Peptic ulcer disease in pediatric practice

Peptic ulcer disease is one of the common diseases, occurring in approximately 10% of the population. It is a chronic relapsing disease tends to progression and development of complications, often associated with the pathology of other organs and systems.

Gastric and duodenal ulcers in elderly and senile age does not occur as often as younger patients. However, in recent decades there has been considerable increase in the incidence of geriatric contingent. Dominated by ulceration of stomach, duodenum and not (as opposed to young and middle age).

According to statistical studies, women suffer from peptic ulcer disease in men at least 2-7 times. Over time, sex ratio vary considerably: in the more elderly women predominate and the ratio shifts to their side - 1.5:1. Peptic ulcer disease in older people occurs more malignant and a large number of complications. So, over two thirds of deaths related to complications of gastric ulcers, it is recorded in the elderly. The number of complications increased from 30% at age 60-65 years to 75-80% at the age of 80-85 years.

Human aging causes numerous changes in his digestive system. The reasons for these changes are: reduction of energy cells, the number of mitochondria and oxidative capacity due to the weakening of tissue respiration, decrease of the genetic activity of cells with reduced protein synthesis, changes in the neuro-vascular wall trophism bodies, limiting the effectiveness of regulatory impacts on the system, etc. In its turn, reduced the processing of food and assimilation in the digestive system during aging exacerbates the metabolic form of general biological laws of nature.

In elderly and senile age there is dilatation, and tortuosity zapustevanie small arterial vessels. Vascular changes leading to disruption of blood supply of the stomach wall, the development of hypoxia in it, which are sensitive secretory cells of the gastric mucosa. Age-related changes in gastric vascular system contribute to the development of its so-called senile ulcers represent a trophic disorders section of the mucosa.

Reduced thickness of the gastric mucosa by reducing its glandular zone changes identified in the various components of the gastric wall and in various secretory cells. Atrophy is diffuse, widespread in nature: first appears in the surface, and then in the deeper layer of cells.

In the epithelium reduced the content of neutral mucopolysaccharides. Reduce the number of parietal glandulotsitov, their mitochondria alter the structure. In the main cells are found granules of mucin significantly fewer pepsinogenovyh granules. Along with the destruction of individual cells are observed hyperplasia and hypertrophy of the surviving structures.

The secretory function of the stomach is determined by the production of gastric juices, which consists of hydrochloric acid, pepsin, chlorides, biermerin, mucous, and other ingredients. Gastric juice consists of two parts - the acidic and basic, the ratio of which the young people of 2:1 or 3:1. With age, this ratio varies in the direction of increasing the mass of the main part, due to a significant decrease in production of acidic components.

It is established that the elderly of the gastric juice is reduced by 1.6 times, hydrochloric acid - 2.1 times, in the elderly - respectively by 2.1 and 2.5. Reduces the number of basal and induced gastric secretion of acid component, and later - alkaline. At least attenuated production of pepsin and biermerin. One reason for this change is more asynchrony superficial parietal glandulotsitov producing hydrochloric acid, and a deeper seat main cells that produce pepsin.

Noted that decreases with age the percentage of pepsin biermerin and breakdown products of proteins, increases the fraction mukoproteaz formed as a result of enzymatic cleavage of mucous substances. Reduced allocation uropepsinogena.

Evacuation function of the stomach in elderly and senile patients are not significantly altered, as evidenced by these X-ray studies. Most often changes the overall tone and the tone of the stomach wall. More pronounced decrease of tone, especially in old age, takes place in the area of ​​the body and antrum. This feature is one of the reasons for the omission of the lower pole of the stomach in the elderly. Are important age-related spinal processes in the muscle tissue of the abdominal wall, pelvic floor weakening ligaments and decrease fat. Gastric motility in the elderly and old age also varies: to reduce the power cuts, quickens the rhythm of tonic contractions, shortens the period of work.

By the pathogenetic factors of the formation of erosions and ulcers in older people are, along with acid-peptic factor and the persistence of H.pylori in the gastric mucosa, hypoxia and associated trophic disturbances in the gastric mucosa and 12 duodenal ulcer. A large role in the pathogenesis of play changes in the vascular system, leading to the development of degenerative disorders of the mucous.

Older identify several forms of the disease: a long - continued illness, which began earlier, "later" that has developed after 60 years, and "senile" ulcer.

The first form of peptic ulcer disease only in the third case is a classic course. Seasonality of exacerbations is often missing. Pain symptom is less pronounced. The secretory function of the stomach is usually not broken. Exacerbation of the disease often begins with complications - massive bleeding or perforation of the ulcer. Exacerbation may be associated with reduced appetite, weight loss, anemia, constipation, causing suspicion of tumor. Predominant localization of ulcers in piloroantralnom department and in the lower third of the gastric body. Exacerbations are rare, although the terms are extended scarring. Malignancy ulcers is possible, though relatively rare.

In the "late" ulcer disease in some patients in the clinical picture is dominated by dyspeptic symptoms, while others - persistent pain. Seasonality does not relapse. Acid gastric secretion is preserved. Ulcers are deep, dominated by large defects. They are located mainly in the upper stomach. Often slow and not cicatrizing ulcer complications - perforation, bleeding, etc.

"Senile" ulcer - the most common form of ulcerative lesions in the elderly. On the manifestations and course of it's close to symptomatic. The primary cause of "senile" ulcers are vascular-degenerative disorders. There is acute, it has erased the clinical picture, pain is usually not intense, short-term, combined with dyspeptic complaints. Sometimes the main clinical symptom of the disease may be weight loss. "Senile" is often accompanied by bleeding ulcer, which may be the only symptom of the disease. Of acid in the stomach is reduced. Ulcers are usually solitary, often enormous, localized mainly in the middle and lower gastric body and lesser curvature. Most of combined ulcers associated with NSAID, at least with Helicobacter pylori infection. "Senile" ulcer scar quickly, without the formation of rough scars, not likely to recur.

Giant duodenal ulcers often develop in patients older than 70 years. Duodenal ulcers, as a "long" and "late", given the clinical picture erased. In both forms of the disease is usually increased gastric secretion or preserved, which is not typical for this age. In patients with a first form of peptic ulcer disease are observed moderate pain, dyspeptic symptoms. In the second form of the disease ulcer is often found incidentally during a study conducted on a different occasion. Ulcer scar slowly and often incompletely. The first symptom is often bleeding, which is more than half of the complications.

Older people more often than younger people, there vnelukovichnye ulcers. They are characterized by persistent pain, dyspeptic symptoms, sudden onset of bleeding, a tendency to relapse. Often there is penetration of the ulcers in the head of the pancreas. When vnelukovichnyh duodenal ulcers may cause spasm, swelling with the development of major duodenal papilla of jaundice, the occurrence of functional stenosis of the duodenum. Gastric secretion is usually increased.

The share of associated ulcers in patients with elderly is higher than that of the young. Pronounced pain, characterized by dyspepsia. The secretory function of the stomach can be retained. Course of the disease more difficult - prolonged periods of exacerbation and remission periods are shortened, the seasonality of exacerbations is absent, are frequent complications (bleeding, perforation, stenosis).

The second most common complication after bleeding in the elderly is a perforation. Atypical clinical picture of perforation in the elderly leads to errors in diagnosis and high mortality. Next in frequency of complications - stenosis of the pylorus, the frequency of which increases with age up to 15%. Polymorphism of clinical symptoms associated with the presence of concomitant pathologies age of the cardiovascular and nervous systems. Often these patients suffer from anemic syndrome, heavier for peptic ulcer disease.

In the diagnostic standards of this disease include: fibrogastroduodenoscopy, a test for H. pylori, a test for occult blood in stool, blood total, biochemical tests: bilirubin, AST, ALT, total protein, albumin, urea. If you need to resort to diagnostic pH-metry, including daily monitoring of pH, the X-rays, consult a surgeon, oncologist.

X-ray method reveals the direct and indirect symptoms. The most important indirect radiological signs of peptic ulcer disease include: scar deformation body, the convergence of the folds and dyskinetic gastroduodenal disorders. "Peptic" niche - a direct indication of the disease. However, the level of radiological errors in the identification of gastroduodenal ulcers is large enough and is 18-35%. One advantage of - access documentation. To increase the information content of X-ray study should be conducted with double-contrast; be polipozitsionnym, accompanied by enlargement film.

The endoscopic method allows detection of defects in the mucosa, to determine the pathomorphology of the ulcer, the rate of ulcer healing. Control of scarring should be carried out depending on the size of ulcer and its treatment. The first controlled study can be given in 10 -14 days of therapy. Cardia of the ulcer and subkardii appropriate control in 4 - 6 weeks. Of great importance is the study of biopsies of patients with stomach ulcers - differential diagnosis between chronic ulcers and cancer. In many patients, this problem can be solved only after a biopsy. Biopsies should be multiple, from the edges and bottom of the ulcer. The accuracy of histological diagnosis of cancer is 100% on taking at least six biopsies. If a biopsy was performed only from the center of "defeat", the number of positive findings was reduced to 48%. Excision of one or two pieces of ulcers is not allowed. In practice, one should proceed from the position, which is formulated as follows: a single biopsy of the ulcer can be not only useless but even harmful to the patient.

Difficult clinical and endoscopic differential diagnosis and that ulceration of stomach cancer may, as usual benign ulcer healing be, the truth is rarely complete healing, but is observed in 70% of patients with early cancer. At the site of ulceration usually formed granulation tissue and mucosa. It re-grows its surrounding tumor, which was soon subjected to repeated ulceration. Due to the fact that gastric cancer grows relatively slowly, such cycles can be repeated many times. It is considered that the development of cancer from the microscopic to the early takes almost 10 years, from early to express with clinical manifestations - 16-25 years old.

Diagnosis of H. pylori infection should be carried out by methods appropriate to the generalized recommendations Consensus Maastricht-3:

∙ If the patient is not performed gastroduodenoscopy, it is advisable to use for the diagnosis of urea breath test, H. pylori antigen in stool or serologic test.

∙ If the patient is performed gastroduodenoscopy, then these can be used for rapid urease test.

∙ The disadvantage of serological test is that it can not distinguish current infection from H. pylori transferred. The advantages of the serological test include its minimally invasive, the ability to detect the microbe in patients with low seeding, the possibility of cross-sectional survey of a large contingent of patients with bleeding gastroduodenal of ulcers, low cost, no effect of prior antisecretory therapy on the outcome.

∙ To monitor the effectiveness of eradication is best to use a breath test, if this is impossible - we recommend the study of H. pylori antigen in stool.

∙ The current antisecretory therapy reduces the frequency of detection of H. pylori antigen in stool and the frequency of positive breath test results.

∙ Identification of certain strains of H. pylori has no role in addressing the need for treatment.

In domestic clinical practice being applied smear method and urease test to determine infection H. pylori eradication and evaluation conducted.

Treatment of gastric ulcer and 12 duodenal ulcer in elderly and senile traditional, subject to a number of geriatric moments. Prolonged restriction of physical activity adversely affects the general condition of older people, helps exacerbate constipation. Bed rest is granted only for a period of intense pain. In appointing the diet takes into account age-specific features of metabolism, individual metabolic disorders, eating habits, concomitant diseases (easily digestible carbohydrates are limited, salt, animal fats, include foods that contain polyunsaturated fatty acids). The diet should be full and balanced.

The main purpose of the antiulcer treatment in the elderly is pain relief, ulcer healing, prevention of complications and relapse prevention. For a long time was that of duodenal ulcer require use of antisecretory drugs and ulcers - drugs that stimulate regeneration. At present it is generally accepted that after the confirmation of a benign nature of gastric ulcers treatment is the same as the treatment of duodenal ulcers (but longer, given the somewhat slower scarring stomach ulcers). Therapy of uncomplicated peptic ulcer without associated pathology can be performed in an outpatient setting. Surgical intervention is indicated in complications.

Basic pharmacotherapy for peptic ulcer disease include: antisecretory drugs (proton pump inhibitors and H2 - blockers). In cases of detection is carried out helikobaktera pyloric eradication therapy, when expressed vascular degenerative changes in prescribed cytoprotective funds. Additional medications - antacids and prokinetics.

Therapy of H. pylori has been well studied in accordance with the standards of evidence-based medicine. Eradication of H.pylori is actually etiotropic treatment of peptic ulcer disease, allowing easier scarring ulcer, to prevent the development of recurrences and complications, avoid continuous therapy and frequent hospitalizations.

In accordance with the recommendations of the "Consensus Maastricht-3 'mandatory indications for eradication are the same as in the recommendations of previous consensus meetings. As for the relative indications (functional dispepesiya, GERD and NSAID-gastropathy), participants Consensus Maastricht-3 found it necessary to clarify these issues.

1. H.pylori and functional dyspepsia. Despite the low incidence on the results of meta-analysis of the disappearance of dyspeptic complaints in patients after eradication of H.pylori, the presence of the infection study and treatment of H. pylori carrying out of such patients (strategy ╚test and treat╩) deemed necessary, particularly in regions with high infection of the population.

2. Анализ взаимоотношений H.pylori и ГЭРБ позволил прийти к выводу, что эта инфекция не является фактором, способствующим возникновению болезни. С другой стороны, нет убедительных подтверждений того, что эрадикация провоцирует развитие или прогрессирование ГЭРБ. Кроме того, устранение микроба не влияет на необходимость антисекреторной терапии при данной патологии. Следует учитывать, что длительное применение блокаторов протонного насоса у H.pylori - положительных больных ГЭРБ способствует развитию атрофического гастрита. В свою очередь, эрадикация помогает снизить у таких пациентов риск развития атрофии слизистой оболочки фундального отдела желудка.

3. H.pylori и НПВС-гастропатия. Оценка имеющихся данных позволяет сделать вывод, что риск развития эрозий язв желудка и двенадцатиперстной кишки при приеме НПВС у H.pylori - положительных больных выше, чем у H.pylori √ отрицательных. Эрадикация снижает риск развития язв и эрозий у больных, получающих НПВС, в связи с чем перед началом приема указанных препаратов необходимо исследование на инфицированность хеликобактером и в случае ее подтверждения ≈ проведение эрадикационной терапии.

Эрадикационные схемы оговорены документами конференций Европейской группы по изучению H.pylori и представлены схемами Маастрихтских соглашений 1996, 2000 и 2005 годов.

Терапия первой линии: ИПП в стандартной дозе 2 раза в день + кларитромицин 500 мг 2 раза в день + амоксициллин 1000 мг 2 раза в день. Тройная терапия назначается, как минимум, на 7 дней, а в случае осложненного течения - до 14 дней.

При отсутствии успеха эрадикации назначается терапия второй линии: ИПП в стандартной дозе 2 раза в день + висмута субсалицилат 120 мг 4 раза в день + метронидазол 500 мг 3 раза в день + тетрациклин 500 мг 4 раза в день. Квадротерапия назначается на 7 - 14 дней.

Если препараты висмута не могут быть использованы, в качестве второго лечебного курса предлагаются схемы на основе ингибиторов протонной помпы.

В случае неэффективности схем эрадикации первой и второй линий Консенсус Маастрихт-3 предлагает практическому врачу несколько приемлемых вариантов дальнейшей терапии. Поскольку к амоксициллину в процессе его применения не вырабатывается устойчивость штаммов хеликобактера, возможно назначение его высоких доз (0,75 г 4 раза в сутки в течение 14 дней) в комбинации с высокими (4-кратными) дозами блокаторов протонного насоса. Другим вариантом может быть замена метронидазола в схеме квадротерапии фуразолидоном (100≈200 мг 2 раза в сутки). Альтернативой служит применение комбинации блокаторов протонного насоса с амоксициллином и рифабутином (300 мг в сутки) или левофлоксацином (500 мг в сутки). Оптимальным путем преодоления резистентности остается все же подбор антибиотиков с учетом индивидуальной чувствительности данного штамма H.pylori.

Известно около 50 метаанализов, касающихся проблем эрадикационной терапии. При сравнении различных ИПП в схемах эрадикации существенных различий в результатах лечения большинство исследователей не обнаружили. В среднем, эффективность эрадикационной терапии не превышает 85%. В то же время при использовании двойной дозы омепразола получены более высокие результаты лечения, частично подтвержденные в рандомизированных контролируемых исследованиях. В успешности эрадикации имеют значение уровень контаминации H.pylori, популяционные и географические особенности.

В многочисленных клинических исследованиях установлено, что между заживлением язвы и способностью лекарственных препаратов подавлять кислотность существует прямая зависимость: заживление язвы детерминировано не только продолжительностью назначения антисекреторных препаратов, но и их способностью удерживать инрагастральный рН > 3 в течении определенного времени. Антисекреторная терапия при лечении гастродуоденальной язвы должна снижать кислотопродукцию желудка примерно на 90%. Для этого необходимо, чтобы рН>3 была 18 часов и больше в сутки.

В настоящее время применяются три основных варианта антисекреторной терапии : в случае НР-позитивной пептической язвы после успешной эрадикации не осуществлять антисекреторную терапию; использовать, наряду с эрадикацией, антисекреторную терапию до появления красного рубца + дополнительно 1≈2 нед.; применение, наряду с эрадикацией, длительной (3-х месячной) антисекреторной терапии до появления белого рубца. Длительное антисекреторное лечение предохраняет от раннего рецидива после репарации язвы и важно для НР-негативных язв или в случаях повышенной кислотопродукции.

Достижению положительных результатов часто препятствует отсутствие приверженности пациентов к лечению. Для восстановления комплаенса рекомендуется использовать комплексные препараты, включающие все компоненты терапии. В настоящее время в Беларуси зарегистрирован комбинированный препарат ╚Пептипак╩, содержащий омепразол, кларитромицин и амоксициллин в соответствии с международными рекомендациями по лечению хеликобактерной инфекции первой линии. Эта форма выпуска очень удобна для использования у лиц пожилого и старческого возрастов, которым, в силу когнитивных личностных расстройств, трудно использовать много лекарств. Один блистер ╚Пептипака╩ содержит полный набор препаратов на один день, что упрощает лечение.

В Республиканском клиническом госпитале инвалидов Великой Отечественной Войны им. PM Машерова в 2006 √ 2007 годах применяли препарат "Пептипак" у 69 пациентов с сочетанной язвенной болезнью желудка и 12-перстной кишки. Длительность курса определялась индивидуально и составила от 10 до 14 дней. У всех больных рубцевание язвенного дефекта наступило после проведенного курса в течение 14 √28 дней. Отмечалась хорошая переносимость препарата. Побочные реакции не выявлены. При повторном обращении контроль эффективности эрадикации проведен у 78% пациентов. У них эрадикация была подтверждена лабораторно. Высокая эффективность препарата у лиц пожилого возраста объясняется более низким уровнем кислотопродукции и наличием возрастных атрофических процессов.

Существенное значение в лечении и профилактике язвенной болезни у лиц пожилого и старческого возраста имеют витамины, адаптогены, продукты пчеловодства. Санаторно-курортное лечение этих пациентов желательно проводить на местных курортах с учетом сопутствующих заболеваний.

У лиц пожилого и старческого возрастов требуется тщательно проанализировать необходимость приема каждого лекарственного средства, назначенного по поводу сопутствующих заболеваний в отношении совместимости с препаратами, используемыми в связи с обострением язвенной болезни, и возможного раздражающего эффекта на желудок.

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