The Duodenitis: symptoms, treatment of duodenitis
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Duodenitis: symptoms, treatment

Content:

Duodenitis symptoms treatment Duodenitis is characterized by the formation of inflammatory-dystrophic changes in the mucosa of the whole duodenum or its separate parts, which are accompanied by its functional disorders.

In the overwhelming majority of cases, chronic variants of this disease are found (in 94%). More often duodenitis is observed in patients - men.



Causes of duodenitis

Depending on the origin, duodenitis is divided into:

  • Primary (an isolated process, not associated with other ailments, occurs in less than a third of patients);
  • Secondary (develops due to other diseases).

Primary duodenitis can be caused by:

  • Irrational nutrition;
  • Side effects of a number of medications (glucocorticosteroids, aspirin, non-steroidal anti-inflammatory drugs);
  • Alcoholic beverages;
  • Parasites;
  • Smoking;
  • Bacterial infections;
  • Viruses;
  • Allergy (often food);
  • Immune breakdowns;
  • Weighed down by heredity;
  • Stress.

Secondary duodenitis is formed on the background:

  • Gastritis (in the duodenal bulb there are islets of the mucosa, whose structure is similar to the gastric, they are called gastric metaplasia, they are inhabited by harmful microorganisms Helicobacter pylori, which in turn provoke inflammation and / or the occurrence of erosions, and also promote subsequent relapses);
  • Ulcerative disease with localization of defects in the duodenum;
  • Pathology of the liver;
  • Pancreatitis;
  • Diseases of the bile duct;
  • Intestinal diseases;
  • Immunodeficiencies;
  • Cardiovascular ailments (the mucous membrane is damaged due to disorders of its circulation);
  • Renal failure.


Classification of duodenitis

In their everyday work, various specialists (clinicians, endoscopists, pathomorphologists) use different classifications of duodenitis. However, all distinguish:

  • Acute duodenitis;
  • Chronic duodenitis.

By the location of inflammation duodenitis is divided into:

  • Bulbit or proximal duodenitis (only the bulb is affected) - the most common form;
  • Postbulbar or distal duodenitis (inflammation is detected in the vaginal departments);
  • Papillitis or local duodenitis (the process is localized in the zone of the duodenal papilla);
  • Diffuse or total duodenitis (the entire organ is involved).

At endoscopic examination on visual data the following types of duodenitis are established:

  • Erythematous (mucous edematous and reddened);
  • Hemorrhagic (when hemorrhages are detected - hemorrhages);
  • Atrophic (this method can detect only indirect signs of atrophy - thinning of the mucosa, visualization of translucent vessels, finally confirm atrophic changes allows histological evaluation);
  • Erosive (in the case of formation of mucosal surface defects - erosion)
  • Nodular (when small formations resemble nodules are visible).

In addition, endoscopists often evaluate the degree of activity of the existing inflammation (I-III).

Considering and analyzing the structure of the duodenal mucosa under a microscope, pathomorphologists distinguish:

  • Superficial duodenitis (only superficial layers of the mucosa underwent changes);
  • Diffuse or interstitial duodenitis (the entire thickness of the duodenal mucosa is affected)
  • Atrophic duodenitis.

In addition, they qualify duodenitis in terms of the levels of active inflammation, the severity of atrophy, the number of inflammatory cells in the mucosa, bacterial colonization.

Duodenitis: Symptoms

Duodenitis can begin either suddenly or gradually. Often he manifests after some dietary excess, alcohol consumption, stress. Duodenitis is usually difficult to distinguish from other ailments of the digestive system. After all, it is characterized by the same clinical signs as for most other gastroenterological ailments:

  • Pain (weak or very intense pain associated with the type and timing of food intake, occur in the upper abdominal areas: epigastric zone, hypochondria);
  • Signs of gastric dyspepsia (heaviness, burning or discomfort in the epigastric zone, belching, nausea, bloating);
  • Problems with stool (chronic diarrhea or regular constipation, their alternation);
  • Psychoemotional disorders (unmotivated irritability, tearfulness, rapid emotional exhaustion, etc.).

Depending on the combination of symptoms, duodenitis may have the following clinical forms:

  • Ulcerous (the most frequent variant, "night" and "hungry" pains at the top of the abdomen are very similar to those that are characteristic of peptic ulcer, they are combined with acidic eructations and persistent constipation);
  • Gastritis-like (pain occurs after eating, they are often accompanied by gastric dyspepsia);
  • Cholecystoid (pain similar to biliary colic, bitterness in the mouth, vomiting of bile);
  • Pancreatic (in patients the leftmost hypochondrium is painful, "shingles", diarrhea, vomiting can be observed);
  • Neuromuscular (sweating, episodes of fainting and weakness, palpitations, etc.);
  • Mixed (with this form, the patients have signs of various other forms of duodenitis);
  • Asymptomatic (established in the case of complete absence of clinical manifestations, common among elderly patients).

Diagnosis of duodenitis

A competent specialist is able to suspect duodenitis after a conversation with the patient who came to him and his examination. But for the final verification of this not too frequent diagnosis, a comprehensive and comprehensive examination is needed. Its volume can be different, because the clinical situations in different patients differ. As a rule, the doctor first recommends:

  • Endoscopic examination - fibrogastroduodenoscopy (the main method that shows the state of duodenal mucosa, the presence of hemorrhages, ulcers, motor disorders and allows to obtain biopsy samples for histological evaluation or detection of microorganisms in them);
  • Chromogastroduodenoscopy (using specific dyes - methylene blue, congos-mouth, endoscopists can indirectly assess the presence and prevalence of sites of gastric metaplasia in the duodenal mucosa and take exactly from them mucosal samples - biopsy samples);
  • Histological (pathomorphological) evaluation of the structure of duodenal mucosa (fixes inflammatory changes and their severity, development of atrophy, gastric metaplasia, dissemination of Helicobacter pylori, differentiates different forms of duodenitis);
  • X-ray examination (X-ray of the duodenum using contrasting suspension and double contrasting can detect triggering heavy duodenitis with coarse thickened folds of mucous and / or erosions, evaluate motor-evacuation abilities, establish post-ulcer cicatricial deformity and distinguish it from spasm typical of duodenitis);
  • Tests for the detection of Helicobacter pylori microbes: express methods for studying biopsies, immunoassay analysis of stool and blood, bacteriological, molecular-genetic, respiratory with urea;
  • Ultrasonography (with severe duodenitis, sometimes an experienced specialist can notice a thickened wall of an inflamed duodenum or signs of a motor disorder, but the method is needed to eliminate the ailments of the pancreatobiliary system, liver, kidneys);
  • Endoscopic ultrasonography (the study can be highly informative with local duodenitis with lesion of the large duodenal papilla, as well as pancreatitis, scars and stones in the ducts, tumor process);
  • Duodenal sounding (a slightly forgotten technique that examines the quality of duodenal secretion, the preservation of cavitary duodenal digestion, reveals a parasitic lesion);
  • Computer gastroenterography (a modern technique for analyzing the motor activity of the duodenum) or duodenokinesisography;
  • Studies of stool and blood for the presence of parasitic agents.

In the case of secondary duodenitis, individual patients may additionally be prescribed floor gauge manometry, retrograde cholangiopancreatography, CT or MRI procedures, biochemical blood tests, coprogram, fecal elastase-1 assessment, fibroileo colonoscopy, 24-hour gastric pH monitoring, enterography, hepatocholecystography, electrocardiography, Renography, ultrasound of the heart and other methods.

Treatment of duodenitis

In general, patients with exacerbation of duodenitis are treated in outpatient settings. However, some patients still have to be sent to a hospital. Indications for this are:

  • Intense pain and / or dyspepsia;
  • Periduodenitis (transition of inflammation from the duodenum to nearby organs and tissues);
  • Bleeding erosion;
  • Suspected development of duodenal obstruction;
  • Decompensated or serious concomitant diseases;
  • Suspicion of a possible oncological nature of the process;
  • Diagnostic difficulties;
  • Failure of outpatient treatment.

Medical measures for duodenitis should be comprehensive. All patients need an orderly regime of the day, refusal of smoking and alcohol, regular walks. They are recommended as diet therapy, and the intake of the necessary medications.

Health food

Patients with duodenitis should change their eating habits. It is advisable fractional food, the volume of a single portion should be placed in the palms of the patient. If the patient has already started to be treated with highly effective modern medicines, chopping and rubbing is necessary only with severe duodenitis. Boiled dishes are allowed. They must necessarily be warm, as the cold can aggravate spasm and motor disorders (clinically the patient will resume or pain will increase).

It is advisable to remove from the diet all products that can irritate or damage the duodenal mucous membrane, stimulate the production of digestive juices and alter the duodenal motility. Such undesirable products are considered to be all sour berries, juices, fruits, spicy seasonings, ketchup, garlic, radish, watercress, onion and green onions, radish, fatty meat, red fish, smoked products, rich fish or meat broths, pickles, lard, Mushrooms, cream, fatty milk, marinades. It is desirable to limit the amount of coffee, strong tea, salt (up to 10 g).

The patient is recommended rice, buckwheat, semolina, oatmeal, mucous and milk soups, soft-boiled eggs, non-acidic jelly, omelettes, vegetable casseroles and soufflé, fresh and low-fat cottage cheese, vegetarian soups (possibly adding boiled meat: veal, chicken, rabbit, Turkey), noodles, lean meat in the form of steam cutlets, dumplings, meatballs, doctor's sausage, puddings, dry biscuits, white dried bread, drying, sweet ripe fruits without coarse fiber. Particular importance is given to vegetable fats, their quota is about one-third of all fats consumed. Different vegetable oils are allowed (soybean, sunflower, corn, pumpkin, etc.).

If the concomitant pathology allows, then when the remission of duodenitis is reached, most of the dietary restrictions are removed. Nutrition can correspond to the normal diet of a healthy person (table number 15).

Drug therapy

Having studied the results of the examination, the doctor develops an individual scheme for taking medications. Its composition and duration vary. However, in most cases the following are used:

  • Antacids and alginates for the relief of symptoms caused by excessive acid production (maalox, renni, relzer, almagel, gelusil-lac, rutatsid, fosfalugel, geviskon, kompensan, etc.);
  • Adsorbing antacids with colloidal bismuth (vicair, ventrisol, de-nol, vikalin), which neutralize excess hydrochloric acid, protect the duodenal mucosa and fix it;
  • Sekretolitiki - means for lowering gastric acid production (famotidine, pantoprazole, esomeprazole, lansoprazole, etc.);
  • Antiparasitic drugs or anthelmintics (their choice is made only after a clear identification of the species of parasite that has settled in the body, since anthelmintic drugs are highly toxic, patients are recommended makmiror, facisin, tinidazole, amnokhinolin, vermitox, nemozol, metronidazole, praziquantel, chloroxil, etc.);
  • The fight against Heicobacter pylori (there are now several internationally verified hard eradication regimens that may include combinations of a few specific antibiotics, secretolytics, bismuth drugs);
  • Antispasmodics, which eliminate spasm and, consequently, pain (fenicaberan, duspatalin, meteospazmil, drotaverin, buscopan, papaverine, etc.);
  • Regulators of duodenal motility (domperidone or motilium, taeopride or ghanaton, metoclopramide or cerucal);
  • Polyenzymes for correction of digestive function in case of atrophic duodenitis (pancitrat, mikrazim, creon, hermital, panzinorm, etc.);
  • Reparants to accelerate the healing of duodenal mucosa (solkoseril, kaleflon, sea buckthorn oil, ethaden, biogastron, riboxin, carnitine, etc.);
  • Holospazmolitiki for relaxing the sphincter apparatus located in the thickness of the duodenal nipple (claston, olimethine, platifillin, preparations of belladonna, etc.);
  • Psychotropic medications (amitriptyline, euglon, attarax, phenazepam, elenium, seduxen, relanium, pyrazidol, etc.).

Sometimes pharmacotherapy is supplemented with some physiotherapeutic procedures that have analgesic, anti-inflammatory and antisecretory effects. Patients with duodenitis are recommended electrophoresis with papaverine, dalargin, novocaine or platifillin, ultrasound, decimeter waves, Bernard currents, UHF, mud therapy (sapropelic, mud, peat mud), coniferous, valerian or radon baths, paraffin applications, acupuncture.

If the patient has been verified erosive duodenitis, then it is not enough to focus only on the positive dynamics, which consists in the disappearance of clinical symptoms. But clinical improvement is not always accompanied by the normalization of the endoscopic picture. Therefore, endoscopic control is necessary, which will confirm the healing (epithelization) of erosion.

In the period of remission patients with duodenitis are shown sanatorium treatment.


| 2 May 2015 | | 1 915 | Uncategorized
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Duodenitis: Symptoms and Treatment

Content:

Duodenitis Duodenitis is characterized by the formation of inflammatory-dystrophic changes in the mucosa of the whole duodenum or its separate parts, which are accompanied by its functional disorders.

In the overwhelming majority of cases, chronic variants of this disease are found (in 94%). More often duodenitis is observed in patients - men.



Causes of duodenitis

Depending on the origin, duodenitis is divided into:

  • Primary (an isolated process, not associated with other ailments, occurs in less than a third of patients);
  • Secondary (develops due to other diseases).

Primary duodenitis can be caused by:

  • Irrational nutrition;
  • Side effects of a number of medications (glucocorticosteroids, aspirin, non-steroidal anti-inflammatory drugs);
  • Alcoholic beverages;
  • Parasites;
  • Smoking;
  • Bacterial infections;
  • Viruses;
  • Allergy (often food);
  • Immune breakdowns;
  • Weighed down by heredity;
  • Stress.

Secondary duodenitis is formed on the background:

  • Gastritis (in the duodenal bulb there are islets of the mucosa, whose structure is similar to the gastric, they are called gastric metaplasia, they are inhabited by harmful microorganisms Helicobacter pylori, which in turn provoke inflammation and / or the occurrence of erosions, and also promote subsequent relapses);
  • Ulcerative disease with localization of defects in the duodenum;
  • Pathology of the liver;
  • Pancreatitis;
  • Diseases of the bile duct;
  • Intestinal diseases;
  • Immunodeficiencies;
  • Cardiovascular ailments (the mucous membrane is damaged due to disorders of its circulation);
  • Renal failure.


Classification of duodenitis

In their everyday work, various specialists (clinicians, endoscopists, pathomorphologists) use different classifications of duodenitis. However, all distinguish:

  • Acute duodenitis;
  • Chronic duodenitis.

By the location of inflammation duodenitis is divided into:

  • Bulbit or proximal duodenitis (only the bulb is affected) - the most common form;
  • Postbulbar or distal duodenitis (inflammation is detected in the vaginal departments);
  • Papillitis or local duodenitis (the process is localized in the zone of the duodenal papilla);
  • Diffuse or total duodenitis (the entire organ is involved).

At endoscopic examination on visual data the following types of duodenitis are established:

  • Erythematous (mucous edematous and reddened);
  • Hemorrhagic (when hemorrhages are detected - hemorrhages);
  • Atrophic (this method can detect only indirect signs of atrophy - thinning of the mucosa, visualization of translucent vessels, finally confirm atrophic changes allows histological evaluation);
  • Erosive (in the case of formation of mucosal surface defects - erosion)
  • Nodular (when small formations resemble nodules are visible).

In addition, endoscopists often evaluate the degree of activity of the existing inflammation (I-III).

Considering and analyzing the structure of the duodenal mucosa under a microscope, pathomorphologists distinguish:

  • Superficial duodenitis (only superficial layers of the mucosa underwent changes);
  • Diffuse or interstitial duodenitis (the entire thickness of the duodenal mucosa is affected)
  • Atrophic duodenitis.

In addition, they qualify duodenitis in terms of the levels of active inflammation, the severity of atrophy, the number of inflammatory cells in the mucosa, bacterial colonization.

Symptoms of duodenitis

Duodenitis can begin either suddenly or gradually. Often he manifests after some dietary excess, alcohol consumption, stress. Duodenitis is usually difficult to distinguish from other ailments of the digestive system. After all, it is characterized by the same clinical signs as for most other gastroenterological ailments:

  • Pain (weak or very intense pain associated with the type and timing of food intake, occur in the upper abdominal areas: epigastric zone, hypochondria);
  • Signs of gastric dyspepsia (heaviness, burning or discomfort in the epigastric zone, belching, nausea, bloating);
  • Problems with stool (chronic diarrhea or regular constipation, their alternation);
  • Psychoemotional disorders (unmotivated irritability, tearfulness, rapid emotional exhaustion, etc.).

Depending on the combination of symptoms, duodenitis may have the following clinical forms:

  • Ulcerous (the most frequent variant, "night" and "hungry" pains at the top of the abdomen are very similar to those that are characteristic of peptic ulcer, they are combined with acidic eructations and persistent constipation);
  • Gastritis-like (pain occurs after eating, they are often accompanied by gastric dyspepsia);
  • Cholecystoid (pain similar to biliary colic, bitterness in the mouth, vomiting of bile);
  • Pancreatic (in patients the leftmost hypochondrium is painful, "shingles", diarrhea, vomiting can be observed);
  • Neuromuscular (sweating, episodes of fainting and weakness, palpitations, etc.);
  • Mixed (with this form, the patients have signs of various other forms of duodenitis);
  • Asymptomatic (established in the case of complete absence of clinical manifestations, common among elderly patients).

Diagnosis of duodenitis

A competent specialist is able to suspect duodenitis after a conversation with the patient who came to him and his examination. But for the final verification of this not too frequent diagnosis, a comprehensive and comprehensive examination is needed. Its volume can be different, because the clinical situations in different patients differ. As a rule, the doctor first recommends:

  • Endoscopic examination - fibrogastroduodenoscopy (the main method that shows the state of duodenal mucosa, the presence of hemorrhages, ulcers, motor disorders and allows to obtain biopsy samples for histological evaluation or detection of microorganisms in them);
  • Chromogastroduodenoscopy (using specific dyes - methylene blue, congos-mouth, endoscopists can indirectly assess the presence and prevalence of sites of gastric metaplasia in the duodenal mucosa and take exactly from them mucosal samples - biopsy samples);
  • Histological (pathomorphological) evaluation of the structure of duodenal mucosa (fixes inflammatory changes and their severity, development of atrophy, gastric metaplasia, dissemination of Helicobacter pylori, differentiates different forms of duodenitis);
  • X-ray examination (X-ray of the duodenum with application of contrast suspensions and double contrasting can detect triggering heavy duodenitis with coarse thickened folds of mucous and / or erosions, assess motor-evacuation abilities, establish post-ulcer cicatricial deformity and distinguish it from spasm typical of duodenitis);
  • Tests for the detection of Helicobacter pylori microbes: express methods for studying biopsies, immunoassay analysis of stool and blood, bacteriological, molecular-genetic, respiratory with urea;
  • Ultrasonography (with severe duodenitis, sometimes an experienced specialist can notice a thickened wall of an inflamed duodenum or signs of a motor disorder, but the method is needed to eliminate the ailments of the pancreatobiliary system, liver, kidneys);
  • Endoscopic ultrasonography (the study can be highly informative with local duodenitis with lesion of the large duodenal papilla, as well as pancreatitis, scars and stones in the ducts, tumor process);
  • Duodenal sounding (a slightly forgotten technique that examines the quality of duodenal secretion, the preservation of cavitary duodenal digestion, reveals a parasitic lesion);
  • Computer gastroenterography (a modern technique for analyzing the motor activity of the duodenum) or duodenokinesisography;
  • Studies of stool and blood for the presence of parasitic agents.

In the case of secondary duodenitis, individual patients may additionally be assigned floor-by-floor manometry, retrograde cholangiopancreatography, CT or MRI procedures, biochemical blood tests, coprograms, assessment of fecal elastase-1, fibroileo colonoscopy, 24-hour gastric pH monitoring, enterography, hepatocholecystography, electrocardiography, Renography, ultrasound of the heart and other methods.

Treatment of duodenitis

In general, patients with exacerbation of duodenitis are treated in outpatient settings. However, some patients still have to be sent to a hospital. Indications for this are:

  • Intense pain and / or dyspepsia;
  • Periduodenitis (transition of inflammation from the duodenum to nearby organs and tissues);
  • Bleeding erosion;
  • Suspected development of duodenal obstruction;
  • Decompensated or serious concomitant diseases;
  • Suspicion of a possible oncological nature of the process;
  • Diagnostic difficulties;
  • Failure of outpatient treatment.

Medical measures for duodenitis should be comprehensive. All patients need an orderly regime of the day, refusal of smoking and alcohol, regular walks. They are recommended as diet therapy, and the intake of the necessary medications.

Health food

Patients with duodenitis should change their eating habits. It is advisable fractional food, the volume of a single portion should be placed in the palms of the patient. If the patient has already started to be treated with highly effective modern medicines, chopping and rubbing is necessary only with severe duodenitis. Boiled dishes are allowed. They must necessarily be warm, as the cold can aggravate spasm and motor disorders (clinically the patient will resume or pain will increase).

It is advisable to remove from the diet all products that can irritate or damage the duodenal mucous membrane, stimulate the production of digestive juices and alter the duodenal motility. Such undesirable products are all sour berries, juices, fruits, spicy seasonings, ketchup, garlic, radish, watercress, onion and green onions, radish, fatty meat, red fish, smoked products, rich fish or meat broths, pickles, lard, Mushrooms, cream, fatty milk, marinades. It is desirable to limit the amount of coffee, strong tea, salt (up to 10 g).

The patient is recommended rice, buckwheat, semolina, oatmeal, mucous and milk soups, soft-boiled eggs, non-acidic jelly, omelettes, vegetable casseroles and soufflé, fresh and low-fat cottage cheese, vegetarian soups (possibly adding boiled meat: veal, chicken, rabbit, Turkey), noodles, lean meat in the form of steam cutlets, dumplings, meatballs, doctor's sausage, puddings, dry biscuits, white dried bread, drying, sweet ripe fruits without coarse fiber. Particular importance is given to vegetable fats, their quota is about one-third of all fats consumed. Different vegetable oils are allowed (soybean, sunflower, corn, pumpkin, etc.).

If the concomitant pathology allows, then when the remission of duodenitis is reached, most of the dietary restrictions are removed. Nutrition can correspond to the normal diet of a healthy person (table number 15).

Drug therapy

Having studied the results of the examination, the doctor develops an individual scheme for taking medications. Its composition and duration vary. However, in most cases the following are used:

  • Antacids and alginates for the relief of symptoms caused by excessive acid production (maalox, renni, relzer, almagel, gelusil-lac, rutatsid, fosfalugel, geviskon, kompensan, etc.);
  • Adsorbing antacids with colloidal bismuth (vicair, ventrisol, de-nol, vikalin), which neutralize excess hydrochloric acid, protect the duodenal mucosa and fix it;
  • Sekretolitiki - means for lowering gastric acid production (famotidine, pantoprazole, esomeprazole, lansoprazole, etc.);
  • Antiparasitic drugs or anthelmintics (their choice is made only after a clear identification of the species of parasite that has settled in the body, since anthelmintic drugs are highly toxic, patients are recommended makmiror, facisin, tinidazole, amnokhinolin, vermitox, nemozol, metronidazole, praziquantel, chloroxyl, etc.);
  • The fight against Heicobacter pylori (there are now several internationally verified hard eradication regimens that may include combinations of a few specific antibiotics, secretolytics, bismuth drugs);
  • Antispasmodics, which eliminate spasm and, consequently, pain (fenicaberan, duspatalin, meteospazmil, drotaverin, buscopan, papaverine, etc.);
  • Regulators of duodenal motility (domperidone or motilium, taeopride or ghanaton, metoclopramide or cerucal);
  • Polyenzymes for correction of digestive function in case of atrophic duodenitis (pancitrat, mikrazim, creon, hermital, panzinorm, etc.);
  • Reparants to accelerate the healing of duodenal mucosa (solkoseril, kaleflon, sea buckthorn oil, ethaden, biogastron, riboxin, carnitine, etc.);
  • Holospazmolitiki for relaxing the sphincter apparatus located in the thickness of the duodenal nipple (claston, olimethine, platifillin, preparations of belladonna, etc.);
  • Psychotropic medications (amitriptyline, euglon, attarax, phenazepam, elenium, seduxen, relanium, pyrazidol, etc.).

Sometimes pharmacotherapy is supplemented with some physiotherapeutic procedures that have analgesic, anti-inflammatory and antisecretory effects. Patients with duodenitis are recommended electrophoresis with papaverine, dalargin, novocaine or platifillin, ultrasound, decimeter waves, Bernard currents, UHF, mud therapy (sapropelic, mud, peat mud), coniferous, valerian or radon baths, paraffin applications, acupuncture.

If the patient has been verified erosive duodenitis, then it is not enough to focus only on the positive dynamics, which consists in the disappearance of clinical symptoms. But clinical improvement is not always accompanied by the normalization of the endoscopic picture. Therefore, endoscopic control is necessary, which will confirm the healing (epithelization) of erosion.

In the period of remission patients with duodenitis are shown sanatorium treatment.


| 4 October 2014 | | 454 | Diseases of the digestive tract
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