Peptic ulcer is a chronic polyetiological pathology that occurs with the formation of ulcerative lesions in the stomach, a tendency to progression and the formation of complications. The main clinical signs of Stomach ulcer disease include pain in the stomach and dyspeptic symptoms. The diagnostic standard is endoscopic examination with biopsy of pathological areas, X-ray of the stomach, detection of H. pylori. Complex treatment: diet and physiotherapy, eradication of Helicobacter pylori infection, surgical correction of complications of the disease.
- Pathology of higher nervous activity – Pathophysiology of Nervous System
- Endocrinology Mnemonics of Pathology – Endocrine System Mnemonics
- Chronic obstructive pulmonary disease: Macro and Micro preparation
- Stromal Vascular Dystrophy – protein metabolism disorder and lipidoses
- Hypertension: Causes, Risk factors, Pathogenesis, Classification
General information of Stomach ulcer
Peptic ulcer (PUD) is a cyclically recurrent chronic disease, a characteristic feature of which is ulceration of the stomach wall. PUD is the most common pathology of the gastrointestinal tract: according to various sources, in the world this disease affects from 5 to 15% of the population, and among urban residents, the pathology occurs five times more often. Many specialists in the field of gastroenterology combine the concepts of gastric ulcer and duodenal ulcer, which is not entirely correct – ulceration in the duodenum is diagnosed 10-15 times more often than stomach ulcers. Nevertheless, peptic ulcer requires careful study and development of modern methods of diagnosis and treatment, since this disease can lead to the development of lethal complications.
About 80% of cases of primary detection of stomach ulcers occur in the working age (up to 40 years). In children and adolescents, gastric ulcer is rarely diagnosed. Among the adult population, there is a predominance of men (women get sick with Stomach ulcer 3-10 times less often); but in old age sex differences in incidence are smoothed out. In women, the disease is milder, in most cases asymptomatic, rarely complicated by bleeding and perforation.
Peptic ulcer disease ranks second among the causes of disability in the population (after cardiovascular disease). Despite the long period of studying this nosology (more than a century), no therapeutic methods of influence have yet been found that can stop the progression of the disease and completely cure the patient. The incidence of peptic ulcer all over the world is constantly growing, requiring the attention of therapists, gastroenterologists, and surgeons.
Causes of Stomach ulcer
The disease is polyetiologic. According to the degree of significance, several groups of reasons are distinguished.
- The main etiological factor in the formation of gastric ulcer is H. pylori infection – more than 80% of patients have positive Helicobacter pylori infection tests. In 40% of patients with gastric ulcer, infected with the bacterium H. pylori, anamnestic data indicate a family predisposition to this disease.
- The second most important reason for the formation of gastric ulcer is considered to be the use of non-steroidal anti-inflammatory drugs.
- Rarer etiological factors of this pathology include Zollinger-Ellison syndrome , HIV infection , connective tissue diseases, liver cirrhosis , heart and lung diseases, kidney damage, exposure to stress factors that lead to the formation of symptomatic ulcers.
Pathogenesis of Stomach ulcer
Of major importance for the formation of gastric ulcer is an imbalance between the protective mechanisms of the mucous membrane and the effect of aggressive endogenous factors (concentrated hydrochloric acid, pepsin, bile acids) against the background of a disorder of the evacuation function of the gastrointestinal tract (hypokinesia of the stomach, duodeno-gastric reflux , etc.) … Oppression of protection and slowing down of the recovery of the mucous membrane is possible against the background of atrophic gastritis , with the chronic course of Helicobacter pylori infection, ischemia of the stomach tissues against the background of collagenoses , prolonged use of NSAIDs (the synthesis of prostaglandins slows down, which leads to a decrease in mucus production).
The morphological picture of gastric ulcer undergoes a number of changes. The primary substrate for the occurrence of ulcers is erosion – superficial damage to the epithelium of the stomach, which forms against the background of necrosis of the mucous membrane. Erosions are usually detected on the lesser curvature and in the pyloric region of the stomach, these defects are rarely isolated. Erosion sizes can range from 2 millimeters to several centimeters. Visually, erosion is a mucosal defect that does not differ in appearance from the surrounding tissues, the bottom of which is covered with fibrin. Complete epithelialization of erosion with a favorable course of erosive gastritis occurs within 3 days without the formation of scar tissue. With an unfavorable outcome, erosion is transformed into an acute gastric ulcer .
An acute ulcer is formed when the pathological process spreads deep into the mucous membrane (beyond its muscular plate). Ulcers are usually single, take on a rounded shape, and look like a pyramid when cut. In appearance, the edges of the ulcer also do not differ from the surrounding tissues, the bottom is covered with fibrin overlays. Black coloration of the bottom of the ulcer is possible when the vessel is damaged and hematin is formed (a chemical formed during the oxidation of hemoglobin from destroyed red blood cells). A favorable outcome of an acute ulcer is scarring within two weeks, an unfavorable one is marked by the transition of the process into a chronic form.
The progression and intensification of inflammatory processes in the area of the ulcer defect leads to increased formation of scar tissue. Because of this, the bottom and edges of a chronic ulcer become dense, differ in color from the surrounding healthy tissues. A chronic ulcer tends to grow and deepen during an exacerbation; during remission, it decreases in size.
Classification of Stomach ulcer
Until now, scientists and clinicians around the world have not been able to reach agreement on the classification of gastric ulcers. Domestic experts systematize this pathology according to the following features:
- causative factor – associated or not associated with H. pylori peptic ulcer, symptomatic ulcers;
- localization – ulcer of the cardia, antrum or body of the stomach, pylorus; large or small curvature, anterior, posterior wall of the stomach;
- number of defects – a single ulcer or multiple ulcerations;
- defect sizes – small ulcer (up to 5 mm), medium (up to 20 mm), large (up to 30 mm), giant (more than 30 mm);
- stage of the disease – exacerbation, remission, scarring (red or white scar), cicatricial deformity of the stomach;
- the course of the disease – acute (the diagnosis of gastric ulcer was established for the first time), chronic (periodic exacerbations and remissions are noted);
- complications – gastric bleeding , perforated gastric ulcer , penetration, cicatricial and ulcerative stenosis of the stomach.
Stomach ulcer symptoms
The clinical course of gastric ulcer is characterized by periods of remission and exacerbation. Exacerbation of ulcer is characterized by the appearance and increase of pain in the epigastric region and under the xiphoid process of the sternum. With an ulcer of the body of the stomach, pain is localized to the left of the central line of the body; in the presence of ulceration of the pyloric region – on the right. Possible irradiation of pain in the left half of the chest, scapula, lower back, spine.
Stomach ulcer is characterized by the occurrence of pain syndrome immediately after eating with an increase in intensity within 30-60 minutes after eating; pylorus ulcer can lead to the development of nocturnal, hungry and late pains (3-4 hours after eating). The pain syndrome is stopped by applying a heating pad to the stomach area, taking antacids, antispasmodics, proton pump inhibitors, and H2-histamine receptor blockers.
In addition to pain, YABZH is characterized by a lining of the tongue, bad breath , dyspeptic symptoms – nausea, vomiting, heartburn , increased flatulence, instability of the stool. Vomiting occurs predominantly at the height of stomach pain, and brings relief. Some patients tend to induce vomiting to improve their condition, which leads to disease progression and complications.
Atypical forms of gastric ulcer can be manifested by pain in the right iliac region (appendicular type), in the region of the heart (cardiac type), lower back (radiculitis pain). In exceptional cases, pain syndrome in peptic ulcer may be absent altogether, then the first sign of the disease is bleeding, perforation or cicatricial stenosis of the stomach, due to which the patient seeks medical help.
Diagnostics of Stomach ulcer
If a stomach ulcer is suspected, a standard set of diagnostic measures (instrumental, laboratory) is performed. It is aimed at visualizing a peptic ulcer, determining the cause of the disease and eliminating complications.
- Esophagogastroduodenoscopy . It is the gold standard for the diagnosis of gastric ulcer. EGDS allows visualizing an ulcer defect in 95% of patients, determining the stage of the disease (acute or chronic ulcer). Endoscopic examination makes it possible to timely identify complications of gastric ulcer (bleeding, cicatricial stenosis), to carry out endoscopic biopsy , surgical hemostasis.
- Gastrography. Radiography of the stomach is of paramount importance in the diagnosis of cicatricial complications and ulcer penetration into nearby organs and tissues. If endoscopic imaging is not possible, radiography can be used to verify gastric ulcers in 70% of cases. For a more accurate result, it is recommended to use double contrasting – in this case, the defect is visible in the form of a niche or a persistent contrast spot on the wall of the stomach, to which the folds of the mucous membrane converge.
- Diagnosis of Helicobacter pylori infection. Considering the huge role of Helicobacter pylori infection in the development of UBG, all patients with this pathology undergo mandatory tests to detect H. pylori (ELISA, PCR diagnostics, breath test, biopsy examination, etc.).
Of auxiliary value in gastric ulcer are:
- Ultrasound of the OBP (detects concomitant pathology of the liver, pancreas),
- electrogastrography and antroduodenal manometry (makes it possible to assess the motor activity of the stomach and its evacuation ability),
- intragastric pH-metry (detects aggressive damage factors),
- analysis of feces for occult blood (performed if gastric bleeding is suspected).
If the patient is admitted to the hospital with a clinical picture of ” acute abdomen “, diagnostic laparoscopy may be required to exclude gastric perforation . Stomach ulcer should be differentiated from symptomatic ulcers (especially medicinal), Zollinger-Ellison syndrome, hyperparathyroidism, stomach cancer.
Stomach ulcer treatment
Conservative treatment of Stomach ulcer
The main goals of therapy in peptic ulcer include the repair of the ulcer, the prevention of complications of the disease, and the achievement of long-term remission. Treatment of gastric ulcer includes non-drug and drug effects, surgical methods.
- Non-drug treatment of peptic ulcer implies adherence to a diet, the appointment of physiotherapeutic procedures (heat, paraffin therapy , ozokerite , electrophoresis and microwave exposure), it is also recommended to avoid stress and lead a healthy lifestyle.
- Drug treatment should be comprehensive, affect all links in the pathogenesis of peptic ulcer. Helicobacter pylori therapy requires the appointment of several drugs for the eradication of H. pylori, since the use of mono-circuits has shown its ineffectiveness. The attending physician individually selects a combination of the following drugs: proton pump inhibitors, antibiotics (clarithromycin, metronidazole, amoxicillin, furazolidone, levofloxacin, etc.), bismuth preparations.
Surgery of Stomach ulcer
With timely treatment for medical help and a complete scheme of anti-Helicobacter pylori treatment, the risk of complications of gastric ulcer is minimized. Emergency surgical treatment of ulcer (hemostasis by clipping or stitching a bleeding vessel, suturing an ulcer ) is usually required only for patients with complicated pathology: perforation or penetration of an ulcer, bleeding from an ulcer, malignancy, and formation of cicatricial changes in the stomach. In elderly patients, with a history of indications of complications of peptic ulcer in the past, experts recommend reducing the duration of conservative treatment to one to one and a half months.
Absolute indications for surgical intervention:
- perforation and malignancy of the ulcer,
- massive bleeding
- cicatricial changes in the stomach with impaired function,
- gastroenteroanastomosis ulcer.
Conditionally absolute indications include:
- penetration of the ulcer,
- giant callous ulcers,
- recurrent gastric bleeding against the background of ongoing conservative therapy,
- lack of ulcer repair after suturing.
A relative indication is the absence of a clear effect from drug therapy for 2-3 years. For decades, surgeons have been discussing the effectiveness and safety of various types of surgery for gastric ulcer. To date, gastric resection , gastroenterostomy , and various types of vagotomy are recognized as the most effective . Excision and suturing of stomach ulcers is used only in extreme cases.
Forecast and prevention of Stomach ulcer
The prognosis for gastric ulcer largely depends on the timeliness of seeking medical help and the effectiveness of anti-Helicobacter pylori therapy. PUD is complicated by gastric bleeding in every fifth patient, from 5 to 15% of patients undergo perforation or penetration of the ulcer, 2% develop cicatricial stenosis of the stomach. In children, the incidence of complications of gastric ulcer is lower – no more than 4%. The likelihood of developing stomach cancer in patients with peptic ulcer is 3-6 times higher than among people without this pathology.
Primary prevention of gastric ulcer includes the prevention of infection with Helicobacter pylori infection, the elimination of risk factors for the development of this pathology (smoking, cramped living conditions, low standard of living). Secondary prevention is aimed at preventing relapses and includes adherence to diet, elimination of stress, the appointment of an anti-Helicobacter pill regimen when the first symptoms of peptic ulcer appear. Patients with gastric ulcer require lifelong observation, endoscopic examination with mandatory tests for H. pylori once every six months.