms and clinical and endoscopic symptom complex. According to the tradition that has developed in domestic pediatrics, treatment of a patient with newly diagnosed ulcer and its exacerbation is carried out in a hospital. At the same time, many foreign pediatricians are more reserved regarding recommendations inpatient treatment.
In case of exacerbation, the average duration of inpatient treatment is about 1 month.
1. Mode. In the first weeks of hospital stay, bed or semi-bed rest.
2. Nutrition. Diet tables No. 1a, 1b, and then N5 are assigned sequentially. Considering the low caloric content of the N1 diet options, the choice of motor mode depends on the duration of its administration. The basis of dietary therapy for ulcers is the principle of preventing thermal, chemical and mechanical irritating effects on the ulcer. That is, very hot or cold foods, extractive, spicy dishes, rich coarse foods are excluded dietary fiber. If ulcer is complicated by bleeding, the Meulengracht diet is prescribed, which includes puree enriched with proteins, salts and vitamins.
For HP-associated peptic ulcer disease in Ukraine, the following treatment regimens are officially recommended, which are based on the provisions of the 2nd Maachtricht Consensus of 2000. In the treatment of HP-associated forms of gastritis and peptic ulcer in children, first- and second-line combination therapy is consistently used.
The main drugs used to eradicate HP:
1. Bismuth preparations. De-nol in a single dose of 4 mg per 1 kg of body weight twice a day, or 120 mg 2 times a day (up to 7 years), 240 mg 2 times a day (after 7 years). Analogue of De-nol - Ukrainian drug Gastro-norm
2. Antibiotics:
Er – erythromycin.
Cl – clarithromycin.
Om - ompeprazole.
Ra - ranitidine.
Fa - famotidine.
Fl - flemoxin - solutab.
After the end of anti-Helicobacter therapy, the following may be prescribed for 3-4 weeks:
Cytoprotectors: smecta, sucralfate (Venter), licorice root preparations (liquiriton).
Remedies: sea buckthorn oil, solcoseryl, etc.
Prokinetics: domperidone (Motilium) is indicated for motility disorders (refluxes, duodenostasis) for 10-14 days.
Sedatives: persen - for 3 weeks; water tincture of valerian.
Anti-stress agents: (sibazon) - for 3 weeks. For asthenodepressive manifestations, a mild antidepressant of plant origin can be prescribed - Deprim, 1-2 tablets per day in the first half of the day for older children and adolescents.
Symptomatic treatment is prescribed in the presence of residual manifestations of pain and dyspeptic syndromes and includes antispasmodics - drotaverine (no-spa), halidor, M2 anticholinergics) for 10-15 days, multivitamin preparations - up to 4 weeks. Some pediatric gastroenterologists emphasize the need to correct drug-induced dysbiosis after treatment for HP infection.
Confirmation of HP eradication is obtained no earlier than 4 weeks during the control FGDS. If the first course of therapy is unsuccessful, they switch to quadruple therapy according to 2nd line regimens. It should be noted that the sensitivity of HP to various drugs has significant regional characteristics and therefore standard eradication schemes do not always justify themselves. For example, existing HP strains are highly resistant to metronidazole, since this drug was widely used in our country. Alternative schemes for eradication measures proposed by North American pediatricians
Drug therapy is prescribed taking into account the severity of the ulcer, the location of the ulcer, and the state of the secretory function of the stomach.
In modern gastroenterology, about 500 drugs are used to treat ulcers, which indirectly proves the ineffectiveness of modern drug therapy. Still, there are groups of drugs that have proven their effectiveness in the composition complex therapy Peptic ulcers and gastritis not associated with HP, or with a tendency to relapse and complications. The current socio-economic situation in the open spaces former USSR dictates the need to also take into account the pharmacoeconomic aspects of treatment (its cost) and the ability to follow the doctor’s recommendations.
Antacids
Patients with high acidity of gastric juice must be prescribed antacids to block acid and peptic factors. In pediatrics, preference is given to antacids that are not absorbed.
Almagel. Almagel is a combined preparation of aluminum hydroxide and magnesium hydroxide. Almagel A also contains anesthesin, which adds an analgesic effect to the antacid effect. Prescribed 1.5-2 hours after meals or at night. Shake the drug before use. Single dose for children under 10 years of age: 1/2 tsp. spoon., 10-15 years 1 teaspoon. spoon.
Phosphalugel. Along with the blockade of the acid-peptic factor, it increases the protective barrier of the coolant and has a large buffer capacity. The effect of the drug is determined by colloidal aluminum phosphate, which has a triple therapeutic effect due to the combination of an antacid, enveloping effect and adsorbing effect. Prescribed 1-2 sachets 3-4 times a day.
Maalox. Combination of algedrate and magnesium hydroxide. It is used as an adsorbent, enveloping and antacid agent, 10-15 ml of suspension 3-4 times a day. Children are prescribed 1 teaspoon in the form of a suspension. spoon 3 times a day. Before use, the suspension is homogenized by shaking the bottle.
Gastal. An antacid drug that effectively reduces the increased acidity of gastric juice without subsequent hypersecretion. Aluminum hydroxide adsorbs and precipitates pepsin in gastric juice, inactivating it back. Used in children 1.5 tablets. 4-6 times a day. It is advisable to prescribe most antacids (combining drugs) 4-5 times a day and always at night.
The effectiveness of antacids increases when they are combined with cytoprotectors, that is, drugs that protect the coolant from the action of aggressive factors.
Cytoprotectors
Sucralfate. Aluminum salt of sulfated sucrose obtained from licorice root. Creates a protective film on the coolant and duodenum, reduces the activity of pepsin. In the acidic environment of the stomach, it forms an adhesive polymer paste-like mass that has alkaline properties. Selectively protects affected areas of the mucous membrane from the influence of aggressive factors such as hydrochloric acid, bile and pepsin. Promotes the secretion of mucus, prostaglandins and bicarbonates in the coolant and duodenum. Apply orally, without chewing, with a small amount of water, 1 hour before meals and before bedtime. Children - 0.5 g - 1.0 g 4 times a day (including 1 time at night) for 4-6 weeks.
Artificial prostaglandins - misoprostol (Cytotec, Cytotec, etc.) have cytoprotective properties. This group of drugs promotes mucus formation, bicarbonate secretion, and improves microcirculation. Misoprostol for adolescents is used orally, during meals and at night, for erosions and ulcers of the stomach and duodenum - 200 mcg 3-4 times a day, it is possible to use 400 mcg 2 times a day (last dose before bedtime). The duration of the course of treatment is 4-8 weeks.
Colloidal bismuth salt creates a protective film on the surface of ulcers and erosions, which protects the coolant from the action of aggressive gastric juice. The drug increases the synthesis of prostaglandin E2, which stimulates the formation of mucus and the secretion of bicarbonates. Prescribed 1 tablet 3 times a day and before bedtime.
Peripheral m-anticholinergics
Metacin. By interacting with M-cholinergic receptors, it prevents the binding of acetylcholine to them. Eliminates spasms of the stomach and duodenum, normalizes motility. Superior to atropine in its analgesic effect. Has antisecretory and antacid effect. Children are prescribed orally before meals in age dosages of 4-7 years - 0.001-0.0015 g 2-3 times a day, 8-14 years - 0.002-0.004 g 2-3 times a day. subcutaneously, intramuscularly from 4-7 years - 0.3 ml-0.4 ml 1-2 times 8-14 years - 0.5-1.0 ml 1-2 times a day. Course 7-10 days
Pirenzepine (gastrocepin)- a specific inhibitor of gastric secretion, a selective blocker of M1 - cholinergic receptors of the parietal and main cells of the coolant. Inhibits the production of hydrochloric acid and pepsin. Dosage in children preschool age 1/2 tablet (0.0125 g) 2 times a day, and for schoolchildren 1 tablet. (0.025 g) 2 times a day.
Myotropic antispasmodics
For pain syndrome, spastic conditions The gastrointestinal tract is prescribed drotaverine (no-spa, no-x-sha, drotaverine-KMP); a myotropic antispasmodic is prescribed at the age of 6 to 12 years in tablets of 20 mg 1-2 times a day. For older children single dose up to 40 mg. For severe pain, IM and IV are prescribed.
Galidor. Prescribed orally, 100-200 mg (1-2 tablets) 1-2 times a day for 3-4 weeks. then they switch to maintenance therapy at 100 mg 2 times a day. Preschool children 50 mg 2 times a day, schoolchildren 50-100 mg 2-4 times a day. The maximum daily oral dose is 400 mg. In urgent situations, in severe cases of the disease - intravenously in a slow stream, drip, dissolving the drug in saline solution 50-100 mg 1-2 times a day, IM 50 mg 1-2 times a day. The average course duration is 3-4 weeks.
Prokinetics
For gastroduodenal motility disorders - gastroesophageal reflux, gastric motility disorders, metoclopramide (cerucal) is prescribed. Children 3-14 years old. the maximum single dose for internal or parenteral use is 0.1 mg/kg body weight. Frequency of administration: 3-4 times a day for 30 minutes. before meals. The maximum daily dose is 0.5 mg/kg body weight. Side effects of cerucal include extrapyramidal disorders, lethargy, etc. Recently, preference has been given to prokinetics, which have less side effects than metoclopramide - domperidone (Motilium). Motilium is prescribed orally over 30 minutes. before eating food. For children over 5 years old with chronic dyspeptic symptoms - 10 mg 3-4 times a day and, if necessary, additionally before bedtime.
Histamine H2 receptor blockers
Pathogenetically justified is the prescription of drugs to patients - histamine H2 receptor blockers, which reduces secretion and acid formation, especially at night. A representative of the first generation of these drugs is cimetidine, which is prescribed at a dose of 15-20 mg per 1 kg of body weight per day (this drug is rarely used in children because it causes gynecomastia and a number of other side effects).
Preparations of the second and third generation of histamine H2 receptor blockers are much more effective and safe. Ranitidine has been well tested at a dose of 2-6 mg per 1 kg of body weight twice a day for 3-4 weeks. Famotidine 1-2 mg/kg body weight per day (20-40 mg) in 2 doses for 4-6 weeks.
Proton pump inhibitors
Proton pump inhibitors (PPIs) omeprazole (omez) 0.5-1.5 mg/kg in the morning and evening (10 mg 2 times a day in children under 10 liters; 20 mg 2 times a day in children) are effective in the treatment of peptic ulcers over 10 years old), the course of treatment is about 2 weeks. Modern IPPs are more effective - lansoprazole, rabeprazole, Nexium, etc., but they have not yet been sufficiently tested in pediatric practice, and therefore can only be used in adolescents.
Stimulators of reparative processes
In order to stimulate the healing process in ulcerative disease, solcoseryl 0.5-2.0 ml intramuscularly can be used, depending on age, for 2-3 weeks. Oil from the fruits and leaves of sea buckthorn, which is prescribed 1 teaspoon, has not lost its importance as a reparative. spoon 3 times a day (use is limited in case of concomitant lesions of the pancreas). For erosive and ulcerative lesions that do not heal for a long time, biostimulants such as aloe, blood products, etc. are sometimes used.
Sedatives and tranquilizers
In order to eliminate disorders of the regulatory functions of the central nervous system and relieve emotional tension, sedatives and tranquilizers are indicated - a course of 2-3 weeks. The most widely used are diazepam (Sibazon), chlordiazepoxide, and phenazepam. Preparations based on herbal components - persen, etc. When ulcers are combined with severe psycho-vegetative disorders and disorders of duodenogastric motility, sulpiride (eglonil) is prescribed at a dose of 5 mg/kg body weight per day.
Physiotherapy
The role of physiotherapy in the treatment of ulcer is currently unclear and therefore secondary. It should be specifically emphasized that the need and usefulness of physiotherapeutic treatment of ulcer is not recognized by all pediatricians.
In the phase of exacerbation of the disease to normalize secretory and motor function stomach, as well as increasing the trophism of the coolant, the following can be prescribed: high-frequency electrotherapy (HF) - inductothermy; Ultra-high frequency therapy (UHF) or microwave therapy: centimeter or decimeter; electrotherapy with pulsed currents (diadynamic therapy). In cases of severe pain, diadynamic currents and electrophoresis with antispasmodics are used.
When the secretory activity of the stomach decreases, the following is prescribed: galvanization of the stomach area; electrophoresis with calcium using the transverse method; electrical stimulation using diadynamic currents.
In the phase of incomplete remission: magnetic therapy, electrosleep, heat therapy (paraffin, ozokerite applications, etc.), hydrotherapy.
To normalize the motor-evacuation function of the stomach and increase the trophism of the coolant, laser and magnetic laser therapy is used.
Contraindications for physiotherapeutic treatment are severe disease, bleeding, individual intolerance to certain physiotherapeutic methods.
Non-drug treatment methods include: reflexology, herbal medicine, homeopathy, microwave resonance therapy.
In the remission stage, along with the use of physiotherapeutic methods, treatment with mineral waters is carried out. During the period of stable remission, sanatorium-resort treatment is indicated, first in a local and then in a climatic sanatorium. In case of bleeding, sanatorium-resort treatment in climatic sanatoriums can be carried out no earlier than after 6 months.
The course of treatment for ulcer lasts up to 1 month, but can last much longer.
The question of prescribing maintenance therapy, the frequency and duration of anti-relapse courses of treatment is decided individually. The length of hospital stay is on average 28 days, with severe cases up to 6-8 weeks.
Treatment of bleeding in ulcerative disease. Emergency measures for bleeding in children with ulcers consist of prescribing a protective regime, fasting and complete rest. Transport the patient only on a stretcher. Therapeutics stopping bleeding: intravenous administration blood coagulation factors, sandostatin (somatostatin), parenteral histamine H2 receptor blockers (ranitidine, famotidine, etc.). If bleeding continues, endoscopic hemostasis is performed (endovascular if possible). All children who have experienced bleeding are subject to step-by-step treatment and observation. In addition to diet therapy, antisecretory drugs are prescribed orally: ranitidine and other histamine H2 receptor blockers.
Indications for surgical treatment I WOULD
perforation, penetration,Dispensary observationMassive bleeding that doesn't stop
Cicatricial subcompensated duodenal stenosis.
Patients with ulcerative disease are under clinical supervision of a district pediatric gastroenterologist. During the period of complete remission, dosed physical activity, but should avoid lifting heavy weight, sudden movements, avoid heavy loads on abdominal Press. In case of severe, recurrent ulcerative disease, courses of outpatient anti-relapse treatment lasting 3-4 weeks are carried out in the fall and spring. In order to prevent relapse, an examination for HP is recommended, and, if necessary, sanitization of the patient’s immediate environment. If possible, eradication of HP should be carried out not only in the child, but also in family members, since the likelihood of reinfection is quite high.
To prevent relapses, more than strict diet, antacids, histamine H2 receptor blockers. The frequency of dispensary examinations is at least 2 times a year; multiplicity endoscopic examination- at least 2-3 times a year or individually.
The criterion for recovery is complete clinical and endoscopic remission for 5 years, after which the children are removed from the dispensary register.
Peptic ulcer of the stomach and duodenum.
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