Protocols for the treatment of peptic ulcer

ULCER TREATMENT PROTOCOLS

STOMACH AND DUODENUM

COMPILERS

ULCER TREATMENT PROTOCOL

STOMACH AND DUODENUM

Code ICD 10: K26

1. Definition: Peptic ulcer is a chronic relapsing disease that occurs with alternating periods of exacerbation and remission, the main symptom of which is the formation of a defect (ulcer) in the wall of the stomach and duodenum penetrating - in contrast to superficial damage to the mucous membrane (erosion) - into the submucosal layer.
2. Selection of patients: Patients are selected after a comprehensive examination (EGDFS, X-ray contrast study, ultrasound of organs abdominal cavity). Depending on the results of the studies, patients are divided into patients subject to conservative treatment and patients subject to surgical treatment (patients who refused surgical treatment are subject to conservative treatment).
3. Classification:

Depending on location:

• gastric ulcers (cardiac and subcardiac sections, stomach body, antrum, pyloric canal);
• duodenal ulcers (bulb and postbulbar section);
• combined ulcers of the stomach and duodenum.

Depending on the size:

• ulcers of small (up to 0.5 cm in diameter) sizes;
• ulcers of medium (0.6-1.9 cm in diameter) sizes;
• large (2.0-3.0 cm in diameter) ulcers;
• giant (over 3.0 cm in diameter) ulcers.

Depending on the number of ulcerative lesions:

• solitary ulcers;
• multiple ulcers.

Depending on the stage:

• exacerbations;
• scarring (endoscopically confirmed stage of "red" and "white" scar);
• remissions;
• the presence of cicatricial and ulcerative deformity of the stomach and duodenum.

Depending on the complications:

• gastrointestinal bleeding,
• Perforation,
• cicatricial stenosis,
• penetration,
• Malignancy.

Severity rating:

When a patient is treated with an uncomplicated form of gastric ulcer or duodenal ulcer, the patient's condition remains satisfactory.

Clinical picture in uncomplicated forms of peptic ulcer:

• The leading syndrome of exacerbation of PU is pain in the epigastric region, which can radiate to the left half. chest and left shoulder blade, thoracic or lumbar spine.
• Pain occurs immediately after a meal (with ulcers of the cardiac and subcardial sections of the stomach), half an hour or an hour after eating (with ulcers of the body of the stomach). With ulcers of the pyloric canal and duodenal bulb, late pains are usually observed (2-3 hours after eating), hungry pains that occur on an empty stomach and disappear after eating, as well as night pains.
• Pain disappears after taking antacids, antisecretory and antispasmodic drugs, application of heat.
• Ulcerative dyspepsia syndrome: sour belching, heartburn, nausea, constipation. A characteristic symptom is vomiting of acidic gastric contents, which occurs at the height of pain and brings relief, and therefore patients can cause it artificially.
• With an exacerbation of the disease, weight loss is often noted, because, despite the preserved appetite, patients limit themselves to food, fearing increased pain.
• It should also be considered with the possibility of an asymptomatic course of peptic ulcer.

In complicated forms of peptic ulcer, the severity of the condition is determined depending on the onset of the complication. Complications such as gastrointestinal bleeding and ulcer perforation are urgent and require urgent therapeutic and diagnostic measures.

Clinical picture of gastrointestinal bleeding:

It is observed in 15-20% of patients with PU, more often with gastric localization of ulcers. It is manifested by vomiting of contents such as "coffee grounds" (hematemesis) or black tarry stools (melena). With massive bleeding and low secretion of hydrochloric acid, as well as the localization of an ulcer in the cardial section of the stomach, an admixture of unchanged blood may be noted in the vomit. Sometimes in the first place in the clinical picture of ulcerative bleeding are general complaints (weakness, loss of consciousness, decreased blood pressure, tachycardia), while melena may appear only after a few hours.

Classification of ulcerative bleeding

Localization of the source of bleeding:

• Gastric ulcer.
• Duodenal ulcer.
• Recurrent ulcer after various surgical interventions on the stomach.

According to the severity of bleeding:

• lung
• medium degree gravity
• heavy

Severity assessment for gastrointestinal bleeding:

I - degree - mild- observed with a loss of 20% of the BCC (up to 1000 ml in a patient with a body weight of 70 kg). The general condition is satisfactory or of moderate severity, the skin is pale (due to vascular spasm), sweating appears, the pulse is 90-100 per 1 minute, blood pressure is 100/60 mm Hg, the patient's agitation changes with slight lethargy, consciousness is clear, breathing is somewhat rapid, reflexes are reduced; in the blood, leukocytosis is determined with a shift of the formula to the left, erythrocytes up to 3.5 x 1012/l, Hb - 100 g/l., oliguria is noted. Without compensation for blood loss, there are no pronounced circulatory disorders.

II - degree - moderate- observed with a loss of 20 to 30% of the volume of circulating blood (1000-1500 ml in a patient weighing 70 kg). The general condition is of moderate severity, there is a pronounced pallor of the skin, sticky sweat, pulse 120-130 per 1 minute, weak filling, blood pressure - 80/50 mm Hg, shallow breathing, rapid, pronounced oliguria; erythrocytes up to 2.5 x 1012 / l, Hb - 80 g / l. Without compensation for blood loss, the patient can survive, but there are significant disturbances in blood circulation, metabolism and the function of the kidneys, liver, and intestines.

ІІІ degree - severe- observed with a loss of more than 30% of the BCC (from 1500 to 2000 ml), the general condition is extremely difficult, motor activity is suppressed, the skin and mucous membranes are pale cyanotic or spotty (due to vasodilation). The patient answers questions slowly, often loses consciousness, the pulse is threadlike - 140 per 1 min., may not be detected periodically, blood pressure - 50/20 mm Hg, shallow breathing, oliguria changes with anuria; erythrocytes up to 1.5 x 1012 / l, Hb within 50 g / l. Without timely compensation for blood loss, patients die due to the death of cells of vital organs (liver, kidneys), cardiovascular insufficiency

When examining a patient, attention is drawn to the pallor of the skin and mucous membranes of the lips; with severe blood loss - a pale cyanotic shade of the mucous and nail plates.

Classification of ulcerative bleeding according to Forrest:

Type F I - active bleeding

I a - pulsating jet;

I b - flow.

Type F II - signs of recent bleeding

II a - visible (not bleeding) vessel;

II b - fixed thrombus clot;

II s - flat black spot(black bottom of the ulcer).

Type F III - an ulcer with a clean (white) bottom.

Clinical picture with ulcer perforation:

It occurs in 5-15% of patients with PU, more often in men. Physical overstrain, alcohol intake, overeating predispose to its development. Sometimes perforation occurs suddenly, against the background of an asymptomatic ("silent") course of peptic ulcer. Ulcer perforation is clinically manifested by acute (“dagger”) pains in the epigastric region, the development of a collaptoid state. When examining a patient, a "board-like" tension of the muscles of the anterior abdominal wall and a sharp pain on palpation of the abdomen, a positive symptom of Shchetkin-Blumberg, are found. In the future, sometimes after a period of imaginary improvement, the picture of diffuse peritonitis progresses.

Classification of perforated ulcers

By etiology

• perforation of chronic and acute ulcers
• perforation of a symptomatic ulcer (hormonal, stress, etc.)

By localization

• a) stomach ulcers

Small or large curvature;

Anterior or posterior wall in the antral, prepyloric, pyloric,

Cardiac department or in the body of the stomach;

• b) duodenal ulcers

front wall

back wall

By clinical form

• a) into the free abdominal cavity (typical, covered);
• b) atypical perforation (into the stuffing bag, lesser or greater omentum, into the retroperitoneal tissue, into the cavity isolated by adhesions);
• c) combination with gastrointestinal bleeding
• d) combination with stenosis of the gastric outlet

By phase of peritonitis (according to clinical periods)

• a) the phase of chemical peritonitis (the period of primary pain shock)
• b) the phase of the beginning of the development of bacterial peritonitis and the syndrome of systemic inflammatory response (the period of imaginary well-being)
• c) phase of diffuse purulent peritonitis (period of severe abdominal sepsis).

Clinical picture of cicatricial stenosis:

It is usually formed after scarring of ulcers located in the pyloric canal or the initial part of the duodenum. Often, the development of this complication is facilitated by the operation of suturing a perforated ulcer in this area. The most characteristic clinical symptoms of pyloric stenosis are vomiting of food eaten the day before, as well as belching with the smell of "rotten" eggs. On palpation of the abdomen in the epigastric region, a "late splashing noise" (Vasilenko's symptom) can be detected, sometimes gastric peristalsis becomes visible. With decompensated pyloric stenosis, exhaustion of patients may progress, electrolyte disturbances join.

Classification of cicatricial stenoses:

1. Compensated stenosis- are characterized by a moderate violation of evacuation (barium is delayed up to 3 hours).

At the same time, the opening of the pylorus and duodenum is narrowed moderately. In order to push the food bolus from the stomach into the duodenum, the muscles of the stomach wall increase in volume (hypertrophy), and the motor activity of the stomach increases. Thus, the stomach compensates for the difficulty in moving food masses.

The patient is concerned about the feeling of fullness in the stomach after eating, frequent heartburn, belching, which has a sour taste. Often there is vomiting of food that is partially digested. After vomiting, patients experience relief. The general condition of the patient is not disturbed. At this stage, fluoroscopic examination reveals an increase in the motor activity of the stomach, frequent contractions of the muscles of the walls of the stomach are visible, but signs of stenosis and a slowdown in gastric emptying are not observed.

1. Subcompensated stenosis- the middle stage of the development of complications, in which there is an overflow of the stomach after taking small portions of food (barium lingers in the stomach for up to 7 hours).

After a few months, and in some patients after a few years, subcompensation or subcompensated stenosis occurs. The patient appears profuse vomiting, after eating, but more often after a certain period of time after eating. After vomiting comes relief. The feeling of fullness in the stomach is usually poorly tolerated by patients and many of them themselves induce vomiting. In the vomit there is food eaten the day before. The character of the eructation changes from sour to rotten. There are pains that accompany the feeling of fullness of the stomach, even when taking a small portion of food. Gradually, weight loss occurs. When examining and probing the abdomen, a splashing noise is detected in the stomach below the navel, i.e. gastric dilatation is found. X-ray examination reveals a large amount of stomach contents on an empty stomach. When fluoroscopy with barium contrasting, a violation of the evacuation function of the stomach is ascertained.

1. Decompensated stenosis- the last stage of the development of complications (barium lingers in the stomach for more than 7 hours), in which there is a significant deterioration in the patient's condition.

After 1.5-2 years, the stage of subcompensation passes into the stage of decompensation. This stage is characterized by a progressive weakening of the motor-evacuation function of the stomach. The degree of stenosis gradually increases. Vomiting becomes frequent and ceases to bring relief. food masses do not completely empty the stomach due to the weakness of the stomach muscles, which are not able to throw out all the contents during vomiting. Belching rotten becomes permanent. There is thirst, which is explained by increased loss of fluid during vomiting. The balance of electrolytes (potassium, calcium, chlorine, etc.) in the blood is disturbed, which is manifested by muscle twitching and even seizures. The patient's appetite is sharply reduced. Weight loss can reach the point of exhaustion. During the examination, a sharply expanded stomach, a decrease in the motor activity of the stomach, a large amount of contents in the stomach during fluoroscopic examination are found.

Clinical picture with ulcer penetration:

Penetration of an ulcer is the penetration of a stomach or duodenal ulcer into the surrounding tissues: the pancreas, the lesser omentum, gallbladder and others. When the ulcer penetrates, persistent pains appear, which lose their former connection with food intake, body temperature rises, an increase in ESR is detected in blood tests. The presence of ulcer penetration is confirmed radiographically and endoscopically.

Stages of development of penetration:

• The stage of the spread of an ulcer to all layers of the wall of the stomach or duodenum.
• The stage of connective tissue fusion with a nearby organ. An adhesion develops as an adhesion between the outer shell of the stomach or duodenum and the outer shell of a neighboring organ.
• The stage of penetration of the ulcer into the tissue of the organ.

Clinical picture with malignant ulcer:

Malignancy - is not such a frequent complication of stomach ulcers, as previously thought. For the malignancy of the ulcer, cases of timely unrecognized infiltrative-ulcerative stomach cancer are often mistaken. Diagnosis of malignant ulcer is not always easy. Clinically, it is sometimes possible to note a change in the course of peptic ulcer with a loss of periodicity and seasonality of exacerbations. Blood tests show anemia elevated ESR. The final conclusion is made by histological examination of biopsy specimens taken from various parts of the ulcer.

It should be noted that duodenal cancer is extremely rare, gastric ulcers are more likely to undergo cancerous degeneration (in 15-20% of cases). Ulcers of the greater curvature and prepyloric stomach are especially unfavorable in this regard. About 90% of ulcers of greater curvature are malignant.

• Callous ulcers are more often exposed to malignancy in patients older than 40 years.
• An ulcer larger than 1.5 cm should be considered potentially malignant.
• Malignancy often begins at the edge of the ulcer, less often from the bottom of it.
• Malignancy is accompanied by a change in symptoms, loss of frequency and seasonality of exacerbations and the connection of pain with food intake, loss of appetite, increased exhaustion, and the appearance of anemia.
• Blood tests reveal anemia, elevated ESR.
• The final conclusion is made during the histological examination of biopsy specimens taken from various parts of the ulcer.

5. Diagnostic criteria:

• Clinical and epidemiological data
• Laboratory confirmation not required

6. The minimum list of laboratory and instrumental research methods:

Laboratory research methods:

1. Complete blood count with an uncomplicated course of peptic ulcer, most often it remains without significant changes. Sometimes there is a slight increase in hemoglobin and red blood cells, but anemia may also be detected, indicating overt or hidden bleeding. Leukocytosis and accelerated ESR occur in complicated forms of peptic ulcer.

2. Analysis of feces for occult blood.

Instrumental research methods:

1.Esophagogastroduodenofibroscopy with targeted biopsy allows:- Identify the ulcer and describe its localization, size, nature, presence and prevalence of concomitant inflammation of the mucosa, the presence of complications of peptic ulcer,

Provide objective control over the effectiveness of anti-ulcer treatment, the speed and quality of scarring;

Carry out highly effective local treatment of ulcers by introducing various medicinal substances directly into the affected area or irradiation of the ulcer with a low-intensity helium-neon laser (endoscopic laser therapy).

2. X-ray contrast study:

The most typical x-ray signs of a stomach or duodenal ulcer are:

1) a symptom of a "niche" (contour or relief of the mucosa) with an inflammatory ridge around it;

2) convergence of mucosal folds towards the niche;

3) symptom of "pointing finger" (de Quervain's symptom);

4) Accelerated progress of barium suspension in the area of ​​ulceration (symptom of local hypermobility);

5) the presence of a large amount of fluid in the stomach on an empty stomach (non-specific sign).

7. Differential diagnosis:

Chronic gastritis

Chronic gastritis unlike peptic ulcer, it is characterized by a greater severity of dyspeptic phenomena. Often there is a feeling of heaviness in the upper abdomen and a feeling of rapid satiety after taking even a small amount of food, heartburn, belching of sour contents, stool disorders. There is a monotony of the course, short periods of exacerbation with a less pronounced pain syndrome than with peptic ulcer. There is a characteristic absence of seasonal periodicity and an increase in pain during the course of the disease. The general condition of patients is not especially disturbed. However, it is impossible to exclude gastritis, guided only by the patient's complaints. Repeated x-ray and endoscopic studies are necessary, in which, in addition to the absence of a niche, characteristic rigidity of the folds of the gastric mucosa and a change in its relief are revealed.

Chronic gastroenteritis

chronic gastroenteritis, as well as peptic ulcer, may be manifested by pain in the epigastric region after eating. But these pains are accompanied by rumbling of the intestines, and severe pain on palpation is determined in the umbilical region and below. In feces, a large number of products of incomplete digestion of food (muscle fibers, neutral fat, starch) are determined. Of the radiological signs, changes in the gastric mucosa are important, rapid evacuation of contrast from small intestine, early filling (after 2-3 hours) of the caecum.

Duodenitis and pyloroduodenitis

Duodenitis and pyloroduodenitis often very reminiscent of a clinic peptic ulcer. Unlike the latter, they are characterized by:

1) the severity of constant hungry and night pains, stopped by eating, and late dyspeptic phenomena;

2) an intermittent course with short periods of exacerbation, followed by short remissions. X-ray examination shows no signs of an ulcer, hypertrophied and atypically intertwining mucosal folds with a granular relief are determined. Repeated studies, gastroduodenoscopy allow you to make the correct diagnosis.

Peptic ulcer disease is often differentiate from periduodenitis of non-ulcer etiology. Usually they are a consequence of a duodenal ulcer, manifesting as a pyloric syndrome with a peptic ulcer clinic. After healing of the ulcer with remaining periduodenitis, the intensity of pain decreases, they become permanent, the seasonality of the phenomenon disappears. Non-ulcerative periduodenitis can be caused by cholecystitis, duodenal diverticulum complicated by inflammation or ulceration, chronic appendicitis. Unlike peptic ulcer, such periduodenitis is manifested by constant pain in the epigastric region and the right hypochondrium, aggravated after eating and radiating to the back. There are also belching, nausea, a feeling of heaviness in the epigastrium. In the diagnosis of their great help is provided by x-ray examination, which reveals the deformation of the bulb, duodenum, its rapid emptying, the absence of direct x-ray signs of peptic ulcer.

Stomach cancer

Stomach cancer, especially in initial stage, may vary clinical symptoms and remind the clinic of peptic ulcer disease. When the tumor is localized in the pyloric region, intense pain can be observed, gastric secretion is preserved. Particularly difficult is the differential diagnosis of ulcerative-infiltrative and primary-ulcerative forms of cancer, which may be accompanied by typical signs of peptic ulcer disease. In some cases, stomach ulcers clinical course may resemble gastric cancer, for example, with a long-term callous ulcer with constant pain, a decrease in gastric secretion and the formation of a large inflammatory infiltrate, determined by palpation of the abdomen. For stomach cancer, the most characteristic signs are: a short history, more elderly age patients, complaints general weakness, fatigue, constant aching pain, little dependent on food intake. Many have anemia, increased ESR, persistent hidden bleeding. Ulcerative-infiltrative forms are characterized by persistence of clinical symptoms, lack of effect from the applied treatment. X-ray, in addition to the niche, reveals infiltration and rigidity of the stomach wall, breakage of the mucosal folds, and the absence of peristalsis in the affected area surrounding the niche. Of decisive importance in the differential diagnosis of cancer and stomach ulcers are the study of the dynamics of the disease, x-ray, cytological studies and gastroscopy with targeted biopsy.

Cholelithiasis and chronic cholecystitis can often imitate peptic ulcer disease, manifested by pain in the upper abdomen and dyspeptic disorders. hallmarks is that diseases of the bile ducts are more common in women, in persons with a hypertensive constitution and obesity. They lack the frequency of exacerbation and the daily rhythm of pain. The occurrence of pain after eating is mainly due to the nature of the food (fatty foods, meat, eggs, spicy dishes, marinades, mushrooms). There are pains at different times after eating and differ in polymorphism - different intensity and duration. Often they are cramping in nature by the type of seizures (colick) and are more intense than with peptic ulcer. Pain is localized in the right hypochondrium and radiates to the right shoulder and shoulder blade. Periodically, jaundice may appear.

At chronic cholecystitis the duration of exacerbation is shorter, usually determined by days, while with peptic ulcer - weeks, months, with a gradual decrease in their intensity.

Of the objective signs, an increase in the liver, palpation and percussion pain in the right hypochondrium and the choledocho-pancreatic zone are noted. Positive symptoms of Ortner, Murphy, phrenicus symptom are revealed. With exacerbation of cholecystitis, fever, pathological changes in bile are observed, some increase in bilirubin in the blood, and urobilin in the urine. Decreased gastric secretion is often noted.

The question of the final diagnosis is solved by X-ray and endoscopic studies of the stomach, duodenum and biliary tract, which help to identify chronic cholecystitis, which is also observed in some patients with peptic ulcer disease.

In such cases, the latter must be differentiated from biliary dyskinesia, which often accompanies duodenal ulcer. Unlike cholecystitis, with dyskinesia, there are no changes in all portions of bile during duodenal sounding. With cholangiography, violations of the motility of the gallbladder, ducts and sphincter of Oddi are noted. With the subsidence of the exacerbation of peptic ulcer, the clinical manifestations of biliary dyskinesia disappear or decrease.

Chronic pancreatitis

Chronic pancreatitis in its course may resemble a peptic ulcer. With it, as well as with peptic ulcer, there are pains in the upper abdomen after eating at the height of digestion. However, they occur more often after fatty foods, are of an uncertain nature, in the case of the formation of stones in the pancreatic ducts, they become cramping. Pain, as a rule, is localized to the left of the midline in the upper abdomen, often girdle, radiating to the left shoulder and shoulder blade. Comparative or deep palpation reveals tenderness to the left of the midline. In some patients, there is an increase in the amount of diastase in the urine, sometimes glucosuria. The diagnosis of chronic pancreatitis in the absence of radiographic and endoscopic signs of peptic ulcer disease is confirmed by pancreatography, pancreatic scanning, and angiography.

Chronic appendicitis

Chronic, appendicitis in some cases may have some resemblance to peptic ulcer. This is due to the fact that in chronic appendicitis, pain in the epigastric region is often observed after eating, which are explained by the presence of a reflex spasm of the pylorus or periduodenitis, which developed as a result of the spread of infection through the lymphatic tract from the ileocecal region. In contrast to peptic ulcer in chronic appendicitis, a history of an attack is noted. acute appendicitis, the frequency of exacerbation with short-term pain phenomena, their intensification during walking and physical exertion. On palpation and percussion, a zone of pronounced soreness is determined in a limited area of ​​the ileocecal region. In difficult cases for diagnosis, X-ray examination of the gastroduodenal system and ileocecal angle helps.

Diverticula of the stomach and duodenum are often asymptomatic. When the diverticulum reaches a large size, pain and a feeling of heaviness in the epigastric region, vomiting appear. When complicated by inflammation or ulceration, the clinical picture may be very similar to that of peptic ulcer. There are pains after eating, the frequency of exacerbation. Diagnosis in these cases can be difficult and X-ray examination and gastroduodenoscopy are decisive here.

In the differential diagnosis of gastric ulcer and duodenal ulcer, in addition to those mentioned above, it is necessary to keep in mind a number of other diseases, although rare, but which can present significant difficulties in recognition (tuberculosis, gastric syphilis, tabic crises, etc.).

Tuberculosis of the stomach

Tuberculosis of the stomach- one of the rare localizations of the tuberculosis process. Pathological changes can manifest as solitary or milliary tubercles, diffuse hyperplastic form, and more often (up to 80%) as flat superficial or small deep crater-like ulcers. Such ulcers are localized more often in the pyloric and antral sections, often causing narrowing of the pylorus or deformity of the stomach. Clinically, the disease is manifested by pain in the epigastric region, but less pronounced than with a stomach ulcer. There are diarrhea, a decrease in gastric secretion. In patients, tuberculous lesions of the lungs and other organs are not uncommon. The absence of characteristic clinical symptoms, the atypical X-ray picture often cause great difficulties in diagnosing the disease, and only a histological examination of biopsy specimens or surgical material allows a correct diagnosis to be made.

Syphilis of the stomach

Syphilis of the stomach is rare. The defeat of the stomach is observed in the tertiary period and is manifested by the formation of gums in the wall of the stomach, which can ulcerate. The clinical picture may resemble chronic gastritis, gastric ulcer or tumor. Patients experience heartburn, nausea and vomiting, pain in the epigastric region, but they do not reach the same intensity as with peptic ulcer, and are often not associated with food intake. In x-ray examination, gumma simulates a tumor or stomach ulcer, which causes difficulties in recognizing the disease.

The diagnosis is made on the basis of a history of syphilis, positive serological reactions, trial specific treatment results, or histological examination of biopsy material or a removed stomach preparation.

Lymphogranulomatosis of the stomach

Lymphogranulomatosis of the stomach refers to rare diseases. Damage to the stomach is more often observed in a systemic disease and rarely as an isolated form. Lymphogranulomatous formations in the wall of the stomach are characterized by the formation of tumor-like nodes protruding into the lumen of the stomach, or superficial or deep ulcerations. The clinical picture of an isolated lesion is very similar to the clinic of cancer or callous ulcer. Ulcerative forms are manifested by pain in the epigastrium, latent or profuse bleeding. Common symptoms include fever, weakness, weight loss, sweating, and pruritus. The blood revealed leukopenia with neutrophilia, eosinophilia and lymphopenia. Due to the rarity of isolated lymphogranulomatosis of the stomach, the originality of the clinic and morphological changes in the wall of the stomach, similar to a stomach ulcer, diagnosis presents exceptional difficulties. The diagnosis is made by microscopic examination of biopsy specimens taken during fibrogastroscopy or from a resected stomach.

duodenostasis

duodenostasis is a violation of the motor-evacuation function of the duodenum. It can develop with diseases of the biliary tract and pancreas, periduodenitis, or be an independent disease of neurogenic origin. It manifests itself with periodic attacks of pain in the epigastric region, resembling pain in peptic ulcer. Its distinctive features are: the occurrence of an isolated swelling in the right hypochondrium during an attack of pain, vomiting of gastric contents mixed with a significant amount of bile.

The diagnosis is established by x-ray examination, which reveals stagnation in the duodenum and its expansion, stenosing peristalsis and antiperistalsis, retrograde stagnation of barium in the stomach and delayed emptying of it.

Tabic crises

Tabic crises develop in patients with tabes dorsalis. They are characterized by attacks of severe pain in the epigastric region with different irradiation, sudden onset and rapid disappearance, lack of pain relief after vomiting,. commonly seen in patients with peptic ulcer, severe general condition sick; apathy, loss of strength are observed. Seizures can be of varying duration. Outside the attacks, the patient does not suffer. The characteristic symptoms of nervous system(anisocoria, lack of knee jerks, imbalance, etc.), changes in the aorta and aortic valves are possible, a positive Wasserman reaction in the blood or cerebrospinal fluid.

Diaphragmatic hernia

At diaphragmatic hernia, as well as with peptic ulcer disease, patients complain of pain in the epigastric region during or after eating, night pains, a feeling of heaviness in the epigastrium and dyspeptic disorders. In some cases, obvious or latent esophageal-gastric bleeding is observed. These complaints are associated with the development of ulcerative esophagitis, localized gastritis.

In contrast to peptic ulcer in diaphragmatic hernia, pain is localized high in the epigastrium, in the region of the xiphoid process and behind the sternum. There is no strict periodicity of them, different intensity and duration. Pain often radiates upward and backward - to the back, to the left shoulder. A burning sensation behind the sternum or along the esophagus during or after eating is characteristic. Of decisive importance in the differential diagnosis of these diseases is a targeted x-ray examination of the organs of the chest and gastroduodenal system.

Hernia of the white line of the abdomen

Hernia of the white line of the abdomen in some cases, it can cause sharp pains in the epigastric region and dyspeptic disorders, like peptic ulcer. In other patients, epigastric hernia may be accompanied by peptic ulcer disease and the underlying disease is not diagnosed. Differential diagnosis of these two diseases during a careful examination of the patient does not cause difficulties, however, the presence of an epigastric hernia obliges the doctor to conduct an X-ray examination of the stomach and duodenum in order to prevent diagnostic and tactical errors when deciding on the operation.

Intestinal dyskinesia

At intestinal dyskinesias clinical manifestations may be similar to the clinic of peptic ulcer. Patients complain of pain in the epigastric region or other localization, dyspeptic disorders. Distinctive signs of dyskinesias complicated by colitis are: a history of prolonged constipation, periodic change of constipation with “false” diarrhea, a feeling of incomplete emptying of the intestine. Often the pain does not depend on the nature of the food taken, there is a relief after the stool and gas discharge. An objective examination is determined by pain along the colon, often transverse, descending and sigmoid.

An x-ray examination shows a pronounced spasm of these sections of the colon or total colospasm. Intestinal dyskinesia, colitis may be accompanied by peptic ulcer, but the absence of signs of peptic ulcer during fluoroscopy or fibrogastroduodenoscopy speaks in favor of dyskinesia.

8. Hospitalization:

Patients with complicated forms of peptic ulcer are subject to hospitalization. Uncomplicated forms of peptic ulcer are treated conservatively on an outpatient basis.

9. Basic therapy:

Treatment of exacerbation of uncomplicated peptic ulcer is the exclusion of physical and mental stress, a diet (sparing, with meals 4-5 times a day), smoking cessation and alcohol consumption, drug treatment.

10. Etiotropic therapy:

• Reducing the secretion of hydrochloric acid (reducing the aggressive effect and creating conditions for the action of antibiotics)
• Sanitation of the mucous membrane of the stomach and duodenum from H. pylori
• Prevention of relapses and complications

The main rule of antisecretory therapy

• The level of intragastric pH during the day (about 18 hours) should be above 3
• To date, only proton pump inhibitors (PPIs) comply with this rule.
• PPIs are taken strictly according to the protocol (omeprazole 10 mg/day, rabeprazole 20 mg/day, lansoprazole 30 mg/day, pantoprazole 40 mg/day, esomeprazole (Nexium) 40 mg/day) with endoscopic control after 4.6 weeks for duodenal ulcer and 6.8 weeks for gastric ulcer.

11.Pathogenetic and symptomatic therapy:

"Maastricht 3" - treatment (1)

First line therapy:

PPI in a standard dose 2 times a day.

Clarithromycin (Macrolides) 500 mg twice daily

Amoxicillin (Penicillins) 1000 mg twice daily or Metronidazole (Antiprotozoal) 500 mg twice daily*

Duration of therapy - at least 7 days, up to 10 days

"Maastricht 3" - treatment (2)

Second line therapy:

PPI at standard dose twice a day

Bismuth subcitrate (gastroprotectors) 120 mg 4 times a day

Metronidazole 500 mg 3 times a day

Tetracycline (antibiotics, polyketides) 250 mg 4 times a day

Duration of therapy - at least 10 days, up to 14 days

* With resistance to metronidazole less than 40%

12. Indications for surgical treatment:

Indications for surgical treatment can be divided into absolute and relative:

Absolute:

1. ulcer perforation;
2. Profuse ulcerative bleeding with symptoms of hemorrhagic shock or non-stop conservatively (including using the available arsenal of endoscopic techniques);
3. The presence of stenosis;
4. High risk of recurrence with stopped ulcer bleeding or recurrent bleeding;
5. Penetrating ulcer;
6. Histologically confirmed malignant degeneration of the ulcer.

Relative:

1. Severe course of peptic ulcer: the frequency of relapses more than 2 times a year, the lack of effectiveness of standard drug therapy;
2. Long-term non-scarring on the background traditional therapy ulcers: stomach ulcer - more than 8 weeks, duodenal ulcer - more than 4 weeks;
3. Repeated bleeding in history against the background of adequate therapy;
4. Callous ulcers not scarring within 4-6 months;
5. Ulcer recurrence after previous suturing due to perforation;
6. Multiple ulcers in combination with high acidity of gastric juice;
7. Lack of opportunity for regular full-fledged treatment;
8. The desire of the patient to be radically cured;
9. Intolerance to the components of drug therapy.

13. Surgical interventions performed for peptic ulcer:

In uncomplicated forms of peptic ulcer, the following are performed:

1. Resection of 2/3 of the stomach with the imposition of gastroduodenoanastomosis according to Billroth-I,
2. Resection of 2/3 of the stomach with the imposition of gastrojejunoanastomosis according to Billroth-II on a long loop with enteroenteroanastomosis according to Brown.

In complicated forms of peptic ulcer, the following are performed:

For bleeding:

Bleeding ulcer closure

For perforated ulcers:

Suturing a perforated ulcer according to Oppel-Polikarpov,

With cicatricial stenosis:

Pyloroplasty (according to Finney, Heineke-Mikulich, Jabulei),

On penetration:

Cutting off the posterior wall of the duodenum from the edges of the penetrating ulcer, followed by removal of the affected segment of the duodenum or with its plastic restoration by duodenoplasty,

Distal resection of the stomach with the formation of a pylorus-modeling gastroduodenoanastomosis,

Selective proximal vagotomy with ulcer removal and duodenoplasty.

For "difficult" ulcers:

Finsterer-Bancroft-Plenk gastric resection for "off"

14. Prevention:

It is conditionally possible to divide the prevention of peptic ulcer into primary and secondary.

primary prevention, aimed at preventing the development of the disease, and the secondary reduces the risk of exacerbations and relapses.

Primary prevention of duodenal ulcer or gastric ulcer includes:

• Prevention of infection with Helicobacter pylori. It is necessary to strictly adhere to the anti-epidemic rules if there is a patient with a peptic ulcer or a person who is a carrier of this microbe in the house. The patient should have an individual set of dishes, cutlery, personal towels. Kissing is not recommended.
• It should be completely avoided alcoholic beverages and also no smoking.
• Monitor the condition of your teeth, treat caries in a timely manner, observe oral hygiene.
• For the prevention of gastric and duodenal ulcers, it is recommended to treat chronic and acute diseases, hormonal disorders.
• Eat healthy food. Eliminate smoked, spicy and spicy dishes, carbonated drinks, too cold or hot dishes from your diet.
• Do not frequently take drugs that can cause ulcers.
• Plan your day for work, sports and leisure.

Secondary prevention duodenal ulcer or gastric ulcer implies a mandatory medical examination:

• In the autumn and spring periods, it is recommended to conduct courses of anti-relapse treatment. The gastroenterologist prescribes the necessary physiotherapeutic procedures, medications, mineral water, herbal medicine.
• The patient needs to undergo a sanatorium-resort preventive treatment ulcers in specialized institutions.
• Follow the diet prescribed by the gastroenterologist.
• Sanitize chronic foci of infection that can cause an exacerbation of an ulcer.
• Constant monitoring of the state of the ulcer, both instrumental and laboratory. This will help in a short time to identify the onset of an exacerbation of the disease and begin treatment.
• It is necessary to adhere to the whole complex of preventive measures, as in the primary prevention of ulcers.

RCHD (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Archive - Clinical Protocols of the Ministry of Health of the Republic of Kazakhstan - 2007 (Order No. 764)

Gastric ulcer (K25)

general information

Short description

peptic ulcer- a chronic relapsing disease, the main morphological substrate of which is a peptic ulcer in the stomach, duodenum or proximal jejunum, with frequent involvement of other organs of the digestive system in the pathological process and the development of various complications.

The etiological factor is Helicobacter pylori(NR) is a gram-negative spiral bacterium. Colonies live in the stomach, the risk of infection increases with age. HP infection in most cases is the cause of gastric and duodenal ulcers, B-cell lymphoma and cancer. distal departments stomach. About 95% of duodenal ulcers and about 80% of gastric ulcers are associated with the presence of HP infection. Separately, symptomatic ulcers associated with the use of non-steroidal anti-inflammatory drugs (NSAIDs), steroid hormones are isolated.

Protocol code: H-T-029 "Peptic ulcer"

For therapeutic hospitals
Code (codes) according to ICD-10:

K25 Gastric ulcer

K26 Duodenal ulcer

K27 Peptic ulcer, unspecified

K28.3 Gastroduodenal ulcer, acute without bleeding or perforation

K28.7 Gastroduodenal ulcer, chronic without bleeding or perforation

K28.9 Gastroduodenal ulcer, not specified as acute or chronic, without haemorrhage or perforation

Classification

Classification (Grebenev A.L., Sheptulin A.A., 1989, 1995)

According to nosological independence

1. Peptic ulcer.

2. Symptomatic gastroduodenal ulcers:

2.1 “Stress” ulcers:

A) with widespread burns (Curling's ulcers);

B) with craniocerebral injuries, cerebral hemorrhage, neurosurgical operations (Cushing's ulcers);

C) with myocardial infarction, sepsis, severe injuries and abdominal operations.

2.2 Medicinal ulcers.

2.3 Endocrine ulcers:

A) Zollinger-Ellison syndrome;

B) gastroduodenal ulcers in hyperparathyroidism.

2.4 Gastroduodenal ulcers in some diseases of the internal organs:

A) with nonspecific lung diseases;

B) with liver diseases (hepatogenic);

C) in diseases of the pancreas (pancreatogenic);

D) with chronic renal failure;

D) with rheumatoid arthritis;

E) in other diseases (atherosclerosis, diabetes, erythremia, etc.).

According to the location of the lesion

1. Stomach ulcers:

Cardiac and subcardiac departments;

Body and corner of the stomach;

Antral department;

pyloric canal.

2. Duodenal ulcers:

Bulbs of the duodenum;

Postbulbar department (intrabulbous ulcers).

3 Combination of gastric and duodenal ulcers. Projection of the lesion of the stomach and duodenum:

Small curvature;

Large curvature;

front wall;

Back wall.

According to the number and diameter of ulcers:

Single;

Multiple;

Small (up to 0.5 cm);

Medium (0.6-1.9);

Large (2.0-3.0);

Giant (> 3.0).

According to the clinical form:

typical;

Atypical (with atypical pain syndrome, painless, asymptomatic).

According to the level of gastric acid secretion:

elevated;

Normal;

Reduced.

By the nature of gastroduodenal motility:

Increased tone and increased peristalsis of the stomach and duodenum;

Decrease in tone and weakening of peristalsis of the stomach and duodenum;

Duodenogastric reflux.

According to the phase of the disease:

phase of exacerbation;

scarring phase;

remission phase.

By scarring time:

With the usual terms of scarring (up to 1.5 months for duodenal ulcers and up to 2.5 months for stomach ulcers);

Difficult scarring ulcers;

By the presence or absence of post-ulcer deformation;

Cicatricial and ulcerative deformity of the stomach;

Cicatricial and ulcerative deformity of the duodenal bulb.

By the nature of the course of the disease:

Acute (for the first time identified ulcer);

Chronic: with rare exacerbations (1 time in 2-3 years); with monthly exacerbations (2 times a year and more often).

Factors and risk groups

The presence of HP;

Taking non-steroidal anti-inflammatory drugs, steroid hormones;

Having a family history;
- irregular intake of medicines;
- smoking;

Alcohol intake.

Diagnostics

Diagnostic criteria

Complaints and anamnesis
Pain: it is necessary to find out the nature, frequency, time of occurrence and disappearance of pain, connection with food intake.

Physical examination

1. Early pain occurs 0.5-1 hour after eating, gradually increases in intensity, persists for 1.5-2 hours, decreases and disappears as gastric contents move into the duodenum; characteristic of gastric ulcers. With the defeat of the cardiac, subcardial and fundic departments pain occur immediately after eating.

2. Late pains occur 1.5-2 hours after eating, gradually increase as the contents are evacuated from the stomach; characteristic of ulcers of the pyloric stomach and duodenal bulb.

3. “Hungry” (night) pains occur 2.5-4 hours after eating, disappear after the next meal, characteristic of duodenal ulcers and pyloric stomach.

4. The combination of early and late pain is observed with combined or multiple ulcers. The severity of pain depends on the location of the ulcerative defect (slight pain - with ulcers of the body of the stomach, sharp pain - with pyloric and extra-bulbous ulcers of the duodenum), age (more intense in young people), and the presence of complications.

The most typical projection of pain, depending on the localization of the ulcerative process, is the following:

With ulcers of the cardiac and subcardial sections of the stomach - the region of the xiphoid process;

With ulcers of the body of the stomach - the epigastric region to the left of the midline;

With ulcers of the pyloric and duodenal ulcers - the epigastric region to the right of the midline.

Laboratory research

In the general blood test: posthemorrhagic anemia, reticulocytosis, increased activity of amylase in the blood serum and urine (when an ulcer penetrates into the pancreas or reactive pancreatitis).
Changes in liver biochemical samples are possible (increased activity of ALT, AST with nonspecific reactive hepatitis, direct bilirubin with involvement in the inflammatory-destructive process of the Vater nipple).

When bleeding from an ulcer, the reaction to occult blood in the feces becomes positive.
The presence of HP is confirmed by microscopic, serological tests and urease breath test (see below).

Instrumental Research

1. The presence of an ulcer on the EGDS. With gastric localization of ulcers, a histological examination is mandatory to exclude malignancy.

2. Examination of the presence of HP in the mucous membrane. HP diagnostics is mandatory for all patients with a history of gastric and duodenal ulcer, as well as a history of peptic ulcer and its complications. Diagnostic interventions to identify HP should be carried out both before the start of eradication therapy and after its completion to evaluate the effectiveness of the measures.

Invasive and non-invasive methods for detecting HP are used. According to the recommendations of Maastricht-3 (2005), in cases where EGDS is not performed, then for primary diagnosis it is preferable to use a urease breath test, determination of HP antigens in feces or a serological test. If EGDS is performed, then a rapid urease test (in a biopsy specimen) is performed to diagnose HP, if it is impossible to perform it, a histological examination of the biopsy specimen with staining according to Romanovsky-Giemsa, Wartin-Starry, hematoxylin-eosin, fuchsin or toluidine blue can be used to detect HP.

To control eradication 6-8 weeks after the end of eradication therapy, it is recommended to use a breath test or study HP antigens in the feces, and if it is impossible to perform them, a histological examination of biopsy specimens for HP.

Indications for expert advice: according to indications.

List of main diagnostic measures:

General blood analysis;

Determination of serum iron in the blood;

General urine analysis;

Endoscopy with targeted biopsy (according to indications);

Histological examination of the biopsy;

Cytological examination of the biopsy;

HP test.

List of additional diagnostic measures:

blood reticulocytes;

Ultrasound of the liver, biliary tract and pancreas;

Determination of blood bilirubin;

Determination of cholesterol;

Definition of ALT, AST;
- determination of blood glucose;

Determination of blood amylase;

X-ray of the stomach (according to indications).

Differential Diagnosis

signs	Functional (non-ulcerative) dyspepsia	peptic ulcer
circadian rhythm of pain	Not typical (pain at any time of the day)	characteristic
Seasonality of pain	Absent	characteristic
Perennial Rhythm pain	Absent	characteristic
progressive course disease	Not typical	Characteristically
Duration of illness	More often 1-3 years	Often over 4-5 years
The onset of the disease	Often still in childhood and adolescence	More common in young adults of people
Pain relief after eating	Not typical	Typically when duodenal ulcer
night pains	not typical	Typically when duodenal ulcer
Association of pain with psycho-emotional factors	characteristic	Meets
Nausea	Common	Rarely
Chair	More often normal	More often constipation
weight loss	Not typical	More often moderate
Symptom of local palpatory soreness	not characteristic	characteristic
Related neurotic manifestations	Characteristic	Dating but not natural and not so pronounced, as in non-ulcer dyspepsia
Data X-ray research	Motor- evacuation dyskinesia stomach	Ulcerative "niche", periduodenitis, perigastritis
FEGDS	Normal or increased tone of the stomach, pronounced vascular drawing, distinct folds	Ulcer, post-ulcer scar, gastritis

Complications

Bleeding;
- perforation;
- penetration;
- perigastritis;
- periduodenitis;
- cicatricial and ulcerative stenosis of the pylorus;
- malignancy.

Treatment abroad

Get treatment in Korea, Israel, Germany, USA

Get advice on medical tourism

Treatment

Treatment Goals

H. pylori eradication. “Suppression (suppression) of active inflammation in the mucous membrane of the stomach and duodenum;

Healing of a peptic ulcer;

Achieving stable remission;

Prevention of development of complications.

Non-drug treatment

Diet No. 1 (1a, 15) with the exception of dishes that cause or increase the clinical manifestations of the disease (for example, spicy seasonings, canned, pickled and smoked foods).

Food is fractional, 5~6 times a day.

Medical treatment

With peptic ulcer of the stomach and duodenum associated with H. pylori, eradication therapy is shown that meets the following requirements:

In controlled studies, HP eradication should occur in at least 80% of cases;

Should not be canceled due to side effects (tolerable in less than 5% of cases);

First line therapy (triple therapy) includes: proton pump inhibitor (omeprazole* 20 mg, pantoprazole* 40 mg, rabeprazole* 20 mg) + clarithromycin* 500 mg + amoxicillin* 1000 mg or metronidazole* 500 mg; All drugs are taken 2 times a day. The combination of clarithromycin with amoxicillin is preferred over clarithromycin with metronidazole due to rapid development resistance of HP strains to metronidazole.

Second line therapy(quadrotherapy) is recommended in case of failure of first-line drugs. Assign: a proton pump inhibitor at a standard dose 2 times a day + bismuth B 120 mg 4 times a day + metronidazole ** 500 mg 3 times a day + tetracycline ** 500 mg 3 times a day.

Alternatively, the above first-line therapy with the addition of bismuth preparations (480 mg per day) can be prescribed.

In case of failure of the first and second line eradication schemes, according to Maastricht-3 (2005), amoxicillin is proposed at a dose of 0.75 g 4 times a day in combination with high (four-fold) doses of proton pump inhibitors for 14 days. Another option may be to replace metronidazole with furazolidone at a dose of 100-200 mg 2 times a day.

Rules for anti-Helicobacter therapy:

1. If the use of the treatment regimen does not lead to the onset of eradication, it should not be repeated.

2. If the above schemes did not lead to eradication, this means that the bacterium previously had or acquired resistance to one of the components of the treatment regimen (nitroimidazole derivatives, macrolides).

3. When a bacterium appears in the patient's body a year after the end of treatment, the situation should be regarded as a relapse of the infection, and not as a reinfection.

After the end of combined eradication therapy according to indications (preservation of symptoms of hyperacidism, large and deep ulcers, complicated course, the need to take ulcerogenic drugs for concomitant diseases), one of the antisecretory drugs should be continued on an outpatient basis for up to 4 weeks with duodenal ulcers and up to 6 weeks with gastric localization of ulcers, followed by histological monitoring.

In cases where HP cannot be detected, one should keep in mind the possible false-negative results of the tests used. The reasons for this may be an incorrectly taken biopsy (for example, from the bottom of an ulcer), the use of antibacterial or antisecretory drugs by patients, insufficient qualifications of morphologists, etc.

peptic ulcer severe course associated with H. pylori, not amenable to eradication;

Peptic ulcer with a syndrome of mutual aggravation (comorbidities).

Necessary amount of examinations before planned hospitalization:
- EGDS;
- general analysis blood;

Analysis of feces for occult blood;
- urease test.

Information

Sources and literature

1. Protocols for the diagnosis and treatment of diseases of the Ministry of Health of the Republic of Kazakhstan (Order No. 764 of December 28, 2007)
   1. 1. Prodigy guidance - Dyspepsia - proven DU, GU, or NSAID-associated ulcer. NICE 2004 Management of Helicobacter pylori Infection. MOH Clinical Practice Guidelines 9/2004 2. I.N. Denisov, Yu.L. Shevchenko. Clinical guidelines plus a pharmacological guide. M.2004. 3. New Zealand guidelines group/ Management of dyspepsia and heartburn, June 2004.) 4. Management of Helicobacter pylori infection. Ministry of health clinical practice guidelines 9/2004/5. Guidelines for clinical care. University of Michigan health system. May 2005. 6. Practice guidelines. Guidelines for the Management of Helicobacter pylori Infection/ THE AMERICAN JOURNAL OF GASTROENTEROLOGY Vol. 93, no. 12, 1998. 7. National Committee for Clinical Laboratory Standards/ Methods for Dilution Antimicrobial Susceptibility Tests for Bacteria That Grow Aerobically-Fift Edition/ Approved Standard NCCLS Document M7-F5, Vol.20, NCCLS, Wayne, PA, January 2000. 8. V.T. Ivashkin. Recommendations for the diagnosis and treatment of peptic ulcer disease. A guide for doctors. Moscow., 2005. 9. Diagnosis and treatment of acid-dependent and Helicobacter-associated diseases. Ed. R.R. Bektaeva, R.T. Agzamova. Astana, 2005 10. A.V. Nersesov. Clinical classifications of the main diseases of the digestive system Educational and methodological manual, Astana, 2003
   2. The choice of drugs and their dosage should be discussed with a specialist. Only a doctor can prescribe the right medicine and its dosage, taking into account the disease and the condition of the patient's body.
   3. MedElement website and mobile applications"MedElement (MedElement)", "Lekar Pro", "Dariger Pro", "Diseases: Therapist's Handbook" are solely information and reference resources. The information posted on this site should not be used to arbitrarily change the doctor's prescriptions.
   4. The editors of MedElement are not responsible for any damage to health or material damage resulting from the use of this site.

peptic ulcer(I WOULD) stomach and duodenum(12PC) refers to the most common diseases digestive system. Her diagnosis and treatment are carried out in accordance with the order No. 613 dated September 3, 2014.

It is proved that the main factor in the development of peptic ulcers is infection. H. pylori(approximately 80% of gastric ulcers and approximately 95% of duodenal ulcers), as well as the use of non-steroidal anti-inflammatory drugs (NSAIDs) (approximately 20% of gastric ulcers and approximately 5% of duodenal ulcers).

Clinic. Leading in the clinic of peptic ulcer of the stomach and duodenum are pain syndrome, often allowing to determine the localization of the ulcer, as well as dyspeptic (heartburn, belching, nausea and vomiting), dyskinetic and astheno-vegetative syndromes.

Diagnostic criteria: endoscopically confirmed ulcerative defect in the duodenum or stomach. FibroEophagogastroDuodenoScopy (FEGDS) is the "gold standard" of diagnosis, FEGDS is necessary to verify the diagnosis, as well as to control the treatment of patients with peptic ulcer of the stomach. If FEGDS is not possible, an X-ray examination of the stomach and 12 PC is performed.

To diagnose an infection H. pylori First of all, direct methods are suitable that detect a bacterium (histology, microbiological dilution method), a representative antigen (faecal antigen test) or a specific metabolic product (ammonia in the rapid urease test, carbon dioxide in the breath test for urea). The sensitivity of these methods of analysis is more than 90%.

Ultrasound of the abdominal organs is also performed, according to indications - a general blood test and a biochemical blood test.

Treatment. To obtain the results of a biopsy to relieve the symptoms of peptic ulcer, if necessary, H2-receptor antagonists, antacids, alginates, antispasmodics (drotaverine, mebeverine, etc.) can be prescribed.

Modifying factors for the effectiveness of therapy against H. pylori are compliance with treatment, smoking and the degree of inhibition of acidity.

With peptic ulcer(peptic ulcers) associated with Hp infection, the main treatment strategy is to conduct anti-Helicobacter therapy for 7-10 days in accordance with the Maastricht Consensus-4 according to one of the first-line regimens: standard three-component therapy or sequential therapy. The first line of therapy in most cases is a proton pump inhibitor (PPI: omeprazole, etc.) + clarithromycin + amoxicillin (in countries where the level of metronidazole resistance exceeds 40%) or metronidazole (in countries with low metronidazole resistance). Triple therapy for 10-14 days. Compared with seven-day triple therapy, it can increase the level of eradication by 12% (Table 1).

Table 1. Standard eradication therapy for HP infection

First line (level A) - 7-14 days
	IPP	Clarithromycin	Metronidazole	Amoxicillin
1	Standard dose*	2 x 500 mg		2 x 1000 mg
2	Standard dose*	2 x 500 mg	2 x 400 mg or 2 x 500
Second line (level A) – 10 days
Bismuth subcitrate:		IPP	Tetracycline	Metronidazole
4 x 120 mg		Standard dose *	4 x 500 mg	3 x 500 mg

* - Standard PPI dose: omeprazole (2 x 20 mg), lansoprazole (2 x 30 mg), pantoprazole (2 x 40 mg), rabeprazole (2 x 20 mg), esomeprazole (2 x 20 mg), etc.

Sequential therapy regimen: PPI at a standard dose 2 times a day + amoxicillin 1000 mg 2 times a day. 5 days with further transition to PPI + clarithromycin 500 mg 2 times / day. + metronidazole (or tinidazole) 500 mg 2 times a day. 5 days.

It is advisable to prescribe probiotics during anti-Helicobacter therapy, they increase the effectiveness of eradication and prevent the development of dysbiotic disorders of the intestine.

The choice of PPIs as the leading antisecretory agent is due to their strength and duration of action and the presence of an anti-Helicobacter pylori effect (Table 2).

Group	international name	Tradename
Proton pump inhibitors (PPIs)	Omeprazole	Omez **, Omeprazole, Gasek, Diaprazole, Loseprazole, etc. Combi: + domperidone (Omez D, Omez DSR, Limzer)
	Lansoprazole	Lancerol , Lansoprol
	Pantoprazole	Zovanta, Zolopent, Controloc **, Nolpaza, PanGastro, Pantasan **, Proxium **, Tekta control, etc.
	Rabeprazole	Pariet**, Barol, Rabimak, etc.
	Esomeprazole	Nexium**, Pemosar, Ezolong, Esomealox
	Dexlansoprazole	Dexilant

** - there are parenteral dosage forms.

In accordance with order No. 613, after eradication for gastric ulcers, PPIs are subsequently prescribed at a standard dose of 2 r / day for 4-6 units. In uncomplicated peptic ulcer of the duodenum, further PPI administration is not necessary.

With regard to NSAID gastropathy, it is noted that the eradication of HP is not enough to prevent them, however, all patients receiving aspirin, NSAIDs and COX-2 inhibitors should be tested for HP.

1. With H.pylori-positive peptic ulcer associated with taking NSAIDs, and in the absence of complications after anti-Helicobacter therapy, PPIs are prescribed in a standard dose or H2-receptor antagonists in a double dose for 14-28 days, depending on the location of the peptic ulcer; additionally, sucralfate, bismuth subcitrate can be prescribed. If long-term use of NSAIDs is required, the drugs of choice are selective inhibitors COX-2.

A minimum of 4 weeks should elapse between the completion of antibiotic treatment and monitoring of the effectiveness of treatment. A minimum of 2 weeks should elapse between the end of PPI therapy and reliable control of the effectiveness of eradication.

If three-component or sequential therapy is ineffective, intolerance or resistance to clarithromycin, second-line therapy (quad therapy) is prescribed. The most effective second line of treatment is still classical quadruple therapy using bismuth subcitrate (De-nol, Gastro-norm, Vis-nol) (Table 1).

Histamine H2 receptor blockers(H2-HB) inhibit the secretion of HCL by blocking the histamine H2 receptors of the parietal cells of the gastric mucosa. They reduce basal and stimulated secretion, reduce the volume of gastric juice, the content of HCL and pepsin in it. Currently, in Ukraine, the 3rd generation of H2-histamine blockers famotidine (Kvamatel and others) is more often used.

Available combined preparations for the treatment of peptic ulcer that make eradication therapy more convenient, such as Clatinol (Lansoprazole, Clarithromycin, Tinidazole).

In cases of unsuccessful eradication and in the second line of treatment, the following options for “rescue therapy” are considered: PPI at a standard dose 2 times a day + amoxicillin 1000 mg 2 times a day + levofloxacin 500 mg 1 time a day, or rifabutin 300 mg 1 time a day for a period of 10-14 days.

When using antisecretory drugs, it must be borne in mind that their appointment levels the manifestations of gastric cancer and makes it difficult to make a diagnosis, so a malignant neoplasm must be excluded before the start of therapy. In addition, by reducing acidity, the drugs eliminate the bactericidal effect of hydrochloric acid, and therefore increase the risk of gastrointestinal infections. The use of PPIs without concomitant H. pylori therapy in the presence of HP increases the risk of atrophic gastritis.

Successful anti-Helicobacter pylori therapy contributes to complete recovery in 80-85% of cases, as a rule, the frequency of ulcer recurrence does not exceed 6%, the complication rate is 2-4%.

The prognosis worsens with unsuccessful attempts to re-eradicate HP, the presence of complications, especially if malignancy is suspected. If HP eradication has not occurred, despite healing, then in the absence of further treatment, recurrence of duodenal ulcers over the next few months, as a rule, occurs in 50-70% of patients. Relapses are associated either with incomplete eradication (most often), or with reinfection, or with the action of a second etiological factor (most often, the use of NSAIDs), or there is a combined etiology of peptic ulcer.

Already in Mastricht-1, strict indications for the eradication of HP infection were formulated: these are PU in the active and inactive phases, ulcerative bleeding, MALT-lymphoma (level A), gastritis with serious morphological changes, the condition after endoscopic resection for gastric cancer.

Recommended indications are also functional dyspepsia (level B), familial cases of gastric cancer, long-term treatment of gastroesophageal reflux disease with antisecretory drugs, planned or ongoing therapy with non-steroidal anti-inflammatory drugs.

Indications for eradication are the prevention of gastric cancer in the absence of risk factors and the absence of symptoms, non-gastroenterological diseases. Now it is recommended to carry out the eradication of HP in immune thrombocytopenia (level B) and unexplained iron deficiency anemia (level B). In addition, Maastricht-4 recommends (grade A) HP eradication for unexplored dyspepsia.

It is emphasized that HP itself does not cause GERD, however, all cases of a combination of HP infection and complicated GERD should be specially considered.

2. For H.pylori-negative peptic ulcers The main treatment strategy is the appointment of antisecretory drugs:

With H.pylori-"-" peptic ulcer and in the absence of complications, PPIs are prescribed in standard doses for 3-4 weeks with duodenal localization of the ulcer, 4-8 weeks with gastric ulcers (additional therapy - bismuth subcitrate or sucralfate).

Bismuth subcitrate, as mentioned above, has a pronounced anti-Helicobacter activity. The gastroprotective effect of bismuth subcitrate preparations (De-nol, Gastro-norm, Vis-nol) is associated with the ability to enhance microcirculation through prostaglandins, activate mitotic activity (repair), and normalize the synthesis of hydrochloric acid and bicarbonates.

After healing of benign gastric ulcers, it is advisable to conduct a control FEGDS after 6 months. In the presence of atrophy of the gastric mucosa, repeated FEGDS with a biopsy to monitor the possible appearance of precancerous changes is performed once every 2-3 years.

Rehabilitation. Recommended sanatorium treatment in the resorts of Transcarpathia. In accordance with the Clinical protocol for the spa treatment of gastric and duodenal ulcers in remission and unstable remission (Order of the Ministry of Health of Ukraine No. 56 dated 06.02.08), mineral waters are prescribed taking into account the state of the secretory function of the stomach., Novomoskovskaya, Soymi, etc.).

Issue No. 13 was prepared by Ph.D. N.V. Khomyak

L A B O R A T O R N Y   A R S E N A L

Peptic ulcer (PU) is a fairly common pathology of the digestive tract. According to statistics, up to 10-20% of the adult population experience it; in large cities, the incidence rate is much higher than in rural areas.

This disease is associated with the formation of ulcers on the mucous membrane of the stomach and duodenum, in the absence of proper treatment PUD leads to serious complications and even death. The disease can be asymptomatic for a long time, but it is very dangerous during exacerbations. Properly chosen scheme for the treatment of gastric and duodenal ulcers ensures healing and prevents complications.

Causes of peptic ulcer

The main reason why the disease occurs is the activity of the bacterium Helicobacter pylori: it provokes inflammation, which eventually leads to the formation of ulcers on the mucous membrane. However, bacterial damage is exacerbated by some additional factors:

• Improper irregular nutrition. Snacking on the go, the lack of a full breakfast, lunch and dinner, an abundance of spices and salty foods in the diet - all this negatively affects the stomach and creates a favorable environment for the growth of bacteria.
• Bad habits. Peptic ulcer disease is especially common in those who smoke on an empty stomach, alcohol intake also contributes to serious damage to the mucous membranes.
• Stress and negative emotions. The development of an ulcer and its aggravation is provoked by constant nervous excitement, as well as constant mental overload.
• hereditary factor. It has already been established that if there were cases of ulcers in the family, then the chance of a similar digestive disorder increases significantly.

An ulcer develops for a long time: at first, a person notices discomfort in the stomach and minor violations of the digestive process, over time they become more pronounced.

If you do not take action on time, an exacerbation with serious complications is possible.

The main symptoms of PU

Exacerbation of PU occurs suddenly, the duration can be up to several weeks.

Various factors can provoke an exacerbation: overeating with a serious violation of the diet, stress, overwork, etc. Symptoms vary depending on the location of the ulcer:

1. If the pain occurs immediately after eating and gradually decreases over the next two hours, this usually indicates the localization of the ulcer in the upper part of the stomach. The pains are reduced, as the food in the process of digestion gradually passes into the duodenum.
2. If, on the contrary, pain occurs within 2 hours after eating, this indicates an ulcer located in the antrum of the stomach: food enters the duodenum from it, and it is in this area that a large accumulation of Helicobacter pylori is most often observed.
3. Night pains, which also occur during long breaks between meals, are most often manifested with a duodenal ulcer.
4. In addition to various pains in the abdomen, characteristic symptom ulcers is heartburn, it is associated with increased acidity of gastric juice. Heartburn occurs simultaneously with pain or manifests itself before them. With weakness of the sphincter and reverse peristalsis, patients experience sour eructation and nausea, these symptoms often accompany peptic ulcer disease.
5. Another common symptom is vomiting after eating, and it brings considerable relief to the patient. Appetite often decreases, some patients have a fear of eating due to fear of pain - because of this, significant exhaustion is possible.

Methods for diagnosing an ulcer

To diagnose gastric and duodenal ulcers, it is necessary to consult a gastroenterologist, the sooner the patient comes for help, the higher the chance of recovery or long-term remission without exacerbations.

With a sharp exacerbation with bleeding, urgent surgical intervention is necessary, in this case it is necessary to urgently call an ambulance.

The main method of examining the stomach is fibrogastroduodenoscopy: it allows the doctor to see the condition of the mucosa in order to detect an ulcer and assess the neglect of the disease. Not only the location of the ulcer is evaluated, but also its condition: the presence of scars, size.

At the same time, a sample of mucosal tissue is taken to detect Helicobacter pylori and a more accurate diagnosis. A clinical blood test is also carried out, it allows you to assess deviations from the norm in the state of the body.

Although FGDS is a rather unpleasant research method, it is the most informative, so it cannot be abandoned. In some cases, it is supplemented by an X-ray examination.

Methods and schemes for the treatment of peptic ulcer

The peptic ulcer treatment regimen is based on taking antibiotics to get rid of Helicobacter pylori and avoid serious complications.

Three- and four-component treatment regimens are prescribed by a gastroenterologist, only a specialist can select specific drugs in accordance with the individual characteristics of the patient. Several groups of drugs are used to treat PU:

• Antibiotics. Two drugs are prescribed at the same time, the doctor selects drugs taking into account possible allergic reactions. Self-administration of antibiotics is unacceptable, they should be selected only by a doctor. The course of treatment takes at least 7-10 days, even with a significant improvement in well-being, you can not stop taking the pills.
• Drugs that should neutralize the action of gastric juice. These include omeprazole, pantoprazole, and other common drugs familiar to most patients with digestive disorders.
• Substances that form a film on the surface of the mucosa. It protects it from the aggressive effects of gastric juice, which contributes to faster healing of the ulcer.
• Antacids, the main purpose of which is to lower the acidity of gastric juice. They significantly reduce heartburn and improve the well-being of patients, such drugs have an adsorbing effect.
• Prokinetics (Cerucal, Motilium and others) are drugs designed to normalize the motility of the duodenum 12, to ensure the normal movement of food through the intestines. They are prescribed for a feeling of heaviness in the abdomen or early satiety.

Complex therapy rarely takes more than two weeks. After that, it is only necessary to help the stomach recover faster; for this, special nutrition schemes and additional methods treatment.

Diet for gastric ulcer

When diagnosing PU, patients are prescribed therapeutic nutrition, designed to provide a sparing regimen for the stomach and duodenum with a decrease in load.

For this, a group of diets No. 1 is used, they are prescribed during the acute phase of the disease. The diet prescribes to patients the following restrictions:

1. Food that irritates the stomach is completely excluded from the diet. These are spicy, sour, fatty dishes, pickles, marinades, etc.
2. You can not eat vegetables containing a large amount of fiber - they can also have a negative effect on digestion during an exacerbation. You can only eat boiled vegetables, in the early days they can be consumed only in pure form.
3. You can not eat sour dairy products and salty cheeses, sour fruits and natural juices are also excluded from the diet.
4. Alcohol and carbonated drinks are completely excluded, drinking coffee is undesirable.

All these restrictions prevent further negative effects on the digestive tract and prevent the development of complications.

Deviations from the diet can lead to serious complications, including bleeding and perforation of the ulcer.

Complementary Therapies

In addition to drug treatment adding methods of physiotherapy and physiotherapy exercises in the recovery stage.

They allow you to strengthen the body and minimize the consequences of indigestion.

At home, according to the doctor's prescription, you can do heating alcohol compresses- heat helps to reduce pain and improve blood circulation.

Patients with peptic ulcer are prescribed sanatorium-and-spa treatment: in addition to health procedures and the climate at the resort, drinking mineral water "Borjomi", "Smirnovskaya", "Essentuki" has a beneficial effect.

Physical therapy exercises are aimed at improving blood circulation and preventing congestion, they improve secretory and motor function, stimulate appetite. A complex of medical and health-improving procedures in compliance with medical recommendations gives an excellent result and helps to eliminate Negative consequences peptic ulcer.

The sooner the patient turns to specialists, the greater the chance for successful healing of the ulcer with normalization of well-being. It is important to take care of yourself in time and go to an appointment with a gastrenterologist already at the first negative manifestations.

Complications of peptic ulcer

Peptic ulcer is dangerous with serious complications during exacerbation, they often require urgent surgery to prevent death. The following complications are common:

• Gastric and intestinal bleeding. A characteristic sign is vomiting, which has the color of coffee grounds, and black stools.
• Ulcer perforation. A breakthrough leads to the entry of the contents of the digestive tract into the abdominal cavity, as a result, a life-threatening condition develops for the patient. Emergency surgery is needed.
• Penetration is a condition of the so-called latent breakthrough, in which the contents of the intestine can enter other organs of the abdominal cavity. The patient can be saved only by an urgent operation.
• When healing scars on the mucous membranes, a narrowing of the pylorus is possible, which leads to disruption of the digestive tract. Treatment is only surgical.
• Signs of complications in peptic ulcer and internal bleeding are sudden weakness, fainting, a sharp drop in pressure, severe pain in the abdomen. With vomiting of blood and other signs of complications, it is necessary to take the patient to the hospital as soon as possible in order to prevent irreparable consequences.

Peptic ulcer is a disease that is largely associated with the wrong rhythm of life in a big city. It is necessary to find time to fully eat, taking care of digestion will relieve discomfort and long-term complex treatment. If problems with digestion have already arisen, there is no need to postpone a visit to the doctor for later. Timely diagnosis is an important factor in successful treatment.

How to treat peptic ulcer with antibiotics, see the video:

Tell your friends! Tell your friends about this article in your favorite social network using social buttons. Thank you!

Most often, an exacerbation of a duodenal ulcer occurs as a result of gross neglect of the diet, alcohol abuse and junk food that irritates the intestinal mucosa, as well as exposure to stress and fatigue.

Signs of exacerbation are mainly diagnosed in the off-season - in spring and autumn. This is due to the deterioration of general immunity during this period. The course of the disease is characterized by cyclicity, when periods of stable remission alternate with exacerbations of the pathology.

Forms of the disease

Exacerbation of duodenal ulcer, its symptoms and treatment depends on the form of the disease.

The disease is classified according to the following features:

• is it possible pea soup with an exacerbation of an ulcer
• propolis treatment for duodenal ulcers
• symptoms of colon ulcer treatment

According to the frequency of relapses:

• a form that has exacerbations from one to three times a year;
• a disease that recurs more than three times in a year.

According to the location and depth of the lesion:

• superficial or deep ulceration;
• an ulcer located in the region of the bulb or in the post-bulb area.

By the number of foci of mucosal lesions:

• single hearth;
• multiple foci.

Acute duodenal ulcer gives a very pronounced clinical picture with vivid symptoms, due to which it is difficult to confuse it with any other disease. Chronic form duodenal ulcers without exacerbation may not give symptoms at all and proceed hidden.

Causes of duodenal ulcer

The causes of the onset of the disease may be due to aggravated heredity, dietary habits and bad habits. In some cases, the disease is caused by the bacterium Helicobacter pylori, which affects the lining of the stomach and intestines.

Without adequate and timely treatment, an ulcer can undergo malignant transformation.

The following are recognized as the most likely factors for the onset of the disease:

• abuse of alcohol and tobacco products, which leads to impaired blood circulation in the organs, as well as irritation of the mucous organs of the gastrointestinal tract;
• irregular meals with long intervals between meals, as well as the predominance in the diet of foods that are fried in fat, too sour, fatty and pickled. Meals, including canned, smoked foods and sauces;
• prolonged and uncontrolled use of NSAIDs, which led to inflammation of the intestinal lining;
• prolonged stress and fatigue can cause duodenal ulcers in people with an unbalanced psyche and mild excitability of the nervous system.

At the first stages, the disease does not always give tangible symptoms, so often the patient goes to the doctor with an advanced form of the disease. The trigger mechanism of the disease can also be existing pathologies. endocrine system, liver and kidney, infectious diseases.

Tuberculosis, diabetes, hepatitis, pancreatitis lead to intestinal irritation and can provoke duodenal ulcer. The causes of the onset of the disease can also be mechanical damage due to surgery.

Symptoms of disease recurrence

Clinical symptoms of duodenal pathology do not appear immediately, often at the very beginning the disease is hidden. A neglected form of peptic ulcer can manifest itself sharply as life-threatening signs. In a third of people with this pathology, the presence of the disease is determined after a post-mortem autopsy.

The main diagnostic signs of a duodenal ulcer:

• epigastric pain;
• symptoms of gastrointestinal dysfunction;
• neurological symptoms.

The main symptom of the disease is soreness "under the spoon" or in the upper part of the navel. Relapse often provokes pain in the back and heart area. This is due to the fact that it can radiate from the place of localization to other parts of the body, distorting ideas about the real source of pain. Therefore, gastroenterologists primarily focus on discomfort in the navel area.

All pain occur on an empty stomach, and immediately after eating the pain in the abdomen subsides. But if the patient overeats or consumes foods prohibited by the nutritionist, then the pain may intensify.

Often, the symptoms of an exacerbation of a duodenal ulcer exhaust the patient, not allowing him to fully rest at night. This is due to excessive production of acid, which irritates the affected area of ​​the intestinal mucosa.

Even during a stable remission, a stressful situation, a violation of the diet and the use of pharmacological preparations(hormones or NSAIDs) can make the condition worse, causing pain and nausea.

The second most important sign of a duodenal ulcer is gastrointestinal dysfunction, characterized by the ability to bring relief to the patient:

• permanent long-term constipation;
• bloating, belching and flatulence;
• dark stools indicating the presence of blood.

The third most important are neurological symptoms. Signs of exacerbation of duodenal ulcer can be: irritability, sleep disturbance, depressed mood, and weight loss.

Diet for exacerbation of duodenal ulcer

Nutrition in the pathologies of the gastrointestinal tract is of paramount importance. In the first days of the disease, food is limited to a small amount of mashed food. Vegetable and bakery products are excluded.

After 5 days, it is allowed to eat vegetarian soups in which white crackers can be soaked. In addition, mashed potatoes or soufflés from boiled poultry and fish fillets are allowed; for dessert, you can eat fruit jelly.

In the second week, the treatment menu is added meat dishes, which should be steamed, it can be meatballs from poultry or fish. In addition, you should eat eggs in the form of an omelet or boiled, milk porridge with a small amount of butter, as well as mashed carrots or potatoes.

Contraindicated in exacerbation of duodenal ulcer:

• mushroom, meat broth;
• confectionery and pastries;
• dishes that are fried in fat;
• too fatty foods;
• fresh fruits and vegetables;
• fatty sea fish;
• alcohol-containing products;
• any non-lean meat;
• spices, sauces and marinades.

To neutralize the aggressive effect of hydrochloric acid, you should eat little and often. It is better to treat a duodenal ulcer in stationary conditions, while dietary table No. 1-a or 1-b is indicated, such nutrition should last 4 months. After discharge, you can stick to diet number 5.

Pathology therapy

Duodenal ulcer depending on severity clinical manifestations can be treated conservatively and surgically.

The method of influence includes the following set of measures:

• medical nutrition;
• pharmacological agents (antibiotics, antacids and antisecretory drugs);
• herbal decoctions;
• surgical treatment is indicated only if conventional methods have failed. Most often, the patient needs prompt assistance after constant exacerbations of the disease, in violation of the healing of the ulcer and gross scarring.

When Helicobacter pylori is detected, treatment should include a complex of several antibiotics that have an antiprotozoal and bactericidal effect:

• Amoxicillin;
• Tetracycline;
• Clarithromycin;
• Metronidazole.

In order to neutralize the acidity of gastric juice, antacids are used:

• Maalox;
• Rennie;
• Phosphalugel;
• Almagel;
• Gastal.

To improve the healing of the duodenal membrane, antiulcer drugs are prescribed:

• De-nol;
• Venter;
• Misoprostol.

In addition, prescribe antisecretory agents:

• Rabeprozole;
• Omeprazole;
• esomeprazole;
• Lansoprazole.

When, after prolonged use of drugs under the supervision of a doctor, the patient does not feel improvement, it is advisable to agree to a surgical intervention, which will consist in removing the affected area or suturing the duodenum.

Complications of duodenal ulcer

With improper therapy of duodenal ulcers, the pathology can periodically worsen and eventually cause serious complications.

• When involved in the process blood vessels the disease can be complicated by hemorrhage. Occult bleeding can be identified by characteristic feature like anemia. If hemorrhage is abundant, then it can be determined by the type stool(they turn black).
• Perforation of an ulcer is the appearance of a hole in the wall of the duodenum. This complication can be determined by the occurrence of acute pain during palpation or a change in body position.
• The narrowing of the lumen of the duodenum occurs as a result of edema or scarring. It is determined by bloating, indomitable vomiting, lack of stool.
• Ulcer penetration - penetration into neighboring organs through a defect in the duodenum. The main symptom is pain radiating to the back.

A duodenal ulcer can worsen during the off-season (autumn, spring) and is most often triggered by a diet or stress. The main symptom is pain in the navel. To avoid this, one must remember about preventive measures, compliance with all conditions prescribed by a specialist, including strengthening immunity and dieting.

By localization:

1. Gastric ulcer.
2. Duodenal ulcer (DUD).
3. Peptic ulcer of unspecified localization.
4. Gastrojejunal ulcer, including peptic ulcer of the anastomosis of the stomach, adductor and efferent loops of the small intestine, fistula with the exception of the primary ulcer of the small intestine.

Phase: exacerbation, remission (cicatricial deformity of the stomach, duodenum).

Complications: bleeding (10-15%), perforation (6-15%), penetration (15%), stenosis (6-15%), perivisceritis, malignancy.

There is no single classification of chronic gastritis. In modern gastroenterology, CG is necessarily considered taking into account the etiology, pathomorphological and endoscopic changes.

According to etiology, they are distinguished:

• Chronic gastritis type A (autoimmune)
• Chronic gastritis type B (associated with HP)
• Chronic gastritis type C
• Chronic gastritis type D (A B)

Special forms of gastritis (rigid antrum-gastritis, Menetrier's disease, polypous gastritis, hemorrhagic, granulomatous gastritis).

According to topographic features (endoscopy data), antral gastritis, gastritis of the body of the stomach, pangastritis are distinguished.

The nature of morphological changes is taken into account: the severity of inflammation (minimal, moderate, severe), atrophy (minimal, moderate, severe), intestinal metaplasia (minimal, moderate, severe), HP contamination (minimal, moderate, severe).

According to the phase of the disease, CG is isolated in the stage of remission or exacerbation.

Peptic ulcers are classified according to:

• localization,
• disease stage,
• the presence of a complication.

According to localization, the disease is divided into:

1. stomach ulcer,
2. duodenal ulcer,
3. ulcers of unspecified localization.

The clinical form of the disease is acute or chronic. Depending on the phase, periods of remission, relapse, fading exacerbation are distinguished.

The form of peptic ulcer is without complications or with complications. The latter include perforation, penetration, stenosis.

The stages of the disease differ in the intensity of symptoms:

• First. The patient complains of severe pain, cannot move, grabs his stomach with his hands. He is thrown into a fever, his lips turn blue and his blood pressure drops.
• Second. It has no expression pain syndrome. Appears dry mouth, increased gas formation, increased body temperature.
• Third. Comes with perforation of the ulcer. At this point, a through defect is formed, which leads to peritonitis. Diagnosis is usually not difficult at this stage, since the patient feels sharp pains comparable to a dagger strike.

1. Gastroesophageal reflux with esophagitis (reflux esophagitis Code k 21.0)

Reflux esophagitis
- inflammatory process in the distal
parts of the esophagus, caused by action on
CO from the organ of gastric juice, bile, and
also pancreatic enzymes and
intestinal secrets in gastroesophageal
reflux. Depending on the expression
and prevalence of inflammation
five degrees of RE, but they are differentiated
only on the basis of the results
endoscopic examination.

Survey.
Mandatory laboratory tests

General
blood test (in case of abnormal
the study is repeated 1 time in 10 days)

once

Group
blood

Rh factor

Analysis
stool for occult blood

General
Analysis of urine

Iron
blood serum

Mandatory
instrumental research

twice

Esophagogastroduodenoscopy
(before and after treatment)

Additional
instrumental and laboratory
research is being done
depending on comorbidities
and severity of the underlying disease.

Consultations
testimony specialists.

Characteristic
medical measures

sleep
raised by at least 15 cm
the head end of the bed;

reduce
body weight, if obese;

Not
lie down after eating for 1.5 hours;

Not
eat before bed;

restrict
fat intake;

stop
smoking;

avoid
tight clothes, tight belts;

Not
take medicines,
having a negative effect on
esophageal motility and tone of the lower
esophageal sphincter (prolonged
nitrates, calcium antagonists, theophylline),
mucosal damage
esophagus (aspirin and other NSAIDs), etc.

domperidone
(motilium and other analogues) or cisapride
(coordinax and other analogues) 10 mg 3 times
per day in combination with an antacid (Maalox
or analogues) at the 1st dose 1 hour after
meals, usually 3 times a day and the 4th time
just before bed.

ranitidine
(zantak and other analogues) 150-300 mg 2 times a day
day or famotidine (gastrosidin, kvamatel,
ulfamide, famocide and other analogues) - 20-40
mg twice a day, for each drug
reception in the morning and in the evening with a mandatory
at intervals of 12 hours);

maalox
(remagel and other analogues) - 15 ml after 1 hour
after meals and at bedtime, i.e. 4 times a day
for the period of symptoms.

Through
6 weeks medicinal treatment stops
if there is a remission.

omeprazole

morning and evening, with a mandatory interval
at 12 noon for 3 weeks (total in
for 8

weeks);
simultaneously administered orally sucralfate
(venter, sukrat gel and other analogues) 1 each
g 30 minutes before meals 3 times a day for
4 weeks and cisapride (coordinax) or
domperidone (motilium) 10 mg 4 times a day
15 minutes before meals for 4 weeks.

Through
8 weeks switch to single dose
in the evening ranitidine 150 mg or famotidine
20 mg and for periodic intake (for heartburn,
feeling of heaviness in the epigastric
areas) Maalox in the form of a gel (15 ml) or
2 tablets.

At
reflux esophagitis of the 5th degree of severity -
operation. Duration of stationary
treatment

At
1-11 severity - 8-10 days,

at
111-IV severity - 2-4 weeks.

Requirements
to treatment outcomes

IN
Treatment is mainly carried out in
outpatient settings.

Cupping

disease (complete remission). With partial
remission is recommended to analyze
patient discipline and
continue drug treatment
within 4 weeks. to the extent stipulated
for 1I1-1V severity of reflux esophagitis,
if this excludes the concomitant
aggravating the course of the underlying disease
pathology.

Sick
with reflux esophagitis are subject to dispensary
monitoring with a complex
instrumental laboratory
examinations at each exacerbation.

II.

(ICB-10)

1.
stomach ulcer (stomach ulcer)
including peptic ulcer of the pyloric
and other parts of the stomach - Code K 25

2.
duodenal ulcer (ulcerative
duodenal disease)
including peptic ulcer of all departments
duodenum - Code K 26

3.
Gastrojejunal ulcer, including peptic ulcer
ulcer of the anastomosis of the stomach, leading and
efferent loops of the small intestine, fistula
with the exception of the primary ulcer of the thin
intestines—Code K 28

At
exacerbation of I B is usually detected
recurrent ulcer, chronic
active gastritis, more often - active
gastroduodenitis associated with
pyloric helicobacteriosis.

Survey

Mandatory
laboratory research

General
blood test (in case of abnormal
the study is repeated 1 time in 10 days)

Group
blood

Rh factor

Analysis
stool for occult blood

General
Analysis of urine

Iron
blood serum

Reticulocytes

Sugar
blood

Histological
biopsy study

Cytological
biopsy study

urease
test (CLO-test, etc.)

once

ultrasound
liver, biliary tract and pancreas
glands

twice

Esophagogastroduodenoscopy
with targeted biopsy and brush
cytological examination

Additional
research
carried out in cases of suspected malignancy
ulcer, in the presence of complications and
concomitant diseases.

Consultations
testimony specialists.

Characteristic
medical measures

Medicinal

associated with Helicobacter pylori (HP)

Survey
and treatment of patients with PU can be carried out
in an outpatient setting.

Target
treatment: HP eradication, ulcer healing,
exacerbation prevention and

complications
I WOULD.

Medicinal
combinations and regimens for HP eradication
(use one of

Omeprazole
(Zerocid and other analogues) 20 mg 2 times a day


clarithromycin (clacid) 250 mg twice daily
metronidazole (trichopolum and other analogues)

Omeprazole
(Zerocid and other analogues) 20 mg 2 times a day
(morning and evening no later than 20 hours, from
obligatory interval of 12 hours)
amoxicillin (flemoxin solutab, hiconcil
and other analogues) 1 g 2 times a day at the end
food metronidazole (Trichopolum and other analogues)
500 mg 2 times a day at the end of meals.

Pyloride

day at the end of a meal clarithromycin (clacid)
250 mg or tetracycline 500 mg or amoxicillin
1000 mg twice daily metronidazole (Trichopolum
and other analogues) 400-500 mg 2 times a day with meals.

Omeprazole
(Zerocid and other analogues) 20 mg 2 times a day
(morning and evening, no later than 20:00, from
obligatory interval of 12 hours)
colloidal bismuth subcitrate (ventrisol,
de-nol and other analogues) 120 mg 3 times in 30 minutes
before meals and 4 times 2 hours after meals
at bedtime metronidazole 250 mg 4 times a day
day after meals or tinidazole 500 mg 2 times
a day after meals, tetracycline or
amoxicillin 500 mg four times a day
food.

Frequency
eradication reaches 95%.

Ranitidine
300 mg in 1-2 doses, famotidine (quamatel)
40 mg in 1-2 doses

potassium salt of disubstituted citrate
bismuth* 200 mg 5 times a day after meals

metronidazole 250 2 tablets 2 times a day
day

tetracycline hydrochloride 250 mg 5 times a day
day

Frequency
eradication reaches 85-90%.

*
Included in the combination drug,
registered in Russia under

name
Gastrostat

After
completion of combined eradication
therapy, continue treatment for another
5 weeks for duodenal and 7 weeks for
gastric localization of ulcers using
one of the following: ranitidine
(zantac and other analogues) - 300 mg at 19-20 hours;
famotidine (gastrosidin, kvamatel,
ulfamide, famocid and other analogues) - 40 mg
at 19-20 hours.

Duration
inpatient treatment (depending on volume
studies and treatment intensity)

At
stomach ulcer and gastrojejunal ulcer -
20-30 days;

At
duodenal ulcer - 10 days.

General
course of drug therapy
should be carried out in outpatient clinics
conditions.

1.
Continuous (for months and even
years) maintenance therapy with antisecretory
drug in half dose, for example,
take 150 mg daily in the evening
ranitidine or famotidine 20 mg
(gastrosidin, kvamatel, ulfamide).

—
the ineffectiveness of the eradication
therapy;

—
complications of PU (ulcer bleeding
or perforation)

—
the presence of concomitant diseases,
requiring the use of non-steroidal
anti-inflammatory drugs;

—
concomitant I B erosive and ulcerative
reflux esophagitis;

—
patients older than 60 years of age
recurrent course of PU despite
for adequate course therapy.

2.
Preventive therapy "on demand",
providing for the appearance
symptoms of an exacerbation
PU, taking one of the antisecretory
drugs (ranitidine, famotidine,
omeprazole) in a full daily dose in
for 2-3 days, and then in half -
within 2 weeks.

If
disappeared completely after such therapy.
exacerbation symptoms, therapy should be
stop, but if symptoms persist
or recur, then it is necessary to conduct
esophagogastroduodenoscopy and others
research as provided
these standards during exacerbation.

Testimony
for this therapy is
onset of symptoms of PU after successful
HP eradication.

progressive
course of PU with recurrence of ulcers in the stomach
or more often in the duodenum
associated with the ineffectiveness of eradication
therapy and less often with reinfection, i.e. With
re-infection with CO HP.

Medicinal
treatment of gastroduodenal ulcers,
not associated with Helicobacter pylori (HP)

(Negative
morphological and urease tests from
targeted biopsy specimens taken in the antrum
section and body of the stomach)

Target
treatment: to stop the symptoms of the disease
and ensure scarring of the ulcer.

Medicinal
combinations and schemes (one is used
of them)

Ranitidine
(zantak and other analogues) - 300 mg per day
mostly once in the evening
(19-20 hours) and an antacid (Maalox,
remagel, Gasterin gel, etc.) as
symptomatic agent.

famotidine

- 40 mg per day, mostly once
in the evening (at 19-20 h) and an antacid drug
(Maalox, Remagel, Gasterin-gel, etc.)
as a symptomatic remedy.

Sucralfate
(venter, sukrat gel) - 4 g per day, more often
1 g in 30 min. before meals and in the evening after 2 hours
after meals for 4 weeks, then 2 g in
day for 8 weeks.

Efficiency
treatment for gastric and gastrojejunal ulcers
ulcer is monitored endoscopically
after 8 weeks, and with duodenal ulcer -
after 4 weeks

Requirements
to treatment outcomes

Cupping
clinical and endoscopic manifestations
disease (complete remission) with two
negative tests for HP (histological
and urease), which are carried out not earlier than
4 weeks after drug withdrawal
treatment, and optimally - with relapse
ulcers.

At
partial remission, which is characterized by
the presence of an unhealed ulcer,
needs to be analyzed
patient discipline in
treatment regimen and continue
drug therapy with
her corresponding adjustments.

If
the ulcer has healed, but at the same time remain
active gastroduodenitis and infection
CO HP, it also means no
complete remission. Such patients need
in treatment, including eradication
therapy.

Preventive
Patients with PU who are
under dispensary observation, With
no complete remission. If
dispensary patient with PU during
3 years no exacerbations and he is in
state of complete remission, then such
the patient is subject to removal from the dispensary
accounting and treatment for PU, as
usually not needed.

III.
International Classification of Diseases
(ICB-10)

1.
Chronic gastritis antral,
fundamental In the newest International
classification of gastritis (gastroduodenitis)
considered in terms of etiology,
pathohistological and endoscopic
changes and severity of the process. Code K
29.5

Dominated
gastritis (gastroduodenitis), associated
with HP infection, but atrophic, as
usually autoimmune, often
manifested by B12 deficiency
anemia. Gastritis is released
associated with bile and drugs,
granulomatous, eosinophilic and others
forms of gastritis.

Survey

once

General
blood analysis

Analysis
stool for occult blood

Histological
biopsy study

Cytological
biopsy study

Two
HP test

General
protein and protein fractions

General
Analysis of urine

once

Esophagogastroduodenoscopy
with targeted biopsy and brush

cytological
research

ultrasound
liver, biliary tract and pancreas
glands

Additional
research and consulting
specialists are carried out depending
from manifestations of the underlying disease and
suspected comorbidities.

Pyloride
(ranitidine bismuth citrate) 400 mg bid
day clarithromycin (clacid) 250 mg 2 times
daily or tetracycline 500 mg twice daily
a day, or amoxicillin 1000 mg twice a day
day metronidazole (Trichopolum) 500 mg 2
times a day.

Omeprazole
(Zerocid and other analogues) 20 mg 2 times a day
clarithromycin (clacid) 250 mg twice daily
a day or tetracycline 500 mg 2 times a day,
or amoxicillin 1000 mg twice a day
metronidazole (Trichopolum) 500 mg twice a day
day.

famotidine
(gastrosidin, kvamatel, ulfamide, famocid)
20 mg twice daily or ranitidine 150 mg 2
once a day de-nol 240 mg 2 times a day
or ventrisol - 240 mg 2 times a day
tetracycline hydrochloride 500 mg tablets
2 times a day with food or amoxicillin
1000 mg 2 times a day

Ranitidine
(zantac) 150 mg twice daily or famotidine
20 mg twice a day, or omeprazole (Zerocid)
20 mg twice daily potassium salt
disubstituted bismuth citrate* 108 mg
in tablets 5 times a day with meals tetracycline
hydrochloride* 250 mg tablets 5 times a day
day with food metronidazole* 200 mg daily
tablets 5 times a day with meals

*
- is part of the drug,
registered in Russia under
called Gastrostat.

At
autoimmune (atrophic) gastritis
with megaloblastic anemia confirmed
research bone marrow and reduced
vitamin B12 levels
(less than 150 pg/ml), drug treatment
includes: intramuscular injection 1 ml
0.1% solution of oxycobalamin (1,000 mcg) for
6 days, then - at the same dose for
months, the drug is administered once a week,
and in the future for a long time (for life)
1 time in 2 months

At
all other forms of gastritis (gastroduodenitis)
symptomatic treatment is carried out
using the following combinations
drugs.

At
ulcerative dyspepsia: Gastrocepin
25-50 mg twice a day maalox** 2 tablets
or 15 ml (package) 3 times a day after 1 hour
after meal

At
symptoms of hypomotor dyskinesia:
Domperidone (motilium) or cisapride
(coordinax and other analogues) 10 mg 3-4 times a day
day before meals maalox** 2 tablets
or 15 ml (package) Zraza a day after 1 hour
after meal

**
- can be replaced with gastal, remagel,
phosphalugel, protab, gelusil varnish
and other antacids with similar
properties.

Duration
inpatient treatment

Definition

once

once

twice

Survey

once

once

complications
I WOULD.

Survey

once

once

The goal is to normalize motor skills gastrointestinal tract and bile acid binding.

Etiology and pathogenesis.

Etiological factors: alimentary, bad habits, stress, taking ulcerogenic drugs; genetic (heredity, O (I) group

blood); HP infection.

The pathogenesis is based on a violation of the balance of protective and aggressive

factors of the gastroduodenal zone.

Protective factors: mucus (bicarbonates, prostaglandins), adequate microcirculation, regeneration, secretion inhibitors (VIP, somatostatin, enteroglucagon), postaglandins.

Factors of aggression: hyperproduction of hydrochloric acid and pepsin (hyperplasia of parietal and chief cells, vagotonia), HP invasion, impaired gastroduodenal motility, duodenogastric reflux (bile acids, pancreatic enzymes), smoking, alcohol, secretion stimulants (histamine, acetylcholine, gastrin, mechanical, chemical, thermal stimuli of food), drugs ( NSAIDs, glucocorticoids).

Among the causes that cause the development of CG, exogenous and endogenous are distinguished.

Exogenous factors: drugs, occupational hazards (vapors of acids, alkalis, cotton, coal, silicate dust, etc.), dietary disturbances, exposure to chemical, mechanical and thermal factors; abuse of alcohol and its surrogates, smoking; and also Hencobacter pyun (HP).

Endogenous factors: metabolic and endocrine disorders; tissue hypoxia against the background of pulmonary heart failure, anemia.

From pathogenetic positions, several types of gastritis are distinguished.

CG type A (15-18% of all CG) is a disease of an autoimmune nature, genetically determined, inherited in an autosomal dominant manner, in which antibodies to parietal cells and / or antibodies to the internal factor of Castle are detected in patients in the blood and gastric juice. Characteristic is the early development of progressive atrophy of the gastric glands and foci of intestinal metaplasia with a predominant localization of the process in the fundus and body of the stomach.

Type B chronic hepatitis (70% of all chronic hepatitis) is associated with the persistence of HP, which colonizes the gastric antrum mucosa and causes chronic inflammation in it. At the same time, erosion, intestinal metaplasia, and atrophy of the gastric epithelium may appear in the mucosa.

HCG type C - ceppsa. (15% of all CG) is subdivided into reflux gastritis, in which damage to the gastric mucosa is caused by the reflux of intestinal contents and bile as a result of duodeno-gastric reflux.

The drug form of type C chronic hepatitis is associated with long-term drug exposure, mainly non-steroidal anti-inflammatory drugs (NSAIDs). With this type of chronic hepatitis, the antrum is always affected, and then the proximal parts of the stomach.

Who to treat

Readings corresponding to the level
"highly recommended"

Readings corresponding to the level
"feasibility" of treatment

Indications (presence of H.pylori) Scientific evidence functional dyspepsia  Eradication H. pylori is an acceptable choice in treatment tactics?  some of the patients eradication H. pylori leads to long improve well-being Gastroesophageal reflux disease H.pylori eradication:  in in most cases is not associated with the appearance of gastroesophageal reflux disease  not reinforces an already existing gastroesophageal reflux disease eradication H. pylori should be done patients who are shown long-term acid suppression treatment products Defeats gastroduodenal mucosa shells caused by the reception non-steroidal anti-inflammatory drugs EradicationH. pylori:  reduces frequency of ulcers if given before Starting an NSAID course  herself by itself is not sufficient for prevent recurrence of ulcers bleeding while taking NSAIDs  not accelerates the healing of duodenal And stomach ulcers in patients receiving antisecretory therapy in the background taking NSAIDs H. pylori and NSAID/aspirin are independent risk factors for ulceration

A stomach ulcer is a focal defect that forms on the mucous membrane. The disease is very dangerous, especially during an exacerbation. Ulcer formation can be superficial and deep.

Superficial - affects only the mucous membrane of the organ, without spreading deep into the tissues. It is eliminated much easier than a deep stomach ulcer. Treatment of such defects can take place without surgical intervention.

Clinical Syndromes

With an ulcer, the effect gives only complex treatment, including diet, drug therapy and limitation of psycho-emotional factors. Individually, these components cannot completely eliminate the disease and provide only short-term relief of symptoms.

Peptic ulcer therapy is based on the following principles:

• active influence on the cause of the disease;
• selection of drugs taking into account concomitant pathologies;
• taking into account the individual characteristics of the patient (activity and age of the patient, the presence of allergic reactions to the medications used, body weight);
• compliance with the treatment regimen;
• nutrition with mechanical and chemical sparing of the mucous membrane;
• the use of phyto- and physiotherapy;
• local treatment of individual ulcer formations.

At first, the ulcer was treated with H2 blockers, and these same drugs were prescribed to prevent recurrence. The sensitivity of bacteria to them was quite high, but due to the acidic environment of the stomach, most of the blockers lost their effectiveness.

And the presence adverse reactions did not allow to increase the concentration of drugs. As a result, instead of monotherapy, a two-component treatment regimen was used, combining drugs with a high bactericidal effect and agents that are resistant to an acidic environment.

Then an even more effective scheme was developed - a three-component one, which is currently considered classical if the disease is caused by the bacterium Helicobacter pylori. Therapy includes taking proton pump inhibitors (the standard dose is 2 times a day, Nexium (esomeprazole) is most often used, but omeprazole and rabeprazole can also be used), antibiotics clarithromycin (500 mg 2 times a day) and amoxicillin (1000 mg 2 times a day).

The second-line regimen, or quadruple therapy, includes taking bismuth tripotassium dicitrate (this is De-Nol, 120 mg 4 times a day), combined with PPI (in a standard dose 2 times a day), tetracycline (500 mg 4 times a day) and metronidazole (500 mg 3 times a day). The duration of quadruple therapy with bismuth preparations is 10-14 days.

Also, the second-line therapy is triple with levofloxacin (500 or 250 mg 2 times a day), in addition to it, the patient takes a PPI at a standard dose 2 times a day and amoxicillin 1000 mg 2 times a day. The duration of therapy is 10 days.

There is also an alternative scheme, where the doctor finds out the individual sensitivity of the pathogen to antibiotics, then prescribes the drug to which Helicobacter pylori does not have resistance. Regardless of the option chosen, the patient must be under the supervision of a doctor in order to avoid various complications and maintain working capacity.

peptic ulcer of the stomach, duodenum

The beginning of the document: 18.06.2013

Approve the standard of specialized medical care with peptic ulcer of the stomach, duodenum according to the application.

Minister V.I. Skvortsova

to the order of the Ministry of Health

Standard for specialized medical care for peptic ulcer of the stomach, duodenum

Complication: no complications

Type of medical care: specialized medical care

Medical care condition: inpatient

Form of medical care: planned, emergency

Average treatment time (number of days): 21

Duodenal ulcer

1. Medical events for diagnosing diseases, conditions

delivery frequency 1

Primary appointment (examination, consultation) with a gastroenterologist

Reception (examination, consultation) of a general practitioner primary

Medical service code

Name of medical service

Average delivery frequency

Average rate of application frequency

Morphological study of the preparation of stomach tissues

Morphological study of the preparation of duodenal tissues

Examination of the material of the stomach for the presence of Helicobacter pylori (Helicobacter pylori)

The study of the level of amylase in the blood

The study of the level of gastrin in blood serum

Study of the level of parathyroid hormone in the blood

Study physical properties gastric juice

Study of the level of acidity of gastric contents (free and bound hydrochloric acid and total acidity)

Microscopic examination of gastric contents

Examination of feces for occult blood

Determination of alpha-amylase in urine

Determination of the main blood groups (A, B, 0)

Carrying out the Wassermann reaction (RW)

Determination of antibodies to Helicobacter pylori (Helicobacter pylori) in the blood

Determination of the antigen to the hepatitis B virus (HBsAg Hepatitis B virus) in the blood

Determination of antibodies of classes M, G (IgM, IgG) to viral hepatitis C (Hepatitis C virus) in the blood

Determination of antibodies of classes M, G (IgM, IgG) to the human immunodeficiency virus HIV-1 (Human immunodeficiency virus HIV 1) in the blood

Determination of antibodies of classes M, G (IgM, IgG) to the human immunodeficiency virus HIV-2 (Human immunodeficiency virus HIV 2) in the blood

General (clinical) blood test detailed

General therapeutic biochemical blood test

General urinalysis

Registration of the electrical activity of the conduction system of the heart

Radiography of the stomach and duodenum

X-ray of the stomach and duodenum

Radiography of the stomach and duodenum, double contrast

Morphological study of the preparation of duodenal tissues

Biopsy from gastric ulcer using endoscopy

Biopsy from duodenal ulcer using endoscopy

Comprehensive ultrasonography internal organs

1 the likelihood of providing medical services or prescribing drugs for medical use(medical devices) included in the standard of care, which can take values ​​from 0 to 1, where 1 means that this event is carried out by 100% of patients corresponding to this model, and numbers less than 1 indicate the percentage of patients specified in the standard of care with relevant medical indications.

2. Medical services for the treatment of a disease, condition and treatment control

Daily examination by a gastroenterologist with supervision and care of middle and junior medical personnel in the hospital department

Daily examination by a general practitioner with supervision and care of middle and junior medical staff in the hospital department

General urinalysis

Biopsy of the stomach using endoscopy

3. List of medicinal products for medical use registered in the territory Russian Federation, indicating the average daily and course doses

Name of the medicinal product**

Other medicines for gastric and duodenal ulcers and gastroesophageal reflux disease

Tetracycline and its derivatives

Penicillins a wide range actions

4. Views medical nutrition, including specialized medical nutrition products

Name of the type of medical nutrition

Diet therapy for diseases of the stomach (table 1a, 1sh, 1l / f, 1p)

* - International Statistical Classification of Diseases and Related Health Problems, X revision

** - international non-proprietary or chemical name of the medicinal product, and in cases of their absence - the trade name of the medicinal product

*** - average daily dose

**** - average course dose

1. Medicinal products for medical use registered in the territory of the Russian Federation are prescribed in accordance with the instructions for use of the medicinal product for medical use and the pharmacotherapeutic group according to the anatomical-therapeutic-chemical classification recommended by the World Health Organization, as well as taking into account the method of administration and use of the medicinal product.

When prescribing medicinal products for medical use in children, the dose is determined taking into account body weight, age in accordance with the instructions for use of the medicinal product for medical use.

Russian gastroenterological
Association, Russian Study Group
Helicobacter pylori.

Adopted at a scientific conference,
dedicated to the 100th anniversary of the birth
Academician of the Academy of Medical Sciences of the USSR V.Kh. Vasilenko:
“Peptic ulcer and gastric cancer. New
views in the era of Helicobacter pylori". Moscow,
April 21, 1997.

Komarov, academician
RAMS V. V

Serov, Academician of the Russian Academy of Medical Sciences V. T

Ivashkin,
Academician of the Russian Academy of Natural Sciences A. V

Kalinin, corresponding member
RANS I. A

Morozov, Professor L. I

Aruin,
Professor P. Ya

Grigoriev, professor A. R

Zlatkina, Professor S. I

Rappoport,
Professor G. V

Tsodikov, professor O. N

Minushkin, professor L.P.

Myagkova, professor
A. A

Sheptulin, Professor V.I.

pogromov,
k. m

A. Isakov, Ph.

Lapin.
.

Approved at the Third Russian
Gastroenterological week 11/18/97.

Helicobacter pylori infection is one of the most
common human infections
known today.

The bacterium Helicobacter pylori is
cause of Helicobacter pylori
chronic gastritis, the most important
factor in the pathogenesis of peptic ulcer
stomach and duodenal ulcer
colon, low-grade gastric lymphoma
malignancy (maltoma), as well as
stomach cancer.

Destruction (eradication) of Helicobacter
pylori in the stomach lining
infected persons leads to:

According to classical ideas, an ulcer is formed as a result of an imbalance between the aggressive and protective mechanisms of the gastrointestinal mucosa. Aggressive factors include hydrochloric acid, digestive enzymes, bile acids; to protective ones - secretion of mucus, cellular renewal of the epithelium, adequate blood supply to the mucous membrane.

The causal significance of H. pylori for chronic gastritis determines the most important place of the microorganism in the development of peptic ulcer.

It turned out that H. pylori is closely related to the factors of aggression in peptic ulcer disease.

The most important result of the destruction of H. pylori is the reduction in the frequency of recurrence of peptic ulcer.

The symptomatology of the disease is quite bright, and the diagnosis is not difficult in a typical case. Necessarily conduct esophagogastroduodenoscopy, which allows you to see

Principles of treatment of peptic ulcer:

• the same approach to the treatment of gastric and duodenal ulcers;

mandatory basic therapy that reduces acidity;

choice of an acid-reducing drug that maintains intragastric acidity