Peptic ulcer is one of the most common diseases of the digestive system, 50% of patients in the gastroenterological department in a city hospital are patients with ulcerative lesions of the stomach or duodenum. As an independent chronic disease, it develops as a result of an imbalance between the activity of gastric juice and the protective capabilities of the mucosa.
Ulcerative lesions should be distinguished as complications of other diseases: liver, cardiovascular system (acute myocardial infarction, heart failure), acute cerebrovascular accident, atherosclerosis of abdominal vessels.
Taking various medications (aspirin, steroid hormones, anti-inflammatory products such as voltaren, metindol, ortofen) also cause ulceration. Ulcers are of different sizes, have a rounded or slit-like shape, can be superficial or deep, penetrating to the muscular wall of the stomach and deeper. When the serous layer undergoes destruction, this is a perforation of the ulcer. Healing occurs by overgrowing with connective tissue with the formation of a scar. The course of peptic ulcer disease is the most diverse: it can last for years with exacerbations from one in several years to annual after a number of months. As a rule, it occurs at a young and middle age, it does not often make its debut after 60 years. “senile” gastric ulcers are prone to bleeding, with long periods of scarring and recurrence, traditionally large (more than 2 cm). More often they are not manifestations of peptic ulcer disease, but secondary to chronic lung diseases, coronary heart disease or obliterating atherosclerosis of large vessels of the abdominal cavity as a result of circulatory disorders in the gastric mucosa.
Detailed signs of peptic ulcer depend on the localization of the ulcer.
Ulcers of the subcardial part of the stomach – more often in people over 50 years of age. Pain appears after eating almost immediately within the xiphoid process (where the sternum ends), sometimes it is given to the region of the heart, so an electrocardiogram is required. A combination of 2 types of research is desirable – X-ray and gastroscopy due to the difficulty of examining this part of the stomach due to its anatomical location. It is with this localization that the ulcer is often complicated by bleeding, penetration, resistance to scarring, i.e. poorly amenable to medical treatment. If the ulcer persists for 3 months, then they resort to surgical intervention.
Ulcers of the angle and body of the stomach are the most common location in gastric ulcers. Pain appears after 10-30 minutes. after eating in the epigastric region, sometimes they are given to the back, the left half of the chest, behind the sternum, to the left hypochondrium. Heartburn, belching, nausea are frequent, sometimes patients themselves induce vomiting to make themselves feel better. The question of surgical treatment is raised when the ulcer recurs 2 or more times a year, complications – perforation, massive bleeding, signs of malignancy – the degeneration of the ulcer into cancer.
Ulcers of the antrum of the stomach – prevail at a young age. Disturbed by “hungry” pains, i.е. 2-3 hours after eating, heartburn, sometimes vomiting with acidic contents. The course is favorable, one of the shortest periods of ulcer scarring.
Ulcers of the color canal, the narrowest part of the stomach when it passes into the duodenum. Sharp pains in the epigastric region at any time of the day, sometimes constant, may be accompanied by persistent vomiting, which leads to weight loss with a simultaneous restriction in food. Complications: bleeding, penetration, perforation, narrowing of the pyloric canal itself with impaired passage of food from the stomach into the duodenum, which causes a surgical method of treatment.
Ulcers of the duodenum are localized more often in its bulb (90% of cases). Accompanied by heartburn, “hungry” pains 1-3 hours after eating or at night, traditionally on the right and above the navel, less often in the right hypochondrium. With extra-bulbous duodenal ulcers, pain is detected on an empty stomach and subsides after eating after 20-30 minutes.
Combined gastric and duodenal ulcers account for approximately 20% of all lesions. Moreover, at first, an ulcerative defect of the duodenum occurs in the diseased, and after many years a stomach ulcer joins it, which dominates in the future.
Multiple ulcers of the stomach and duodenum – more often in the aftermath of taking drugs of an ulcerogenic nature (i.e., causing ulceration), stressful situations.
Complications of peptic ulcer
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. With heavy bleeding, vomiting appears with an admixture of dark blood or “coffee grounds”, pale skin, dizziness, even fainting of various durations. During the following days, as a rule, there is a low blood pressure, the stool is liquid black. Hemoglobin may remain within normal limits. Massive bleeding can be stopped only in a hospital, it is very rare that it is so colossal that a fatal outcome begins in a few minutes. Slight gastric bleeding can stop on its own, the state of health is not disturbed, its only sign is the color of black stool.
Perforation or perforation of the ulcer– this is a violation of the integrity of the wall of the stomach or duodenum 12. As a result, the contents of the cavity of these organs flow into the abdominal cavity and cause peritonitis. It often develops as a result of drinking alcohol, overfilling the stomach with food, excessive physical stress, trauma. Sometimes perforation of an ulcer is the first manifestation of a peptic ulcer, especially at a young age. The pains are very strong, sharp “dagger”, accompanied by signs of collapse: cold sticky sweat, pallor of the skin, cold extremities, thirst and dry mouth. Vomiting is not common. Arterial pressure goes down. A few hours later, flatulence develops – bloating of the abdomen due to non-excretion of gases. After 2-5 hours, an imaginary improvement in well-being begins: pain subsides, tense abdominal muscles relax. The appearance of well-being can drag on for up to a day. During this time, the patient develops peritonitis and his condition begins to deteriorate rapidly. You will need to 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 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, the wall of the stomach or duodenum fused with the surrounding organs. More common in men. Characteristic symptoms: nocturnal pain attacks in the epigastric region, often pains radiate to the back. Despite the most vigorous therapy, pains are not stopped. Treatment is operative.
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 section of the duodenum 12. Deformation and narrowing of the lumen as a result of scarring of the ulcer leads to difficulty or complete cessation of the evacuation of food from the stomach. A slight degree of narrowing of the pylorus is manifested by episodes of vomiting of food eaten, heaviness in the pit of the stomach for several hours after eating. As the stenosis progresses, there is a constant retention of part of the food in the stomach cavity and its overdistension, a putrid smell from the mouth appears, patients complain of gurgling in the abdomen (the so-called “splash symptom”). Over time, all types of metabolism are disturbed (fats, proteins, carbohydrates, salts, which leads to exhaustion).
Subdiaphragmatic abscess . A rare complication of peptic ulcer, difficult to diagnose. It is a collection of pus between the diaphragm and adjacent organs. It develops as a result of perforation of an ulcer or the spread of infection during an exacerbation of peptic ulcer through the lymphatic system of the stomach and duodenum. The main symptoms are pain in the right hypochondrium and above, often given to the right shoulder, high fever. There is lethargy, general weakness, loss of appetite. The number of leukocytes in the blood increases. If the abscess is not opened and the pus is not evacuated, then sepsis develops in 20-30 days.
Examination methods for peptic ulcer disease. Examine the acidity of gastric juice by pH-metry and determining the amount of hydrochloric acid in portions of gastric contents taken with a probe. More often with peptic ulcer, acidity is increased. The study of feces “for occult blood” allows you to establish bleeding and requires special preparation: for three days do not eat meat, fish and products from them, do not brush your teeth with bleeding gums, do not take iron-containing medicines. An X-ray examination with an open ulcer determines the symptom of a “niche” or “depot” of a contrast agent, as well as violations of the contractile function of the stomach in the form of pyloric spasm, impaired tone and peristalsis of the stomach. 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.
Conservative treatment of peptic ulcer. During the period of complications with severe pain syndrome, nutrition in the first week according to diet No. 1a, 16. In case of an uncomplicated course of exacerbation – diet No. 1. 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, confectionery, soft bread and black bread are excluded from food. 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 onset of scarring of the ulcer, preserved teeth, meat and fish can be consumed in a piece, but well cooked. Among other dishes, soft-boiled eggs, stewed vegetables, jelly from sweet berries, baked or grated raw sweet apples, stale white bread or dry biscuit cookies are recommended, pureed liquid cereals, milk, cream, butter. After scarring of the ulcer, even with good health, the patient should continue to follow the diet, eat 4-5 times a day, do not use canned food, smoked meats, spices, marinades and pickles. Soups should be cooked on weak meat and fish broths from low-fat varieties. Avoid smoking and alcohol completely.
Medical treatment.With a pronounced pain syndrome, products from the group of anticholinergics (atropine, platifillin, metacin in tablets and injections) or antispasmodics (no-shpa, papaverine) are prescribed. It should be remembered that anticholinergics are contraindicated in the elderly with glaucoma, prostate adenoma. Antacid preparations, i.e. neutralizing hydrochloric acid produced by the gastric mucosa, and antisecretory action, i.e. suppressing the secretion of hydrochloric acid, are indicated for duodenal ulcer in almost all cases, as well as the stomach with normal and increased acidity. Soluble antacids, for example, soda and magnesium oxide, give a quick effect on the neutralization of hydrochloric acid, but a short, moreover, long-term intake of soda leads to electrolyte imbalance in the body. Of the insoluble antacids (they are not absorbed into the blood, but only coat the gastric mucosa), the most popular are almagel, phosphalugel, which take 1-2 dessert spoons 1-1.5 hours after eating. Their long-term use is not desirable in chronic renal failure. Among the drugs that suppress the secretion of hydrochloric acid, the M-anticholinergic gastrocepin, 1 tab. 2 times a day, also a group of histamine H2 receptor blockers. Assign to the last group of medicines after determining the acidity of gastric juice during stimulation with histamine. Cimetidine (belomet, tagomet) belongs to the first generation of the group of H2-receptor blockers with the intake of 1 tab during an exacerbation. 3 times after meals and at night. By the second generation – ranitidine products (Zantac, ranisan) with the intake of 1 tab. 2 times a day or 2 tab. for the night. Third generation – famotidine derivatives, 1-2 tab. once a day. Doses are prescribed individually by the attending physician. After scarring of an ulcer with increased or normal acidity, one of the products of this group is recommended in maintenance doses at night for a period of several months to a year to prevent exacerbation. “Helicobacter pylori” is a group of numerous medicines that suppress bacteria that are on the gastric mucosa and in some cases contribute to ulcer formation. Treatment is carried out in courses of up to 2 weeks with Trichopolum, Oxacillin, Furagin, each product individually or in combination, de-nol course up to 4 weeks. Medications are prescribed that affect the process of ulcer scarring by restoring a healthy gastric mucosa: retabolil, methyluracil, allanton, actovegil, jefarnil, solcoseryl, in short courses and depending on concomitant diseases. So, it makes sense to use solcoseryl for concomitant vascular diseases. De-nol and sucralfate (venter), which form a protective film in the ulcer zone from the effects of hydrochloric acid, are taken 3-4 times a day for an hour or 2 hours after a meal, it is not recommended to combine them with Almagel. Preparations containing bismuth are used in the treatment of peptic ulcer (vikalin, vikair, de-nol), but with caution, since bismuth is contraindicated in kidney damage. Exacerbations are best treated in a hospital setting. De-nol and sucralfate (venter), which form a protective film in the ulcer zone from the effects of hydrochloric acid, are taken 3-4 times a day for an hour or 2 hours after a meal, it is not recommended to combine them with Almagel. Preparations containing bismuth are used in the treatment of peptic ulcer (vikalin, vikair, de-nol), but with caution, since bismuth is contraindicated in kidney damage. Exacerbations are best treated in a hospital setting. De-nol and sucralfate (venter), which form a protective film in the ulcer zone from the effects of hydrochloric acid, are taken 3-4 times a day for an hour or 2 hours after a meal, it is not recommended to combine them with Almagel. Preparations containing bismuth are used in the treatment of peptic ulcer (vikalin, vikair, de-nol), but with caution, since bismuth is contraindicated in kidney damage. Exacerbations are best treated in a hospital setting.
Sanatorium treatment – only outside the exacerbation of peptic ulcer disease.