Ulcers can be either single or multiple (more than three). Their significant difference from more superficial mucosal defects (eg, erosion) is that this damage affects deeper layers (including 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 significantly increases with the onset of menopause (this is associated with a deficiency in the production of such female hormones as estrogens). Mortality does not exceed 5%, mainly it is associated with formidable complications of the disease (perforations, bleeding).
Causes of Stomach Ulcers
Modern scientists believe that the development of peptic ulcer disease is disturbed by a shaky 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 integral ingredients: hydrochloric acid and pepsin;
- duodenogastric reflux (reverse entry of contents from the duodenum together with bile components into the stomach);
- infection with gastric mucous microbes Helicobacter pylori (with these tiny microorganisms associated up to 75% of gastric ulcers and more than 90% of ulcers found in the duodenum, the substances they produce provoke inflammation and destruction of cells of the mucosa).
It should be noted that not all types of microorganisms Helicobacter pylori have ulcerogenicity (potential for ulceration). And far from all infected people develop peptic ulcer and other associated with these microbes ailments (stomach cancer, chronic gastritis , MALT-lymphoma).
Factors of protection 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 immunity to the mucosa.
With peptic ulcer, the activity of aggression factors increases against the background of deficiency or insufficient function of the protective factors, which leads to the formation of ulcerative defects.
In addition, the occurrence or new relapses of peptic ulcer are facilitated by:
- irrational, erratic eating;
- 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 the healing of already formed ulcerative defects);
- alcohol abuse (hot drinks stimulate the production of aggressive gastric juice);
- already existing chronic gastritis with high secretory activity (production of gastric juice);
- ecological problems.
As a rule, to the realization of the existing genetic defect (the excess of cells synthesizing hydrochloric acid, or the deficit of the production of protective components of mucus) results in a combined effect of various factors.
Classification of the disease
By location separately are allocated:
- stomach ulcers:
- cardiac ulcer;
- an ulcer of the body of the stomach;
- anthrax ulcer;
- ulcer pyloric canal;
- duodenal ulcers (localized in the duodenum):
- ulcer bulbs;
- ulcer ulcer;
- combined ulcers (simultaneously affecting both the stomach and duodenum).
Depending on the size of large ulcers are divided into:
- large ulcers (measuring more than 2 centimeters);
- giant ulcers (their diameter exceeds 3 centimeters).
In the course of peptic ulcer disease distinguish:
- a phase of exacerbation (relapse);
- the phase of a subsiding or dying exacerbation;
- phase of remission.
Symptoms of a stomach ulcer
The peptic ulcer has rather characteristic clinical manifestations. Therefore, often on the complaints of a patient who has come to the clinic, an experienced specialist can suspect this disease. As a rule, patients are concerned about:
- permanent or paroxysmal aching pains in the epigastric region or localized immediately under the xiphoid process of the sternum, associated directly with eating (with the location of the ulcer in the cardiac part they appear or intensify in just a few minutes, with lesions of the body of the stomach pain begin in half an hour or 1 , 5 hours, and in case of duodenal localization they develop on an empty stomach and are stopped by food);
- "Night" pain (are the prerogative of duodenal ulcers and ulcerative defects formed in the outlet gastric department);
- irradiation or spreading of emerging pains in the back, hypochondrium or peribulary zone (non-permanent symptom);
- feeling of heaviness, burning, overflow and discomfort in the stomach area on an empty stomach or after eating;
- nausea, which can be replaced by the abundant vomiting that occurs at the peak of digestion (after about half an hour or 1.5 hours after eating) and resulting in marked relief (disappearance of both nausea and pain), vomit contains eaten food, sometimes in them bile is visualized;
- disorders of stool (tend to reflex locks 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 fear of resumption of pain);
- psychoemotional disorders (low mood, excessive anxiety, aggressiveness, fatigue, suicidal thoughts, internal tension, sleep disorders).
Usually the disease develops gradually. However, sometimes there is a completely asymptomatic course of the disease. In such clinical cases, the disease debuts with the appearance of complications or long-term post-ulcer scars become an unexpected finding in endoscopic examination.
Complications of stomach ulcers
The peptic ulcer is fraught with formidable complications, which can be fatal. Each of them is characterized by its special clinical signs. These specific complications include:
- gastrointestinal hemorrhage (its development is evidenced by sudden weakness, sensation of faintness, vomiting of black color and liquid tarry stool, there may be a loss of consciousness, while the existing abdominal pains cease);
- perforation (the process extends to the entire thickness of the gastric or duodenal wall, through the resulting defect, acidic content penetrates into the abdominal cavity and provokes the development of peritoneal inflammation-peritonitis, this complication is accompanied by intense "dagger" pains and a dull muscle tension in the epigastric zone) ;
- Penetration (penetration of ulcers into a number of located organs, more often - into the pancreas, after which there are signs of inflammation called pancreatitis : character changes and irradiation of pains, they are not removed with traditional antiulcer drugs);
- stenosis (severe scar deformation leads to a significant narrowing of the bulb of the duodenum or the outlet of the stomach, which manifests by malodorous vomiting yesterday's food, significant weight loss, decreased appetite, metabolic disorders);
- stomach cancer (malignant transformation is observed in 4% of cases of gastric ulcers, its signs can serve as an increasing loss of weight, changes in pain, loss of their connection with food, aversion to food, progressive weakness, sometimes swallowing disorders or the above-described manifestations of stenosis).
Diagnosis of the disease
Already from a single physical examination of the patient with a relapse or debut of peptic ulcer, a competent specialist can obtain indicative important diagnostic information. In severe exacerbation, which is accompanied by severe pain, the patients lie on their side or back with knees bent at the knees and press the painful abdominal zone with their hands. This helps reduce the tension of the abdominal press. If the ulcer defect is located on the posterior gastric wall, then the patients become slightly lighter when they lie down on the stomach and put a pillow under it. This position reduces the pressure of the inflamed stomach on the celiac neural plexus and significantly reduces pain.
The tongue of such patients is coated with a white and yellow coating. Absence of movements of the abdominal wall, synchronous with breathing, is observed in the development of peritonitis (an unchanged consequence of perforation of gastric or duodenal ulcers). When pressing and tapping the abdomen, the doctor reveals a limited local soreness in the projection zone of the stomach and duodenum and sometimes local muscle tension. In addition, sometimes soreness appears in the reflex zones (spinous processes of a number of thoracic vertebra VII - XII - the point of Openchovsky, etc.). In the case of pyloroduodenal cicatricial stenosis development, when tapping the epigastric zone, a splash noise specific for this complication can be detected.
After analyzing the complaints and data of the medical examination, to clarify the suspected diagnosis, the specialist recommends a comprehensive examination:
- endoscopic examination (fibro-esophagogastroduodenoscopy) is the main diagnostic method that allows to see ulcer defects, determine their location, quantity, appearance, magnitude, depth, inflammatory changes of the mucosa around the ulcer, fresh and old scars, bleeding, establish dissemination of Helicobacter pylori bacteria, bioptates (samples of gastroduodenal tissue) to exclude pre-cancerous transformation of the mucosa and the already developed oncological process, treatment (stopping bleeding, cutting gastroduodenal ulcers with slow scarring);
- Chromogastroscopy with contrasting dyes (reveals excessive gastric secretion and the formation of precancerous changes);
- morphological analysis (microscopic examination confirms ulcerative lesion, assesses the intensity of inflammation, atrophic and sclerotic processes, excludes malignant degeneration of the gastric mucosa);
- fluoroscopy with contrasting barium suspension - the technique verifies and clarifies the location of ulcerative defects, their size and depth, excludes the development of complications (stenosis, penetration), assesses motor activity, the presence of scar deformities infiltrating the gastric wall of cancer processes, but can not serve as a full replacement for endoscopic examination ;
- survey radiography for the detection of free air trapped in the abdominal cavity (a specific sign of perforation);
- methods for detecting Helicobacter pylori (histological, express methods, seeding biopsy specimens for specific bacteriological environments, respiratory, serological tests, etc.);
- endoscopic ultrasonography - the method is used when there is a suspicion of the formation of cancer infiltration (thickening of the gastric wall);
- pH-metry - the study assesses the state of the acid-forming function of the stomach (with peptic ulcer it is usually increased or normal).
Treatment of gastric ulcer
Depending on the specific clinical situation, the patient is assigned:
- conservative treatment:
- diet therapy;
- medicamentous (medicinal) treatment;
- minimally invasive surgical procedures;
- radical surgical treatment.
Most patients are treated on an outpatient basis. Hospitalized patients with severe pain syndrome, suspected complications of the course, giant, deep and multiple ulcers, lack of the effect of adequate outpatient treatment, 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 generally recommend that patients adhere to certain dietary rules. They are reduced to the following requirements:
- with the aim of chemical shaking of inflamed mucous it is necessary to exclude all pickled, smoked, spicy, acidic and excessively salty dishes (including rye bread, cranberries, plum, cranberries, red currants, ketchup, etc.);
- forbidden rich in extractive substances vegetables (onions, radish, garlic, radish, watercress, etc.) and rich broth;
- It is undesirable to use too cold or too hot dishes;
- food is given in a cooked form (it is not necessary to wipe it);
- (as a kind of building material) for the healing of gastroduodenal mucosa the protein enters the body of patients with a sufficient amount of boiled non-lean lean meat, lean fish, egg protein, soy and dairy products, special protein nutrient mixtures (nutridrink, supro 2640, nutrison, beramine, nutricomp, etc.);
- fractionality of food (up to 6 times a day).
The diet can be supplemented with medicinal mineral waters. They should be of low mineralization, with minimal or no carbon dioxide, with a neutral, alkaline or slightly acid reaction. These requirements correspond to such mineral waters as Essentuki No. 4, Jermuk, Borjomi, Berezovskaya, Slavyanskaya, Smirnovskaya No. 1. They should be drunk slightly warmed after 2 hours (with duodenal ulcers and gastric ulcers) or half an hour after eating a diet (in case of localization of ulcers in the body of the stomach). Begin the treatment with a third of a glass of mineral water at the reception. In the future, under the condition of normal tolerance, its volume is increased to a whole glass.
Currently, there are many highly effective antiulcer drugs, so competent drug therapy is the basis for the treatment of patients with peptic ulcer. The recommended drug regimens can include the following groups of drugs:
- secretolitics - drugs that reduce the production of hydrochloric acid and contribute to cicatrization of ulcerative defects:
ü M-holinolitiki (platifillin, gastrocepin, metacin, telenzepin, etc.);
ü H2 blockers (histamine) receptors (roxacidin, ranitidine, famotidine, nizatidine, pyloride, etc.);
ü Proton pump inhibitors (pantoprazole, omeprazole, lansoprazole, esomeprazole, rabeprazole, etc.) are the most powerful and modern of all secretolytics;
- means for complete elimination (eradication) of microorganisms Helicobacter pylori (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 can neutralize excess hydrochloric acid and stop muscle spasm (renni, protab, maalox, gastal, almagel, kompensan, phosphalugel, gelucil-lac, Gaviscon, etc.);
- gastrocytoprotectors, strengthening resistance gastroduodenal mucosa:
- preparations of colloidal bismuth (ventrisol, de-nol, etc.);
- cytoprotectors, stimulating the formation of protective mucus (saitotec, carbenoksolon, enprostil, etc.);
- smect (forms a protective film);
- astringent and enveloping preparations (vicair, vikalin, etc.);
- Reparants stimulating the restoration of gastroduodenal mucosa and scarring of ulcers (solkoseril, gastropharm, sea buckthorn oil, atemine, kaleflon, etaden, retabolil, etc.);
- psychotropic drugs (elenium, diazepam, seduksen, motherwort infusion and valerian).
A key role is played by secretolitics and eradication therapy. The rest of the drugs are a supplement. The duration of the course of antisecretory drugs is determined by the size, amount, depth, location of ulcerative defects, the state of the gastroduodenal mucosa surrounding them, accompanying diseases. Usually it is from 2 to 8 weeks. Effective eradication of microorganisms Helicobacter pylori is able to prevent further recurrences of peptic ulcer.
Adequate treatment leads to the rapid disappearance of pain (sometimes in 3 days), but the relief of pain does not indicate the healing of ulcers and does not allow to stop taking prescribed medications. Control endoscopic examination to evaluate the success of the treatment is usually recommended to be carried out through 4 (duodenal ulcers) or 6 (gastric ulcers) weeks.
Physiotherapeutic methods demonstrate their effectiveness in combination with mandatory medication. 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.
In order to avoid complications and intensify the pain, classes begin during the period when the aggravation of the disease subsides. Gymnastic complex should be made individually for each patient. The patients are shown general developing and breathing exercises (dynamic and static). In addition, after the onset of remission, special exercises are used for the abdominal muscular press with a cautious increase in the load.
A good effect is exercising physical therapy in the pool, health walk (walking) in the fresh air, metered sports games (bowling alley, croquet, badminton, etc.).
Phytotherapy does not replace medical treatment. It increases its effectiveness. In the case of peptic ulcer, the correct use of medicinal plants (as a supplement to the medicinal products taken) allows:
- reduce the intensity of the existing inflammation;
- coping with pain;
- protect gastroduodenal mucosa from aggression factors;
- improve the supply of gastroduodenal mucosa nutrients;
- stimulate the healing of ulcers;
- normalize the stool.
Anti-inflammatory effect has healing fees, including St. John's wort, yarrow, calendula, etc. In the role of natural antispasmodics, mint, oregano, chamomile, dill may perform. Eliminating the spasm of the gastrointestinal musculature, these wonderful medicinal plants stop the pain. The enveloping action is inherent in licorice, elecampane, flax seed. Complete cicatrization of ulcers is facilitated by celandine, chicory, kipreja, shepherd's bag, burdock root. To relax the stool, you can use buckthorn, jaoster, rhubarb, triple leaf watch, etc.
These medicinal plants are recommended to be used as infusions, decoctions, phytoapplications on the abdominal wall and therapeutic baths. At the same time, we should not forget that phytoapplications are strictly forbidden for bleeding, pregnancy (the entire period), fever, any cancer.
Minimally invasive surgical procedures
If the control endoscopic examination reveals that the ulcers did not heal, and the ongoing complex treatment was adequate, in some cases traditional therapy is supplemented with endoscopic treatment procedures. These may include:
- application to 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 obturation of gastroduodenal ulcers (through the endoscope with the help of a special needle directly into the mucous enter drugs (antiperspirants, antioxidants, immunomodulators): dalargin, solcoseryl, eikonol, oxyferriccorbon, interferon, Roncoleukin, etc.);
- intragastric laser therapy (ulcers through the endoscope are irradiated with a low-energy laser: argon, krypton, copper vapor, helium-neon, helium-cadmium);
- Irradiation of ulcers with incoherent red light from a halogen lamp.
The main inconvenience for patients of these techniques is due to the fact that for effective treatment, repeated and often unpleasant endoscopic manipulations are necessary.
Radical surgical treatment
In our time, doctors are forced to resort to the surgical treatment of patients with peptic ulcer when developing complications of this disease or in the absence of any effect from all possible methods of complex conservative therapy.
When bleeding, a bleeding blood vessel is stitched or gastric resection (the part where the ulcer is located), or vagotomy (intersect the vagus nerve stimulating the acid production of the stomach) with pyloroplasty.
If the patient develops a peptic ulcer, the surgeons can perform a resection of a part of the stomach with a defect, carry out vagotomy with pyloroplasty, or suture the defect. Sometimes combine several techniques.
In the case of decompensated stenosis, the doctor resect the stomach or impose a gastrojejnoanastomoz (anastomosis between the jejunum and stomach).
Prevention of Stomach Ulcers
To avoid peptic ulcer it is necessary to refuse smoking, not to abuse hot drinks, to normalize a diet, to not forget about high-grade rest, to avoid stresses. In addition, if a patient suffers from chronic gastritis and has an increased acid-forming function of the stomach, he must get rid of the microorganisms Helicobacter pylori.
If the peptic ulcer has already developed, then in addition to the measures already mentioned (in order to prevent its possible exacerbations), it is necessary to discuss with your doctor the tactics of behavior when resuming abdominal pain. So, some patients are sometimes advised to take antisecretory medications constantly or "on demand".
Remission of a peptic ulcer is considered complete if the patient has no signs of aggravation for three years or more.