Stomach ulcer of a stomach
Stomach ulcer of a stomach – the chronic polietiologichesky pathology proceeding with formation of ulcer damages to a stomach, tendency to progressing and formation of complications. Carry pain in a stomach to the main clinical symptoms of stomach ulcer and the dispepsichesky phenomena. The standard of diagnostics is carrying out an endoscopic research with a biopsy of pathological sites, a stomach X-ray analysis, identification of H. pylori. Treatment is complex: diyeto-and physical therapy, eradikation of a helikobakterny infection, expeditious correction of complications of a disease.
Stomach ulcer of a stomach
The Stomach Ulcer of a Stomach (SUS) – cyclically recurrent chronic disease which characteristic sign the stomach wall ulceration is. YaBZh is the most widespread pathology of digestive tract: according to different data, in the world this illness suffer from 5 to 15% of the population, and among residents of the cities pathology meets five times more often. Many experts in the field of gastroenterology unite concepts of stomach ulcer of a stomach and a duodenum that is not absolutely correct – ulcerations in a 12-perstny gut diagnose at 10-15 times more often than ulcers in a stomach. Nevertheless, YaBZh demands careful studying and development of modern methods of diagnostics and treatment as this disease can lead to development of lethal complications.
About 80% of cases of primary detection of stomach ulcer are the share of working-age (up to 40 years). For children and teenagers stomach ulcer of a stomach is diagnosed extremely seldom. Among adult population prevalence of men is noted (women are ill YaBZh 3-10 times more rare); but at advanced age sexual distinctions of incidence smooth out. At women the disease proceeds easier, in most cases asymptomatically, seldom is complicated by bleedings and a perforation.
Stomach ulcer of a stomach takes the second place among the population invalidization reasons (after cardiovascular pathology). Despite the long period of studying of this nosology (more century), the therapeutic methods of influence capable to stop progressing of a disease still are not found and to completely cure the patient. Incidence of YaBZh around the world continuously grows, requiring attention therapists, gastroenterologists, surgeons.
Classification of stomach ulcer of a stomach
Till today scientists and clinical physicians of the whole world could not reach consent in classification of ulcer defects of a stomach. Domestic experts systematize this pathology on the following signs:
- causal factor – YaBZh associated or not connected with H. pylori, symptomatic ulcers;
- localization – an ulcer of a sebesten, antralny department or a body of a stomach, a pylorus; big or small curvature, forward, back wall of a stomach;
- amount of defects – a single ulcer or multiple ulcerations;
- the extent of defect – a small ulcer (to 5 mm), average (to 20 mm), big (to 30 mm), huge (more than 30 mm);
- disease stage – an aggravation, remission, scarring (a red or white hem), cicatricial deformation of a stomach;
- the course of a disease – sharp (the diagnosis stomach ulcer of a stomach is established for the first time), chronic (periodic aggravations and remissions are noted);
- complications – gastric bleeding, probodny stomach ulcer, a penetration, a cicatricial and ulcer stenosis of a stomach.
Reasons and pathogenesis of stomach ulcer of a stomach
As the major etiologichesky factor of formation of stomach ulcer of a stomach serves H.pylori infection – more than at 80% of patients positive tests for a helikobakterny infection come to light. At 40% of the patients with stomach ulcer of a stomach infected with a bacterium a helikobakter, anamnestichesky data indicate family predisposition to this disease. The reason of formation of stomach ulcer of a stomach, the second for the importance, consider reception of nonsteroid anti-inflammatory medicines. Rank Zollingera-Ellison's syndrome, HIV infection, diseases of connecting fabric, cirrhosis as more rare etiologichesky factors of this pathology, a heart trouble and lungs, damage of kidneys, influence of stressorny factors which lead to formation of symptomatic ulcers.
Major importance for formation of stomach ulcer of a stomach has violation of balance between protective mechanisms of a mucous membrane and influence of aggressive endogenous factors (the concentrated hydrochloric acid, pepsin, bilious acids) against the background of disorder of the GIT evakuatorny function (a stomach hypodynamia, a duodeno-gastralny reflux etc.). Oppression of protection and delay of restoration of a mucous membrane is possible against the background of atrophic gastritis, at the chronic course of a helikobakterny infection, ischemia of tissues of stomach against the background of kollagenoz, long reception of NPVS (there is a delay of synthesis of prostaglandins that leads to decrease in production of slime).
The morphological picture at stomach ulcer of a stomach undergoes a number of changes. Primary substratum of developing of an ulcer is the erosion – the superficial damage of an epithelium of a stomach which is formed against the background of a necrosis of a mucous membrane. Erosion usually reveal on small curvature and in pilorichesky department of a stomach, these defects seldom happen single. The sizes of erosion can fluctuate from 2 millimeters to several centimeters. Visually the erosion represents defect mucous, not different by the form from surrounding fabrics which bottom is covered with fibrin. The full epitelization of an erosion at the favorable course of erosive gastritis occurs within 3 days without formation of cicatricial fabric. At a failure of an erosion are transformed to sharp stomach ulcer.
The sharp ulcer is formed at distribution of pathological process deep into of a mucous membrane (is farther than its muscular plate). Ulcers are usually single, gain rounded shape, on a cut pyramids have an appearance. On appearance of edge of an ulcer also do not differ from surrounding fabrics, the bottom is covered with fibrinous imposings. Black coloring of a bottom of an ulcer is possible at damage of a vessel and formation of hematin (the chemical which is formed at oxidation of hemoglobin of the destroyed erythrocytes). The favorable outcome of a sharp ulcer consists in scarring within two weeks, adverse is marked by transition of process to a chronic form.
Progressing and strengthening of inflammatory processes in the field of ulcer defect leads to the increased formation of cicatricial fabric. Because of it the bottom and edges of a chronic ulcer become dense, on color differ from surrounding healthy fabrics. The chronic ulcer has tendency to increase and deepening in the period of an aggravation, during remission it decreases in sizes.
Symptoms of stomach ulcer of a stomach
The clinical course of stomach ulcer of a stomach is characterized by the periods of remission and an aggravation. Emergence and increase of pain in epigastralny area and under a xiphoidal shoot of a breast is peculiar to an aggravation of YaBZh. At a stomach body ulcer pain is localized to the left of the central line of a body; in the presence of an ulceration of pilorichesky department – on the right. Irradiation of pain in the left half of a breast, a shovel, a waist, a backbone is possible. Emergence of a pain syndrome directly after food with increase of intensity within 30-60 minutes after meal is characteristic of stomach ulcer of a stomach; the ulcer of a pylorus can lead to development of night, hungry and late pains (in 3-4 hours after food). The pain syndrome is stopped by applying of a hot-water bottle to area of a stomach, reception of antatsid, spazmolitik, inhibitors of a proton pomp, blockers of H2-histamine receptors.
Besides a pain syndrome, YaBZh the language oblozhennost, an unpleasant smell from a mouth, the dispepsichesky phenomena – nausea, vomiting, heartburn, the raised meteorizm, instability of a chair are inherent. Vomiting mainly arises at height of pain in a stomach, gives relief. Some patients are inclined to cause vomiting for improvement of the state that leads to progressing of a disease and emergence of complications.
Atypical forms of stomach ulcer of a stomach can be shown by pains in the right podvzdoshny area (as appendicular), in heart (kardialny type), a waist (radikulitny pain). In exceptional cases the pain syndrome at YaBZh can be absent in general, then bleeding, perforation or a cicatricial stenosis of a stomach because of which the patient also asks for medical care becomes the first symptom of a disease.
Diagnosis of stomach ulcer of a stomach
The gold standard of diagnosis of stomach ulcer of a stomach is the ezofagogastroduodenoskopiya. EGDS allows to visualize ulcer defect at 95% of patients, to define a disease stage (a sharp or chronic ulcer). The endoscopic research gives the chance in due time to reveal complications of stomach ulcer of a stomach (bleeding, a cicatricial stenosis), to carry out an endoscopic biopsy, a surgical hemostasis.
The stomach X-ray analysis (gastrografiya) paramount value acquires in diagnostics of cicatricial complications and a penetration of an ulcer in the located bodies and fabrics nearby. At impossibility of carrying out endoscopic visualization the X-ray analysis allows to verify stomach ulcer in 70% of cases. For more exact result use of double contrasting is recommended – at the same time defect is visible in the form of a niche or a resistant contrast spot on a wall of a stomach to which folds of a mucous membrane meet.
Considering a huge role of helikobakterny infection in development of YaBZh, to all patients with this pathology carry out mandatory tests for identification of H. pylori (IFA, PTsR diagnostics, the respiratory test, a research of bioptat, etc.).
At stomach ulcer of a stomach the elektrogastrografiya and an antroduodenalny manometriya (gives the chance of assessment of physical activity of a stomach and its evakuatorny ability), an intragastric rn-metriya (finds aggressive factors of damage), the analysis a calla on the hidden blood have auxiliary value ultrasonography of OBP (reveals the accompanying liver pathology, ) (it is carried out at suspicion of gastric bleeding). If the patient came to a hospital with a clinical picture of "a sharp stomach", the diagnostic laparoscopy for an exception of perforation of a stomach can be required. Stomach ulcer of a stomach should be differentiated with symptomatic ulcers (especially medicinal), Zollingera-Ellison's syndrome, giperparatireozy, stomach cancer.
Treatment of stomach ulcer of a stomach
At YaBZh carry a reparation of ulcer defect, the prevention of complications of a disease, achievement of long remission to main objectives of therapy. Treatment of stomach ulcer of a stomach includes non-drug and medicamentous influences, operational methods. Non-drug treatment of YaBZh implies observance of a diet, purpose of physiotherapeutic procedures (heat, a parafinoterapiya, ozokerite, an electrophoresis and microwave influences), it is also recommended to avoid stresses, to lead a healthy lifestyle.
Drug treatment has to be complex, influence all links of pathogenesis of YaBZh. Antikhelikobakterny therapy demands purpose of several medicines for an eradikation of H. pylori as use of monoschemes showed the inefficiency. The attending physician in an individual order selects a combination of the following medicines: inhibitors of a proton pomp, antibiotics (, metronidazole, amoxicillin, , furasolidone, , etc.), bismuth medicines.
At the timely request for medical care and carrying out the full scheme of antikhelikobakterny treatment the risk of complications of stomach ulcer of a stomach is minimized. The emergency surgical treatment of YaBZh (a hemostasis by clipping or a proshivaniye of the bleeding vessel, ushivany ulcers) usually is required only to patients with the complicated course of pathology: perforation or a penetration of an ulcer, bleeding from an ulcer, malignizatsiy, formation of cicatricial changes of a stomach. At elderly patients, in the presence in the anamnesis of instructions on YaBZh complications in the past, experts recommend to reduce terms of conservative treatment to one-one and a half months.
Absolute indications to surgical intervention: a perforation and a malignization of an ulcer, massive bleeding, cicatricial changes of a stomach with violation of its function, an ulcer of a gastroenteroanastomoz. Rank the ulcer penetration, huge kallezny ulcers recuring gastric bleedings against the background of the performed conservative therapy, lack of a reparation of an ulcer after its ushivaniye as conditionally absolute indications. The relative indication is a lack of obvious effect of medicamentous therapy for 2-3 years.
For decades surgeons discuss efficiency and safety of different types of surgery at stomach ulcer of a stomach. Today the stomach resection, a gastroenterostomiya, different types of vagotomiya are recognized as the most effective. Excision and an ushivaniye of stomach ulcer is applied only in extreme cases.
Forecast and prevention of stomach ulcer of a stomach
The forecast at stomach ulcer of a stomach in many respects depends on timeliness of the request for medical care and efficiency of antikhelikobakterny therapy. YaBZh is complicated by gastric bleeding at every fifth patient, from 5 to 15% of patients transfer perforation or a penetration of an ulcer, at 2% the cicatricial stenosis of a stomach develops. At children the frequency of complications of stomach ulcer of a stomach is lower – no more than 4%. The probability of development of cancer of stomach in patients with YaBZh is 3-6 times more, than among the people who do not have this pathology.
Primary prevention of stomach ulcer of a stomach includes the prevention of infection with a helikobakterny infection, an exception of risk factors of development of this pathology (smoking, the constrained accommodation conditions, the low standard of living). Secondary prevention is directed to the prevention of a recurrence and includes observance of a diet, an exception of stresses, purpose of the antikhelikobakterny scheme of medicines at emergence of the first symptoms of YaBZh. Patients with stomach ulcer of a stomach demand lifelong observation, an endoscopic research with obligatory carrying out tests for H. pylori once in a half-year.