Ulcers can be both single and multiple (more than three). Their significant difference from more superficial defects of the mucous membrane (for example, erosion) is that this damage affects the deeper layers (including the submucosal, muscular) of the gastric or intestinal wall. After healing of such ulcers, scars are always formed.
On average, the prevalence of the disease reaches 10%. The duodenum is affected four times more often than the stomach. Among the patients dominated by men of young and middle age with the first 0 (I) blood group. In women, the incidence of peptic ulcer disease increases significantly with the onset of menopause (this is associated with a deficiency in the production of female hormones such as estrogens). Mortality does not exceed 5%, basically it is associated with terrible complications of the disease (perforations, bleeding).
Causes of gastric ulcers
Modern scientists believe that the development of peptic ulcer disease is a violation of the fragile balance between the factors of aggression and the factors of protection of the gastroduodenal mucosa. Such factors of aggression are:
- excessive production of gastric juice with its essential ingredients: hydrochloric acid and pepsin;
- duodenogastric reflux (a return hit of a contents from a duodenum together with bilious components in a stomach);
- infection of the gastric mucosa with Helicobacter pylori microbes (up to 75% of gastric localization ulcers and more than 90% of ulcers found in the duodenum are associated with these tiny microorganisms and the mucous membrane cells are inflamed and destroyed).
It should be noted that not all species of Helicobacter pylori microorganisms have ulcerogenicity (potential ability to ulcerate). And far from all infected people develop peptic ulcer and other diseases associated with these microbes (stomach cancer, chronic gastritis , MALT-lymphoma).
Protection factors include:
- bicarbonates (substances to neutralize excess hydrochloric acid);
- mucoproteins (mucus that covers the cells of the gastric mucosa):
- sufficient blood supply to the gastroduodenal mucosa;
- adequate local mucosal immunity.
In case of a peptic ulcer, the activity of aggression factors increases against the background of a deficiency or insufficient function of protection factors, which leads to the formation of ulcerous defects.
In addition, the occurrence or recurrence of peptic ulcer disease contribute to:
- poor nutritional habits;
- chronic and acute stress or mental overload;
- burdened heredity (in 15–40% of patients, close relatives also have peptic ulcer of one or another localization);
- smoking (it also slows down the healing of already formed ulcers);
- alcohol abuse (strong drinks stimulate the production of aggressive gastric juice);
- already existing chronic gastritis with high secretory activity (production of gastric juice);
- environmental problems.
As a rule, the combined effect of various factors leads to the realization of an existing genetic defect (an excess of cells synthesizing hydrochloric acid, or a deficiency in the production of protective components of mucus).
By location separately emit:
- stomach ulcers:
- cardiac ulcer;
- stomach ulcer;
- antral ulcer;
- ulcer pyloric canal;
- duodenal ulcers (localized in the duodenum):
- bulb ulcer;
- ulcer ulcer;
- combined ulcers (simultaneously affecting both the stomach and the duodenum).
Depending on the size of the large ulcers are divided into:
- large ulcers (more than 2 centimeters in size);
- giant ulcers (their diameter exceeds 3 centimeters).
During peptic ulcer disease are distinguished:
- phase of exacerbation (relapse);
- phase of subsiding or fading aggravation;
- remission phase.
Symptoms of stomach ulcers
Peptic ulcer disease is quite characteristic clinical manifestations. Therefore, an experienced specialist can often suspect this disease according to the complaints of the patient who came to the reception. As a rule, patients are worried about:
- constant or paroxysmal aching pains in the epigastric (epigastric) area or localized immediately under the xiphoid process of the sternum, directly related to eating food (if ulcers are located in the cardiac part, they appear or increase literally in a few minutes, if the stomach is affected, the pain begins in half an hour or 1 , 5 hours, and in the case of duodenal localization, they develop on an empty stomach and are stopped by food);
- "Night" pain (are the prerogative of duodenal ulcers and ulcers, formed in the output of the gastric section);
- Irradiation or spread of pain in the back, hypochondrium, or umbilical region (non-permanent symptom);
- feeling of heaviness, burning, overflowing and discomfort in the stomach on an empty stomach or after food;
- Nausea, which can be replaced by abundant vomiting that occurs at the peak of digestion (about half an hour or 1.5 hours after eating food) and leads to pronounced relief (disappearance of both nausea and pain), vomitus contain eaten food, sometimes bile is visualized;
- violation of the chair (more often there is a tendency to reflex constipation during exacerbation);
- increased appetite (due to increased gastric secretion);
- weight loss (some patients begin to reduce the amount of food eaten and the frequency of its use because of the fear of renewed pain);
- psycho-emotional disorders (low mood, excessive anxiety, aggressiveness, fatigue, suicidal thoughts, internal stress, sleep disorders).
The disease usually develops gradually. However, sometimes asymptomatic disease is observed. In such clinical cases, the disease debuts with the appearance of complications or long-standing post-ulcer scars become an unexpected finding with endoscopy.
Complications of gastric ulcers
Peptic ulcer disease is fraught with terrible complications that can be fatal. Each of them is characterized by its specific clinical features. These specific complications include:
- gastrointestinal bleeding (its development is indicated by sudden weakness, feeling of nausea, black vomiting and runny tarry stools, loss of consciousness may be observed, while existing abdominal pains stop);
- perforation or perforation (the process extends to the entire thickness of the gastric or duodenal wall, through the resulting acidic defect penetrates into the abdominal cavity and provokes the development of peritoneal inflammation - peritonitis; this complication is accompanied by intense "dagger" pains and doskomobraznym muscular tension in the supporting tissue) ;
- penetration (penetration of ulcers into adjacent organs, more often into the pancreas, after which signs of inflammation, called pancreatitis , appear: the nature and irradiation of pains change, they are not relieved by traditional anti-ulcer drugs);
- stenosis (severe cicatricial deformity leads to a significant narrowing of the duodenal bulb or the outlet of the stomach, which manifests fetid vomiting yesterday's food, a significant weight loss, a decrease in appetite, metabolic disorders);
- stomach cancer (malignant transformation occurs in 4% of cases of gastric ulcers, its signs can be increasing weight loss, change in pain, disappearance of their connection with food, aversion to food, progressive weakness, sometimes swallowing disorders or stenosis described above appear).
Diagnosis of the disease
Already from one physical examination of a patient with a relapse or debut of a peptic ulcer, a competent specialist can obtain indicative important diagnostic information. With severe exacerbation, which is accompanied by severe pain, patients lie on their side or back with their legs bent at the knees and press the abdominal area with their hands. This helps to reduce the tension of the abdominals. If the ulcerative defect is located on the back of the gastric wall, then it becomes a little easier for patients when they lie on the stomach and place a pillow under it. This provision reduces the pressure of the inflamed stomach on the celiac nerve plexus and significantly reduces pain.
The tongue in such patients is coated with a white-yellow bloom. The absence of abdominal wall movements that are synchronous with breathing is observed during the development of peritonitis (a constant consequence of perforation of gastric or duodenal ulcers). When pressing and tapping the abdomen, the doctor reveals in the area of the projection of the stomach and duodenum limited local pain and sometimes local muscle tension. In addition, pain is sometimes found in the reflex zones (spinous processes of a number of thoracic vertebrae VII - XII - Openchowski points, etc.). If pyloroduodenal cicatricial stenosis develops when tapping the epigastric zone, a splash noise specific to this complication can be detected.
After analyzing the complaints and medical examination data, to clarify the suspected diagnosis, the specialist further recommends a comprehensive examination:
- Endoscopic examination (fibroesophagogastroduodenoscopy) is the main diagnostic method that allows you to see ulcers, determine their location, number, appearance, size, depth, inflammatory changes of the mucosa around the ulcer, fresh and old scars, bleeding, establish contamination with Helicobacter pylori bacteria, produce multiple scars biopsy specimens (gastroduodenal tissue samples) to exclude pre-cancerous mucosal transformation and an already developed oncological process, carry out local treatment (stopping bleeding, obkalyvanie gastroduodenal ulcers with slow scarring);
- chromogastroscopy with contrast dyes (reveals excess gastric secretion and the formation of precancerous changes);
- morphological analysis (microscopic examination confirms the ulcer lesion, assesses the intensity of inflammation, atrophic and sclerotic processes, eliminates the malignant degeneration of the gastric mucosa);
- fluoroscopy with contrasting barium suspension - the technique verifies and clarifies the location of ulcers, their size and depth, eliminates complications (stenosis, penetration), assesses motor activity, the presence of cicatricial deformities, infiltrating the gastric wall of oncological processes, but cannot serve as a complete replacement for endoscopic examination ;
- general radiography for the detection of free air trapped in the abdominal cavity (a specific sign of perforation);
- methods for the detection of Helicobacter pylori (histological, rapid methods, planting biopsy specimens for special bacteriological environments, respiratory, serological tests, etc.);
- endoscopic ultrasonography - the method is used in case of suspected formation of cancer infiltration (thickening of the gastric wall);
- pH-metry - a study evaluates the state of the acid-forming function of the stomach (with a peptic ulcer it is usually elevated or normal).
Stomach ulcer treatment
Depending on the specific clinical situation, the patient is prescribed:
- conservative treatment:
- diet therapy;
- drug (drug) treatment;
- minimally invasive surgical procedures;
- radical surgical treatment.
Most patients are treated on an outpatient basis. Patients with an intense pain syndrome, suspicion of a complicated course, are hospitalized with gigantic, deep and multiple ulcers, lack of effect from adequate outpatient treatment, and patients with an unclear diagnosis.
With the advent of powerful and highly effective drugs, the diet has become of secondary importance in the treatment of patients with peptic ulcer. However, doctors usually recommend that patients adhere to certain rules of nutrition. They boil down to the following requirements:
- for the purpose of chemical sparing of the inflamed mucosa, all marinated, smoked, spicy, sour and excessively salty foods (including rye bread, cranberries, plums, lingonberries, red currants, ketchup, etc.) should be excluded;
- vegetables rich in extractive substances (onions, radishes, garlic, radish, cress, etc.) and rich broths are prohibited;
- It is undesirable to use too cold or too hot dishes;
- food is boiled (optional wipe);
- necessary (as a kind of building material) for healing the gastroduodenal mucous protein enters the body of patients with a sufficient amount of boiled non-lean lean meat, lean fish, egg white, soy and dairy products, special protein nutrient mixtures (nutridrink, super 2640, nutrizon, berlamin, nutricomp and others);
- fractional nutrition (up to 6 times per day).
The diet can be supplemented with medicinal mineral waters. They should be low-mineralized, with minimal or no carbon dioxide, with a neutral, alkaline, or slightly acidic reaction. Mineral waters such as Essentuki No. 4, Jermuk, Borzhomi, Berezovskaya, Slavyanovskaya, Smirnovskaya No. 1 meet these requirements. They should be drunk in a slightly heated form after 2 hours (for duodenal ulcers and ulcers of the outlet part of the stomach) or half an hour after eating dietary foods (if ulcers are localized in the body of the stomach). Begin treatment with a third of a glass of mineral water at the reception. Subsequently, under the condition of normal tolerance, its volume is increased to a whole glass.
Currently, there are many highly effective anti-ulcer drugs, so competent medical therapy is the basis for the treatment of patients with peptic ulcer. Regimens recommended by doctors may include the following groups:
- sekretolitiki - means that reduce the production of hydrochloric acid and promote the scarring of ulcers:
ü M-anticholinergics (platifillin, gastrocepin, metacin, telenzepin, etc.);
ü H2 (histamine) receptor blockers (roxacidin, ranitidine, famotidine, nizatidine, pyloride, etc.);
ü proton pump blockers (pantoprazole, omeprazole, lansoprazole, esomeprazole, rabeprazole, etc.) are the most powerful and modern of all secretolytics;
- means for the complete elimination (eradication) of Helicobacter pylori microorganisms (effective eradication schemes are combinations of proton pump blockers with individual antibiotics (tetracycline, clarithromycin, levofloxacin, metronidazole) and preparations containing bismuth);
- nonabsorbable and absorbed antacids, which allow to neutralize excess hydrochloric acid and arrest muscle spasm (renny, protab, maalox, gastal, almagel, compensated, phosphalugel, gelusil varnish, Gaviscon, etc.);
- gastrocytoprotectors that increase the resistance of the gastroduodenal mucosa:
- colloidal bismuth preparations (ventrisol, de-nol, etc.);
- cytoprotectors that stimulate the formation of protective mucus (cytostech, carbenoxolone, enprostil, etc.);
- smect (forms a protective film);
- astringent and enveloping preparations (vikair, vikalin, etc.);
- reparants, stimulating the restoration of the gastroduodenal mucous membrane and scarring of ulcers (solcoseryl, gastropharm, sea buckthorn oil, acemin, keleflon, eden, retabolil, etc.);
- psychotropic drugs (Elenium, diazepam, seduxen, infusion of motherwort and valerian).
The key role is played by secretolytics and eradication therapy. The remaining drugs are supplement. The duration of the course of antisecretory drugs is determined by the size, quantity, depth, location of ulcerative defects, the state of the surrounding gastroduodenal mucosa, and related illnesses. It usually ranges from 2 to 8 weeks. Effective eradication of Helicobacter pylori microorganisms can prevent further recurrences of peptic ulcer.
Adequate treatment leads to the rapid disappearance of pain (sometimes after 3 days), but the relief of pain does not mean the healing of ulcers and does not allow for stopping the medication prescribed by the doctor. Endoscopic examination to assess the success of the treatment, usually recommended after 4 (duodenal ulcers) or 6 (gastric ulcers) weeks.
Physiotherapy techniques demonstrate their effectiveness in combination with the mandatory drug treatment. Они способствуют уменьшению болей, улучшают местное крово- и лимфообращение, обладают противовоспалительным воздействием, ускоряют восстановление гастродуоденальной слизистой.
На пике обострения заболевания пациентам обычно назначают микроволновую терапию, синусоидальные токи, диадинамические токи, ультразвук, магнитотерапию, гальванизацию, электрофорез с папаверином, новокаином или даларгином, гипербарическую оксигенацию.
В период стихания обострения разрешаются торфяные, парафиновые, грязевые, озокеритовые аппликации на подложечную (эпигастральную) область, гальваногрязь, УВЧ, электрофорез с теми же лекарственными средствами, валериановые ванны или ванны с минеральной водой.
Противопоказаниями к применению любых физиотерапевтических процедур служат все осложнения (см. выше) язвенной болезни.
Правильно подобранные комплексы нехитрых гимнастических упражнений могут:
- стабилизировать нервную регуляцию гастродуоденальной зоны;
- увеличить локальное кровоснабжение и окислительно-восстановительные процессы в слизистой;
- поднять мышечный тонус (общий и местный);
- улучшить психоэмоциональный статус пациентов;
- оказать общетонизирующий эффект.
Во избежание осложнений и усиления болей занятия начинают в период стихания обострения недуга. Гимнастический комплекс должен составляться индивидуально для каждого пациента. Больным показаны общеразвивающие и дыхательные упражнения (динамические и статические). Кроме того, после наступления ремиссии применяются особые упражнения для брюшного мышечного пресса с осторожным увеличением нагрузки.
Хороший эффект оказывают занятия лечебной физкультурой в бассейне, терренкур (ходьба) на свежем воздухе, дозированные спортивные игры (кегельбан, крокет, бадминтон и др.).
Фитотерапия не заменяет медикаментозное лечение. Она увеличивает его эффективность. В случае язвенной болезни правильное использование лекарственных растений (в качестве дополнения к принимаемым лекарственным препаратам) позволяет:
- уменьшить интенсивность имеющегося воспаления;
- справиться с болью;
- защитить гастродуоденальную слизистую от факторов агрессии;
- улучшить снабжение гастродуоденальной слизистой питательными веществами;
- стимулировать заживление язв;
- нормализовать стул.
Anti-inflammatory effects have healing fees, including St. John's wort, yarrow, calendula, etc. The role of natural antispasmodics can be mint, marjoram, chamomile, dill. Eliminating the spasm of the gastric smooth muscle muscles, these wonderful medicinal plants relieve pain. The enveloping action is inherent in licorice, pommel, flax seed. Celandine, chicory, willow-herb, shepherd's purse, burdock root contribute to full-fledged ulcers. To ease the chair, you can apply buckthorn, zhoster, rhubarb, three-leaf watch, etc.
The mentioned medicinal plants are recommended to be used in the form of infusions, decoctions, phytoapplications on the abdominal wall and therapeutic baths. It should not be forgotten that phytoapplication is strictly forbidden for bleeding, pregnancy (all period), fever, any oncological diseases.
Minimally invasive surgical procedures
If during the control endoscopic examination it turns out that the ulcers did not heal, and the comprehensive treatment being carried out was adequate, in some cases traditional therapy is supplemented with endoscopic medical procedures. These may include:
- application of a directly ulcerative defect of drugs (eikonol, etc.) or medical glue through a special Teflon catheter inserted into the biopsy channel of the endoscopic apparatus;
- local obkalyvanie gastroduodenal ulcers (through the endoscope with a special needle directly into the mucosa injected drugs (reparants, antioxidants, immunomodulators): dalargin, solcoseryl, eikonol, oksiferriskorbon, interferon, roncoleukin, etc.);
- intragastric laser therapy (ulcers through the endoscope are irradiated with a low-energy laser: argon, krypton, on copper vapor, helium-neon, helium-cadmium);
- irradiation of ulcers with incoherent red light from a halogen lamp.
The main disadvantage for the patients of these techniques is the fact that repeated and frequent unpleasant endoscopic manipulations are necessary for effective treatment.
Nowadays, doctors have to resort to surgical treatment of patients with peptic ulcer in the development of complications of this disease or in the absence of any effect from all possible methods of complex conservative therapy.
In case of bleeding, a bleeding blood vessel is stitched or gastric resection is performed (in the part where the ulcer is located), or vagotomy (the vagus nerve is stimulated to stimulate the acid production of the stomach) with pylorosplasty.
If the patient has developed ulcerative perforation, then surgeons can perform a resection of a part of the stomach with the resulting defect, perform vagotomy with pyloroplasty or close the defect. Sometimes combine several techniques.
In the case of decompensated stenosis, the doctor resects the stomach or imposes gastrojejunostomy (a fistula between the jejunum and the stomach).
Prevention of gastric ulcers
To avoid peptic ulcer disease, you should quit smoking, do not abuse alcoholic beverages, normalize diet, do not forget about proper rest, avoid stress. In addition, if the patient suffers from chronic gastritis and has an increased acid-forming function of the stomach, then he needs to get rid of Helicobacter pylori microorganisms.
If the peptic ulcer has already developed, then in addition to the measures already mentioned (in order to prevent its possible exacerbations), you should discuss with your doctor the tactics of behavior in the resumption of abdominal pain. For example, some patients are sometimes advised to take antisecretory drugs continuously or “on demand.”
Doctors consider the remission of a peptic ulcer to be complete if within three years or more the patient has absolutely no signs of its exacerbation.