LIVING DISEASE

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Ulcer disease is a chronic relapsing disease, the main symptom of which is the formation of a defect (ulcer) in the wall of the stomach or duodenum.

Ulcers of the duodenum are much more common than ulcers of the stomach. The prevalence of duodenal ulcer localization is most typical for young people and especially for men. The most susceptible to peptic ulcer is people whose work is associated with neuropsychic stress, especially in combination with irregular nutrition (for example, drivers of motor vehicles).

In the emergence of the disease, many factors play a role, including violations of the regime and the nature of nutrition (for example, the systematic use of acute and rough food, hasty food and dry food, large breaks between meals), smoking , alcohol abuse, strong coffee, psycho-emotional overload (Insufficient rest and sleep, irregular working day, stressful situations), physical overstrain. An important place is given to hereditary and constitutional factors. To provoke the development of peptic ulcer can long-term use of drugs that adversely affect the mucous membrane of the stomach and duodenum (acetylsalicylic acid, glucocorticoids, reserpine, caffeine, etc.). It is believed that Helicobacter pylori plays an important role in the development of peptic ulcer and its recurrent course, parasitizing the gastric mucosa and increasing its sensitivity to the action of hydrochloric acid of gastric juice.

At the heart of peptic ulcer is the imbalance between the aggressive properties of gastric contents and the protective capabilities of the mucous membrane of the stomach and duodenum. Causes of increased acid-peptic aggression may be an increase in the secretion of hydrochloric acid and a violation of the motility of the gastrointestinal tract, leading to a long delay in acid content in the outlet of the stomach, too fast entering it in the bulb of the duodenum, duodenogastric reflux of bile. Weakening of the protective properties of the mucous membrane can occur with a decrease in the production of gastric mucus and a deterioration in its qualitative composition, inhibition of the production of hydrocarbonates that make up the gastric and pancreatic juice, impaired regeneration of the epithelial cells of the mucous membrane of the stomach and duodenum, a decrease in the content of prostaglandins in it, .

Clinical picture and course. The leading symptom of peptic ulcer disease is pain that occurs more frequently in the epigastric region to the left of the median line (with ulcers of the body of the stomach) or to the right of it (with ulcers in the canal and duodenal canal), often radiating to the left half of the thorax, the region of the xiphoid process Sternum, thoracic or lumbar spine. Pain is usually clearly associated with eating. So, with ulcers of the body of the stomach, they usually appear 30 to 60 minutes after eating (early pains), with ulcers of the canal and duodenal bulb - after 2 -3 hours (late pains), and also on an empty stomach ("hungry pains "). Close to the mechanism of the occurrence of "hungry" pain night pain (usually occur between 11 pm and 3 am), which are observed more often when the ulcer is located in the duodenum. The pains are usually stopped by antacid, antispasmodic agents, with the action of heat, late and "hungry" pains also stop after eating, especially dairy.

A typical symptom of peptic ulcer is vomiting with acidic gastric contents, arising at the height of the pain and bringing relief, in connection with which patients sometimes cause it artificially. Often noted and other dyspeptic disorders (heartburn, nausea , eructation, constipation). Despite good, and sometimes even increased appetite, weight loss may be noted due to the fact that patients often limit themselves in eating, fearing the occurrence or intensification of pain. On the other hand, there are often asymptomatic forms of peptic ulcer; In such patients, the disease is detected by accident or its first clinical manifestations are complications, which is especially characteristic of young and old people.

Peptic ulcer usually occurs with alternating exacerbations and remissions. Aggravations are often seasonal in nature, occurring mainly in spring and autumn; Their duration is from 3 to 4 to 6 - 8 weeks or more. Remissions can last from a few months to several years.

Complications : bleeding, perforation and penetration of ulcers, perivistseritis, cicatricial stenosis of the pylorus, malignancy of the ulcer.

The most common complication occurring in 15-20% of patients is bleeding. Clinically, it manifests itself by vomiting with contents that resemble coffee grounds and (or) black tarry stools (melena). The appearance in the emetic masses of an impurity of unchanged blood may indicate a massive bleeding pattern or a low secretion of hydrochloric acid. Sometimes bleeding may initially manifest as general symptoms of gastrointestinal bleeding - weakness, dizziness, falling blood pressure, pale skin, etc., while its direct signs, for example melena , appear only after a few hours.

Perforation of the ulcer occurs in 5-15% of patients, more often in men, appearing in some patients the first symptom of the disease. Predisposing factors can be physical overstrain, alcohol intake, overeating. Sign of perforation of the ulcer - acute ("dagger") pain in the epigastric region, often accompanied by the development of collapse, vomiting. Suddenness and intensity of pain are not expressed to such an extent for any other disease. The muscles of the anterior abdominal wall are sharply strained ("dace-shaped" abdomen), pronounced tenderness is noted upon palpation, symptoms of irritation of the peritoneum (Shchetkin-Blumberg symptom), disappearance of hepatic dullness. In the outcome (sometimes after a brief period of imaginary improvement) a pattern of diffuse peritonitis develops.

Penetration - penetration of an ulcer beyond the walls of the stomach or duodenum into surrounding organs (pancreas, small omentum, liver and bile ducts, etc.). It is manifested by loss of the previous periodicity of pain, which becomes permanent irradiate into one or another area (for example, into the lumbar pancreas during penetration of the ulcer). Body temperature rises to subfebrile digits, leukocytosis is noted , an increase in ESR.

Stenosis of the doorman develops as a result of scarring of ulcers located in the pyloric canal or in the initial part of the duodenum, and also in patients who have undergone the operation of sealing the perforated ulcer of this region. Patients complain of discomfort in the epigastric region, belching with the smell of hydrogen sulfide, vomiting (sometimes food taken on the eve). When examined, "sand noise", visible convulsive peristalsis, is revealed. Progression of the process leads to depletion of patients, severe violations of the water-electrolyte balance.

Malignancy, which is characteristic of stomach ulcers, can be accompanied by a change in symptoms, such as a loss of periodicity and seasonality of exacerbations and the association of pain with food intake, loss of appetite, increased exhaustion, the appearance of anemia .

The diagnosis is based on history, clinical picture, examination results, laboratory and instrumental studies. When collecting anamnesis, pay attention to previous diseases (for example, gastritis, duodenitis), neuro-emotional stress, including those related to professional activity, eating disorders, smoking , alcohol abuse, seasonality of exacerbations, burdened heredity. In assessing patients' complaints, the periodicity and the characteristic rhythm of pain are of greatest importance.

When palpating the abdomen during an exacerbation, it is often possible to identify local tenderness in the epigastric region, often in combination with moderate resistance of the muscles of the anterior abdominal wall. Percutally there also defines a restricted area of ​​soreness. Soreness can be noted on the left or right side of the spine when pressing on it in the area of ​​the thoracic, 1st lumbar vertebrae.

An important place in the diagnosis of peptic ulcer is the analysis of feces for latent blood. Repeated positive results of the reactions of Gregersen and Weber (with the exclusion of other causes of hemorrhage) may serve to confirm the exacerbation of the disease.

One of the main methods of diagnosing peptic ulcer, as well as its complications, is an x-ray study. X-ray diagnosis of the disease is based mainly on the detection of direct radiographic signs - a niche and cicatricial and ulcerative. Deformation of the affected wall of the stomach or duodenum. The niche is an x-ray image of a ulcerative defect in the wall of a hollow organ filled with radiopaque substance and the marginal shaft caused by inflammatory and functional changes of the tissues adjacent to the ulcer.

The leading role in the diagnosis of peptic ulcer and its complications is played by endoscopy. It allows you to confirm or reject the diagnosis, accurately determine the localization, shape, depth and size of the ulcer defect, assess the condition of the bottom and edges of the ulcer, clarify the accompanying changes in the mucosa, as well as violations of the motor function of the stomach and duodenum, provides the ability to monitor the dynamics of the process. Special techniques allow to identify Helicobacter pylori in biopsy specimens of the mucous membrane of the stomach and duodenum.

Differential diagnosis is carried out primarily with chronic cholecystitis and pancreatitis. At the first pain usually arise after intake of fatty or fried food, localized in the right hypochondrium, do not have a clear periodicity, do not decrease after taking antacids. With chronic pancreatitis, the pains are localized mainly in the left or right hypochondrium in the form of a "half-ring" or are shrouded, strengthened soon after eating, accompanied by a violation of the bowel function. In both cases there is no seasonality of exacerbations.

Treatment . Patients with uncomplicated course of peptic ulcer in most cases undergo conservative therapy. If the disease worsens, patients are hospitalized in the gastroenterological or general therapeutic department. In the hospital, they are provided with a medical-protective regime with the maximum restriction of physical and emotional loads. When the aggravation subsides, the patients are transferred to a rehabilitation (suburban) department. In the polyclinic, there is clinical examination and anti-relapse treatment.

Food should be fractional (5 - 6 times a day), food - mechanically and chemically sparing. For most patients, both in the period of exacerbation and in the course of further, including anti-relapse, treatment, diet No. 1 is shown. From the diet, fried dishes, raw vegetables and fruits containing coarse vegetative cellulose (cabbage, pears, peaches, etc., ), Marinades, pickles, smoked products, strong broths, spices, carbonated drinks, coffee, cocoa.

Food should contain a sufficient amount of protein and vitamins. Milk and dairy products are most preferable, in the morning the soft-boiled egg and oatmeal or semolina porridge. Meat and fish are used in the form of dishes cooked for a couple, apples, beets, carrots, black currants - only wiped.

Applied holinolitiki peripheral action (atropine subcutaneously or inward, metacin, platifillin parenterally and inward, as well as selective m-holinolitik gastrocepin, which has less side effect). In patients with localization of ulcers in the duodenum, as well as with gastric ulcers that occur against the background of preserved and increased secretion of hydrochloric acid, cholinolytics of peripheral action are often combined with antacid agents (magnesium oxide, calcium carbonate, bismuth nitrate, aluminum hydroxide and aluminum phosphate, In the composition of drugs Almagel, Almagel-A and phosphalogel), which is expedient to use 1.5 to 2 hours after eating, timing their effect at the time of the onset of pain.

The most effective anti-ulcer drugs: blockers of histamine H2-receptors, which have a pronounced antisecretory effect (cimetidine 200 mg 3 times a day and 400 mg per night, ranitidine 150 mg twice daily, famotidine 20 mg twice daily or 40 mg At night). These funds, however, should continue to be taken in maintenance doses (400 mg of cimetidine or 150 mg of ranitidine in the evening) and after cicatrization of the ulcer within 1.5 to 2 months. The rapid cessation of the administration of histamine H2-receptor blockers in achieving the effect may lead to the development of a "withdrawal syndrome", consisting in the recurrence of the disease, sometimes with gastroduodenal bleeding and perforation of the ulcer due to increased gastric secretion. Avoiding the "withdrawal syndrome" allows the appointment of anticholinergics, and first of all gastrotsepin, in combination with antacids at the time of the termination of maintenance therapy with blockers of histamine H2-receptors. The effectiveness of H2-histamine blockers is not inferior to omeprazole , which is prescribed internally in a daily dose of 20 - 40 mg (in 1 - 2 admission); Its important feature is the absence of a "withdrawal syndrome".

Widespread use in peptic ulcer found drugs that enhance the protective properties of the mucosa of the gastroduodenal zone - sucralfate, which is a complex of sulfated sucrose and aluminum hydroxide (appoint 1 g 3-4 times a day for 1 hour before or 2 hours after meals and at night ), And de-nol - colloidal bismuth subcitrate (prescribed 0.24 g 2 times a day for 1 hour before or 2 hours after ingestion). When ingested, these drugs form a complex with necrotic masses of the area of ​​the ulcer crater, creating a barrier for the acid-peptic factor. They also help to reduce pepsin activity, increase mucus production, accelerate the regeneration of epithelial cells, increase the content of prostaglandins in the gastric mucosa; De-nol, in addition, depresses the vital activity of Helicobacter pylori. When detecting in the mucous membrane of the stomach and duodenum Helicobacter pylori to the therapy of de-nol, ranitidine or omeprazole add antibacterial agents - amoxicillin , metronidazole , tetracycline .

With hard-to-cut ulcers of the stomach and duodenum, hyperbaric oxygenation, laser therapy (5-10 sessions for 1-3 minutes 2 - 3 times a week) are used. Various methods of local action on the ulcer through the endoscope are also applied: mechanical cleansing of the bottom and edges of the ulcer, washing of the ulcer defect with alcohol and collagolum, irrigation of the ulcer with antibiotics, sea buckthorn oil, solcoseryl and other preparations, administration of substances blocking nerve endings (for example, novocaine solution) And forming a film on the surface of the ulcer (gastrozole, lyfuzol, etc.).

Physiotherapeutic treatment can be prescribed only when the exacerbation subsides and there are no signs of bleeding. Recommended thermal procedures (warmers, poultices, paraffin and ozocerite applications), electrophoresis 3 - 5% solution of novocaine, microwave radiation, etc.

At the spa resorts treatment is shown no earlier than 2-3 months after the aggravation subsides. In addition to the main therapeutic factor - mineral waters, - mud and peat treatment, coniferous-sea baths, climatic factors are used.

Operative treatment is carried out in absolute and relative indications. Absolute indications include perforation of the ulcer, profuse bleeding, decompensated stenosis of the pylorus, malignancy of the ulcer. Relative indications are penetrating gastroduodenal ulcers, callous ulcers of the stomach, gross cicatricial and ulcer deformations of the stomach and duodenum, accompanied by a violation of the evacuation function of the stomach, as well as repeated bleeding. The question of surgical treatment is also placed with the often recurring course of peptic ulcer, which do not heal the stomach and duodenal ulcers for a long time. With penetrating ulcers, the operation can be performed in a planned manner, and in case of perforation of the ulcer, an emergency operation is the only reliable method of treatment.

In the postoperative period, all patients operated on for peptic ulcer are given an infusion therapy (on the day of the operation and the patient usually receives 1.5 to 2 liters of liquid intravenously in the first two days after the operation) under the control of laboratory data and diuresis. Adequacy of the infusion therapy is of special importance for patients operated on for pyloroduodenal stenosis, as well as for evacuation from the stomach developed after surgery.

In the first days of the postoperative period, patients undergo a gastric monitoring test twice a day. Persons with impaired evacuation from the stomach showed a constant aspiration of the contents of the stomach through the gastric tube. "

Liquid intake in a limited amount (up to 500 ml) is allowed, as a rule, on the first day after the operation (not counting the day of the operation). From the 2nd-3rd day the patient can drink practically without restriction. Food is given from the 2nd -3rd day (diet No. 0) every 2 to 3 hours in small portions. Gradually, the diet is expanded, and on the 6th-7th day patients receive diet No. 1A with the exception of dishes cooked on whole milk; Food fractional - 6 times a day.

The patient is shown to have motor activity. Movement with the feet (both passive and active) is resolved immediately upon awakening after anesthesia. Starting from the first day of the postoperative period, respiratory gymnastics is prescribed. Get out of bed in the absence of contraindications (the severity of the general condition, the threat of recurrence of bleeding from the sore ulcer, drainage of the abdominal cavity) is allowed on the 2nd - 3rd day after the operation. With a favorable course of the process, the sutures are removed on the 7th-8th day, the patients are discharged from the hospital after organ-saving operations with vagotomy on the 10th day, after resection of the stomach (antrumectomy) - on the 12th-14th day.

The prognosis depends in many respects on the age and sex of the patient, the localization of the ulcerative defect, the peculiarities of the course of complications, concomitant diseases, working and living conditions. With timely recognition and full-scale complex treatment in the absence of complications, it is usually a favorable, possibly complete recovery.

Prevention is aimed at eliminating possible etiological factors of ulceration: refusal from smoking and alcohol, organization of the regime of work and rest, proper nutrition. Patients with peptic ulcer should be under clinical supervision. Anti-relapse treatment should be comprehensive, long-lasting (courses lasting 1.5-2 months for at least 5 years from the moment of the last exacerbation). In the usual course of the disease, anti-relapse courses are conducted 2 times a year during the most likely occurrence of relapse, i.e. In spring and autumn, with frequent and prolonged exacerbations - 3-4 times a year.