1. Etiologically: 1) a form associated with Helicobacter pylori; 2) a form not associated with N.R.
2. By localization: secrete gastric ulcers and duodenal ulcers. Gastric ulcers: 1) cardiac and subcardiac departments; 2) the body of the stomach; 3) antrum; 4) pyloric department. Duodenal ulcers: 1) bulbs; 2) post-bulbous section (extra-bulbous ulcers). Allocate also combined ulcers of the stomach and duodenum.
3. Type of ulcers: single and multiple.
4. By clinical course: 1) typical; 2) atypical (with atypical pain syndrome; painless, but with other clinical manifestations; asymptomatic).
5. According to the level of gastric secretion: 1) with increased secretion; 2) with normal secretion; 3) with reduced secretion.
6. By the nature of the flow: 1) newly diagnosed peptic ulcer; 2) relapsing course: a) with rare exacerbations (1 every 2-3 years or less); b) with annual exacerbations; c) with frequent exacerbations (2 times a year or more).
7. According to the stage of the disease: 1) exacerbation; 2) remission.
8. According to the presence of complications: bleeding, perforation, stenosis, malignancy (degeneration into a cancerous tumor).
Etiology and pathogenesis. Helicobacter pylori (H.P.) plays a major role in the development of peptic ulcer. As noted above, the disease, as a rule, is preceded by the development of chronic
Nic non-atrophic (Helicobacter pylori) gastritis. At present, it is believed that the formation of a stomach or duodenal ulcer occurs as a result of changes in the ratio of local factors of "aggression" and "protection", while there is a significant increase in "aggression" against the background of a decrease in "protection" factors. ". TO factors of "aggression" include: bacteria (N.R.); increased acidity and peptic activity of gastric juice in conditions of impaired motility of the stomach and duodenum; violations of the evacuation of food from the stomach, etc. Decreased activity "protective" factors due to: a decrease in the production of mucobacterial secretion (the main components of the bicarbonate-mucous barrier); slowing down the processes of physiological regeneration of the surface epithelium; decrease in blood circulation of the microcirculatory bed and nervous trophism of the mucous membrane; inhibition of the main mechanism of sanogenesis - the immune system, etc. "No acid - no ulcer!" - this provision can still be considered true for most cases of DU, although this condition is not always necessary for GU.
clinical picture. It is characterized by high polymorphism and depends on the location of the ulcer, its size and depth, the secretory function of the stomach, and the age of the patient. The main syndrome is pain. They, as a rule, have a clear rhythm of occurrence, connection with food intake, frequency. In relation to the time elapsed after eating, it is customary to distinguish between early, late and "hungry" pains. early pain appear 0.5-1 hour after eating, gradually increase in intensity, persist for 1.5-2 hours, decrease and disappear as the gastric contents are evacuated into the duodenum. Such pains are characteristic of stomach ulcers. With the defeat of the cardiac, subcardial and fundal departments, pain occurs immediately after eating. late pain occur 1.5 - 2 hours after a meal, gradually increasing as the contents are evacuated from the stomach. They are characteristic of ulcers of the pyloric stomach and duodenal bulb. The combination of early and late pain is observed in patients with combined and multiple ulcers of the stomach and duodenum. "Hungry" (night) pains occur 2.5 - 4 hours after eating and disappear after the next meal. These pains are also characteristic of ulcers of the duodenum and pyloric stomach.
The severity of pain sensations depends on the localization of the ulcerative defect (insignificant - with ulcers of the body of the stomach, sharp - with pyloric and extra-bulbous ulcers), on age (more intense - in young people), and the presence of complications. Pain usually stops after taking antisecretory drugs.
The clinical course of peptic ulcer disease can be complicated by bleeding, perforation of the ulcer in the pyloric cavity, narrowing of the pylorus. With a long course, cancerous degeneration of the ulcer may occur. In 24–28% of patients, the ulcer may proceed atypically - without pain or with pain resembling another disease ( angina pectoris, osteochondrosis, etc.), and is detected by chance.Peptic ulcer may also be accompanied by gastric and intestinal dyspepsia, asthenoneurotic syndrome.
Treatment. Patients with an exacerbation of uncomplicated peptic ulcer disease are usually treated on an outpatient basis. The following categories of patients are subject to hospitalization: with newly diagnosed peptic ulcer; with a complicated and often recurrent course; with severe pain syndrome, not relieved by outpatient treatment; with peptic ulcer developing against the background of severe concomitant diseases.
In case of peptic ulcer, complex therapy is used, similar to the treatment of chronic gastritis: diet therapy, drug therapy, physiotherapy, spa treatment (in remission), exercise therapy. In the form not associated with H.R., all groups of antisecretory drugs are used.
A certain category of patients undergoes surgical course. Absolute indications for surgical liver are the following complications: ulcer perforation; profuse gastrointestinal bleeding; stenosis, accompanied by severe evacuation disorders. Relative indications: multiple profuse gastrointestinal bleeding in history; large callous penetrating ulcers resistant to drug treatment.
In the complex treatment of patients with ulcerative disease, a wide range of non-drug agents are used that have a local and general effect on the body: hyperbaric oxygen therapy, laser therapy, balneotherapy, mud therapy, drinking mineral water, physiotherapy, therapeutic exercises in the hall and in the pool (with the selection of individual motor modes). However, all these remedies for the treatment of peptic ulcer (including exercise therapy) have mainly an auxiliary, symptomatic effect on the body.
Prevention. For the prevention of exacerbations of peptic ulcer, two types of therapy are recommended with patients observing general and motor regimens, as well as a healthy lifestyle.
1. Supportive care(for several months and even years) antisecretory drugs in half the dose. This type of therapy is used in the following cases: with the ineffectiveness of antibiotic therapy; with complications of peptic ulcer; in patients older than 60 years with an annual recurrent course of the disease.
2. Preventive therapy "on demand". When symptoms of exacerbation of peptic ulcer appear within 2-3 days, antisecretory drugs are used. If the symptoms disappear completely, the therapy is stopped.
A very effective means of primary and secondary prevention of PU is sanatorium treatment.
Forecast. With uncomplicated peptic ulcer - favorable. With effective antibacterial treatment, relapses during the first year occur only in 6-7% of patients. Early diagnosis and timely treatment with modern methods prevent the development of possible complications and preserve the ability of patients to work. The prognosis worsens with a long duration of the disease in combination with frequent, prolonged relapses, as well as with complicated forms of peptic ulcer - especially with malignant degeneration of the ulcer.
Control questions and tasks
1. Define chronic gastritis (CG). What is its prevalence?
2. Tell us about the classification of CG and name the main etiological factors.
3. Describe the main pathogenetic mechanisms of CG.
4. Tell us about the clinical picture and the course of this disease.
5. What are the main syndromes and symptoms of CG?
6. What disorders of the stomach function are observed in chronic hepatitis?
7. Tell us about the methods and means of treating chronic gastritis.
8. Define peptic ulcer (PU) of the stomach and duodenum.
9. Tell us about the classification of peptic ulcer and the main etio-1
logical factors.
10. What are the main mechanisms of the pathogenesis of I B?
11. Describe the clinical picture and course of peptic ulcer.?
12. What types of pain are distinguished in this disease?
13. List the means of complex therapy in the treatment of peptic ulcer.
14. Tell us about the means of prevention and prognosis of this disease.
A chronic disease in which ulcers form on the stomach lining is called peptic ulcer. Pathology lends itself well to conservative treatment, but only if the diet prescribed by the doctor is followed. Without treatment, peptic ulcer disease can lead to bleeding, perforation, and even stomach cancer.
The purpose and objectives of the classification of stomach ulcers
Modern scientists have studied peptic ulcers very deeply, so such pathologies have a multifaceted classification. It is necessary to draw up a treatment strategy to eliminate ulcers. The classification of peptic ulcer of the stomach and duodenum is the same, since the mechanisms for the development of pathologies do not differ.
Types of stomach ulcers
According to ICD-10, the disease has the code K25. Of its subspecies, 4 acute, 4 chronic and one unspecified form are distinguished. Each has its own designation - a number from 0 to 9 is added to the K25 code through a dot. Acute and chronic forms are divided into ulcers that occur with or without bleeding, with perforation / without it, or with two pathologies at once.
Due to development
All causes of the development of ulcerative lesions of the gastric mucosa are divided into non-infectious and non-infectious. Classification of pathology taking into account etiological factors:
| Type of peptic ulcer | Description |
| Associated with Helicobacter pylori | It develops as a result of damage to the digestive tract by the bacterium Helicobacter pylori. It produces toxins that damage the mucous membrane. It is believed that about 60% of people are infected with this bacterium, but it causes an ulcer only when local immunity is weakened. |
| Not associated with Helicobacter pylori | It has nothing to do with the bacterium Helicobacter pylori. The reason may be increased production of hydrochloric acid. |
| symptomatic | Occurs due to the action of ulcerogenic factors. The main types of symptomatic form of the disease:
|
By the nature of the flow
Peptic ulcer of the stomach in different patients can occur in varying degrees of severity, which depends on the severity of the symptoms. With this in mind, physicians have compiled the following classification of the disease:
Depending on the quantitative and qualitative characteristics
Given the number of mucosal defects, ulcers are single or multiple. Classification of the disease depending on the size of ulcers:
- Small. Diameter up to 5 mm.
- Average. Ulceration reaches 20 mm in diameter.
- Big. The size of the ulcer is up to 30 mm.
- Giant. Such ulceration in diameter exceeds 30 mm.
According to the localization of ulcerative defects
In the stomach itself, an ulcer can have a different localization. Damage in the area where the organ passes into the duodenum is considered more dangerous, since the defect causes stagnation of the food bolus. In general, taking into account the location, an ulcerative lesion of the following sections of the stomach is isolated
- cardiac;
- subcardial;
- body of the stomach;
- antral;
- pyloric.
Other classification features
Separately, it is worth noting the classification of ulcers according to Johnson. It is used when choosing a method of surgical treatment. According to this classification, there are:
- I type. This is a mediogastric ulcer that occurs in 60% of cases.
- II type. This is a combined ulcer of the stomach and duodenum 12. According to statistics, it occurs in 20% of patients.
- III type. This includes the pyloroduodenal form of the disease. The frequency of its occurrence is also 20%.
To draw up treatment tactics, specialists have compiled several more classifications. They are based on differences in the features of the course of peptic ulcer:
| Classification sign | Types of stomach ulcers |
| flow type |
|
| Clinical form |
|
| According to the level of gastric secretion |
|
| By disease phase |
|
| Ulceration condition |
|
Classification of complicated peptic ulcer
When determining the tactics of treatment, the complications that accompany the pathology are also taken into account. The most common consequences of peptic ulcer:
- Bleeding. The frequency of occurrence is 15–20%. Bleeding can be acute or chronic, according to the nature of the course, it has 4 degrees of severity.
- Penetration. It often accompanies other complications. Pathology is the spread of ulceration to neighboring organs and tissues: the liver, pancreas, sigmoid colon, etc.
- Pyloric stenosis. It occurs against the background of an advanced stage of pathology, causes a narrowing of the lumen in the pylorus area, which prevents the normal flow of water and food into the stomach.
- Malignancy. This is a malignant transformation. According to various sources, an ulcer causes cancer in 2-12% of cases.
- Perforation. Occurs in 4-10% of patients. This is a through damage to the wall of the stomach at the site of ulceration. The condition is dangerous by the development of peritonitis.
Penetrates into the wall of the stomach to various depths. It destroys all layers, including the muscular layer, and sometimes reaches the serous layer.
- The bottom of the ulcer is smooth, sometimes rough.
- The edges are wavy raised, dense.
- The serous membrane in the area of the ulcer is thickened.
- It is localized mainly on the lesser curvature. The lower third of the body and the corner of the stomach.
- Sizes from 1 to 4 cm.
- And it was noted that the more proximal the ulcer is located, the larger its size.
Microscopic picture:
- in the period of exacerbation: in the area of the bottom and edges of the ulcer, a zone of fibrinoid necrosis appears. The zone of necrosis is delimited by granulation tissue with a large number of thin-walled vessels. Deeper, after the granulation tissue, there is coarse fibrous scar tissue.
- During the period of remission, a reverse microscopic picture is observed: granulation tissue grows into the necrosis zone, which matures into a coarse-fibrous cicatricial tissue, epithelialization of the ulcer often occurs. In the vessels located in the area of the ulcer, wall sclerosis and obliteration of the lumen develop.
Thus, gastric ulcer leads to increased cicatricial changes in the stomach and exacerbates the violation of the trophism of its tissues.
The newly formed scar tissue is easily destroyed during the next exacerbation.
ENDOSCOPIC SIGNS OF CHRONIC ULCER.
1. The shape is often oval or round, less often linear, slit-like.
2. The edges are smooth, clear, evenly delimited from the surrounding mucosa.
3. Absence of infiltration of the surrounding mucous membrane - edema!
4. The same color of the edges and the mucous membrane surrounding the ulcer, often hemorrhagic / submucosal / spots.
5. The bottom is smooth, often covered with a yellow or gray coating.
6. The bottom and edges of the ulcer are sharply delimited from each other along the circumference.
7. Bleeding more often than the bottom of the ulcer.
8. The convergence of the folds of the mucous membrane to the ulcer is visible evenly over the entire circumference and reaches its edges.
9. Deformation of the wall in the area of the ulcer is quite common, but it is more limited, often there is a retraction of the wall in the area of the ulcer - in the form of a "tent".
10. With a targeted biopsy, rigidity of the edges of the ulcer is rarely noted. There was no fragmentation on biopsy.
Ways of ulcer healing, 4 options:
1. Healing by epithelialization from the periphery to the center, and the ulcer retains a round or oval shape.
2. Healing through the stage of a linear ulcer perpendicular to the lesser curvature.
3. Healing by dividing into 2 “mirror” or “kissing” ulcers.
4. Healing through the stage of a linear ulcer parallel to the lesser curvature /for deep/. Ulcers that heal according to type 2-3 often recur.
Callous ulcer- this is an ulcer that is not prone to healing, with dense edges and a bottom. prone to cancer. In the direction from the pylorus to the cardiac section, the tendency to malignancy increases 5 times, i.e. the higher the ulcer is located in the stomach, the more likely its malignant nature.
Senile ulcer- solitary, flat with unexpressed signs of inflammation around. It occurs against the background of atrophic gastritis, similar to ulcerated cancer. Heals in 1-2 months. without wall deformation. Not prone to relapse.
Slit-like or trench-like ulcer occurs in patients over 60 years of age with preserved gastric secretion. It is localized along the lesser curvature of the stomach. It can be up to 10cm long.
Features of ulceration of the stomach and duodenum, depending on the type of chronic gastritis
| Morphological changes in the gastric mucosa | Interpretation |
|---|---|
|
Normal mucosa |
Peptic ulcer is impossible. If there is an ulcer, it is most likely caused by the use of NSAIDs. |
| Chronic antral or pangastritis, no atrophy in the fundus (+ bulbitis) | Peptic ulcer is possible or even available; the risk is high |
| Chronic pangastritis with atrophy in the fundus | Peptic ulcer 12p of the intestine is impossible. Stomach ulcer is possible, although it is unlikely |
| Chronic pangastritis or fundic gastritis + severe atrophy in the fundus | Peptic ulcer is impossible; if there is an ulcer, then most likely it is malignant |
In connection with the above, and after the discovery of H. pylori, a concept arose that finds more and more supporters about “ gastritis-associated peptic ulcer”as about its most frequent variant. G. Borsch (1987) in this tandem "gastritis-ulcer" puts gastritis in the first place and formulates it as follows:
- "gastric and duodenal ulcers are not just a violation of the integrity of the epithelium, but an episodic and recurrent complication superimposed on more pronounced and diffuse lesions of the mucous membrane, in the form of type B gastritis or gastroduodenitis."
An indispensable condition for chronic ulcers- development in the bottom and edges of scar tissue that disrupts the trophism of the newly formed mucous membrane and contributes to the recurrence of ulcers.
When healing, a chronic ulcer goes through 4 stages.
The allocation of these stages is based on a comparison of endoscopic and histological pictures:
1. Stage of initial healing.
Endoscopically and when studied with a stereoscopic microscope, it is characterized by the creeping of the epithelium in the direction from the edges to the center and the presence of spindle-shaped protrusions on the surface. Histologically, growth of prismatic epithelium is noted.
2. Stage of proliferative healing (membranous regeneration).
Endoscopic and stereomicroscopic examination reveals low fusiform protrusions, histological - regenerating epithelium covering these protrusions with one layer.
3. Stage of palisade scar.
The ulcer crater is not visible, in its place are palisade-like strands, converging towards the center of the ulcer. There are many capillaries in the scar tissue, immature pseudopyloric glands appear.
4. Stage of cobblestone scar.
It is named because of the characteristic appearance that the newly formed mucous membrane has when viewed through an endoscope or a stereoscopic microscope. Small holes are also visible. Histologically, there are many pseudopyloric glands.
Ulcer healing is considered complete only when forming a "cobblestone" scar.
The quality of ulcer healing.
Peptic ulcer disease is characterized not only by the presence of a long-term non-healing (chronic) ulcer, but also, no less important, by its tendency to recur. In this case, relapses usually occur at the site of a healed ulcer.
The optimal outcome of any reparative regeneration is restitution, i.e. complete restoration of the structure of the lost tissue.
In the stomach, restitution occurs during the healing of erosions and with artifactual injuries after a biopsy or endoscopic polypectomy.
Unlike erosion, ulcers destroy not only the mucous membrane, but also the underlying layers. In this case, the type and completeness of regeneration fundamentally changes.
All ulcers heal by secondary intention with granulation tissue. The structure of the mucous membrane is not completely restored.
Such a picture of the mucous membrane at the site of a healed ulcer was designated by the term " substitution» Usually, substitution refers to such an outcome of healing, in which the site of necrosis is replaced by connective tissue, which is subsequently subjected to scarring.
Thus, the concept of the quality of healing determines not only the completeness of regeneration, but also the prognosis.
In recent years, it has been established that the leading role in the restoration of the extracellular matrix after damage belongs to the transforming growth factor (TGF).
Increased production of TGF is the cause of excessive scarring. The importance of TGF for the quality of ulcer healing has recently been established. Local administration of TGF to the ulcer zone accelerated their healing, but was accompanied by the development of severe and severe sclerosis at the site of the healed ulcer.
At the same time, the injection of antibodies neutralizing TGF also accelerated healing, but the severity of sclerosis was much less, and the quality of healing was higher due to this.
It is possible that this way of improving the quality of ulcer healing can also find clinical application. Here, however, it is important to find the moment when appropriate introduce this growth factor into the bottom of the ulcer. In the experiments, TGF was administered, as it were, prophylactically, immediately after applying 100% acetic acid to the serous membrane.
It is important to decide whether to administer TGF in the active phase or in the phase of clearing the bottom of the ulcer.
Zollinger-Ellison Syndrome
Zollinger-Ellison syndrome is characterized by hypergastrinemia, hypersecretion of HCL, the presence of persistently recurrent duodenal or jejunal ulcers, diarrhea, and impaired digestion and absorption.
In the USA, the incidence varies between 0.1-3 cases per 1 million inhabitants.
There are 2 types of Zollinger-Ellison syndrome.
With type 1 there is a pronounced hyperplasia of G-cells in the antrum of the stomach.
With type 2- hormonally active tumor (gastrinoma).
In 80% of patients, gastrinomas are located in the so-called " gastrinomous triangle”, limited by the pancreas, duodenum and the confluence of the cystic duct into the common bile duct.
Gastrinomas of the stomach, liver, ovaries, parathyroid glands, and even lymph nodes have also been described.
There are no gastrin-producing cells in the normal pancreas, and therefore the source of gastrinoma development remains unclear.
In almost 1/3 of patients, gastrinoma metastasizes to the lymph nodes, in 10-20% - to the liver.
Hypergastrinemia- an indispensable component of the Zollinger-Ellison syndrome causes hyperplasia of parietal cells. This is due to the well-known trophic action of gastrin.
Macroscopically:
- Ulcers in most patients are solitary, in 25% - multiple.
- Their sizes usually do not exceed 2 cm,
- they are often complicated by bleeding and perforation,
- as a rule, recur after resections of the stomach.
Only total gastrectomy or removal of gastrinoma can prevent relapses.
- Almost a third of patients with Zollinger-Ellison syndrome have diarrhea.
If it is possible to completely cut off all sources of excess gastrin production, Zollinger-Ellison syndrome undergoes a reverse development. In this case, not only ulcers heal, but the normal structure of the fundic glands is restored.
Giant stomach ulcers.
Giant ulcers are usually called gastric ulcers, the diameter of which exceeds 3 cm.
Features of giant stomach ulcers:
- are among the most severe forms of peptic ulcer disease.
- They usually do not respond well to drug therapy.
- often (40-50%) are complicated by bleeding,
- and penetrate 40-70% into neighboring organs.
- Quite often, with giant gastric ulcers, perforations and gastrointestinal fistulas occur.
- The frequency of giant gastric ulcers according to endoscopic examination is 8.6%.
Endoscopically:
In all giant gastric ulcers, 2 zones can be distinguished - central and peripheral.
The presence of the central and peripheral zones gives giant gastric ulcers a peculiar trapezoidal shape with a wide base facing the lumen of the stomach. The narrow part is directed to its outer surface.
The value of biopsies in the differential diagnosis of gastric ulcers.
The main task facing the morphologist in the study of biopsy specimens of patients with stomach ulcers is the differential diagnosis between chronic ulcers and cancer. As is well known, in many patients this problem can be solved only after a biopsy.
Complicating clinical and endoscopic differential diagnosis is the fact that an ulcerated cancerous tumor of the stomach can, like an ordinary benign ulcer, undergo healing, although such healing is rarely complete, but it is observed in 70% of patients with early cancer. At the site of ulceration, the usual granulation tissue and mucous membrane may form. The tumor surrounding it again grows into it, which soon undergoes repeated ulceration.
Due to the fact that stomach cancer grows relatively slowly, such cycles can be repeated many times.
There is evidence that the development of cancer from microscopic to early takes almost 10 years.
And from early to severe with clinical manifestations - 16-27 years.
And that early type 1 cancer doubles in size in 6.5 years, and early cancers of other types in 2-3 years.
If the gastric juice destroys the tumor, and the resulting defect, in the process of reparative regeneration, is replaced by a “non-cancerous” mucous membrane, then an assumption arises about the possibility of “self-healing” of superficial cancer.
Apparently, this can explain those rare sectional observations when the pathologist finds metastases in the liver or in the lymph nodes, and in the stomach - a benign ulcer or postulcerous scar.
The possibility of healing ulcerated tumors of the stomach requires a new attitude to the indications for surgery.
Until recently, it was generally accepted that the need for surgical treatment of patients after 4-6 weeks. unsuccessful conservative therapy.
It was meant that if the ulcer does not heal during these periods, then it is either cancerous or may become malignant. However, it is now quite well known that completely benign ulcers may not heal for months, and a cancer ulcer “heal” in the usual time.
Therefore, the main method in differential diagnosis and in determining treatment tactics is gastroscopy with multiple biopsies.
Biopsies must certainly be multiple, both from the edges and from the bottom of the ulcer.. It is well known that carcinomatous changes can be observed only in certain areas of the bottom and edges of the ulceration, which may not be in the excised material. Very expressive data supporting this rather well-known, but unfortunately not always fulfilled requirement is illustrated by the materials of A. Misumi et al. (1978).
They found that the accuracy of the histological diagnosis of cancer was 100% when taking at least 6 biopsies. If the biopsy was performed only from the center of the "lesion", the number of positive findings decreased to 48.5%, from the outer edge to 19.6% and from the area around the "lesion" to 1.6%;
The doctor must know, what excision of 1-2 pieces with ulcers is unacceptable . In the absence of tumor elements in them, the medical documents will indicate that “no signs of malignant growth were found during histological examination.” It is well known how such a recording relieves the clinician's much-needed oncological alertness and how this can delay the establishment of a true diagnosis for a long time.
Therefore, in practical work, one should proceed from the position, which can be formulated as follows:
"A single biopsy from an ulcer can be not only useless, but harmful to the patient."
It should be borne in mind that even an experienced endoscopist is not always able, for various reasons, to excise pieces from the edges and bottom of the ulcer. In these cases, the pathologist should not be limited to simply describing what is delivered to the laboratory. In the "Specialist's opinion" it should be noted that the delivered material does not contain tissue from the bottom and (or) the edges of the ulceration.
Such a record tells the clinician that the biopsy was not informative, and the task that the clinician set when prescribing a biopsy was not completed.
This conclusion serves as an indication for a second biopsy.
And briefly about
COMPLICATIONS OF ULCER
With peptic ulcer, the following complications are distinguished:
- bleeding,
- penetration,
- malignancy,
- perforation,
- ulcerative scarring.
- perivisceritis (perigastritis, periduodenitis).
Bleeding occurs in connection with arrosion of the walls of blood vessels, as a rule, during an exacerbation of peptic ulcer. It manifests itself with vivid clinical symptoms: vomiting of blood, "coffee grounds", tarry stools, hemodynamic disturbances.
The classification of the degree of bleeding activity according to Forrest is, in fact, the criteria for the endoscopic prognosis of recurrent bleeding:
Forrest I. Continued bleeding:
Ia) massive jet arterial bleeding from a large vessel;
Ib) moderate, when the outflowing blood from a venous or small arterial vessel quickly fills the source after it is washed off and flows down the wall of the organ in a wide stream; jet arterial bleeding from a small vessel, the jet nature of which periodically stops;
ic) weak (capillary), weak leakage of blood from a source that may be covered by a clot.
Forest II. Past bleeding:
IIa) the presence in the source of bleeding of a thrombosed vessel, covered with a loose clot, with a large amount of altered blood with clots or contents such as "coffee grounds";
IIb) a visible vessel with a brown or gray thrombus, while the vessel may protrude above the bottom level, a moderate amount of content such as "coffee grounds";
IIc) the presence of small point thrombosed brown capillaries that do not protrude above the bottom level, traces of contents such as "coffee grounds" on the walls of the organ.
Forest III. Absence of signs of bleeding that were visible at the time of examination.
Perforation /perforation/ occurs during an exacerbation, when the ulcer increases in size and destroys all the walls of the stomach. There are observations when perforation occurs when receiving a closed abdominal injury, as well as after endoscopic manipulations. Perforation of the ulcer leads to peritonitis and the need for urgent surgical assistance.
Endoscopically in the center of the ulcer is determined by the "black hole" or serosa of the adjacent organs, the omentum. The lumen of the organ does not expand well due to the discharge of air through the perforation into the abdominal cavity.
It makes sense to perform urgent endoscopy in patients in whom the presence of perforation is beyond doubt, to determine the localization of the ulcer and the degree of cicatricial stenosis, since the expected volume and method of surgical assistance depends on this.
Ulcer penetration- germination of ulcerative infiltrate beyond the wall of the stomach into neighboring organs:
- small seal,
- head and body of the pancreas
- hepatoduodenal ligament,
- liver,
- transverse colon,
- gallbladder.
Cicatricial pyloric stenosis- against the background of ulcerative dyspepsia, signs of gastrostasis are determined, depending on the degree of compensation of electrolyte disturbances. Sometimes the scar pulls the stomach in the middle part and divides it like an hourglass.
Malignancy of a chronic ulcer occurs in 15-25% of cases.
Antral department.
Pyloric department.
II. Ulcers of the duodenum:
1.Pylorobulbar zone.
2. Bulbs of the duodenum.
3. Postbulbar department.
III. Combined gastric and duodenal ulcers
B) according to the phase of the course of the ulcerative process
Remission.
Incomplete exacerbation ("pre-ulcerative condition")
Aggravation.
incomplete remission.
C) BY THE NATURE OF THE DISEASE
II. Chronic
1. Latent peptic ulcer.
*2. Mild (relapse 1 time in 2-3 years or less) course.
*3. Moderate (1-2 relapses per year).
*4. Severe (3 relapses per year or more) or continuously relapsing disease, development of complications.
* - refers to duodenal ulcer
D) ACCORDING TO THE CLIC FORM
I. Typical (up to 25%)
II. Atypical
with atypical pain syndrome.
Painless (but with other clinical manifestations).
Asymptomatic.
D) BY SIZE
I. For the stomach:
Up to 1.0 cm - normal.
From 1.0 cm to 1.5 cm - large.
More than 1.5 cm - giant.
II. For duodenum 12:
1.Up to 0.5 cm - normal.
2. From 0.5 to 1.0 cm - large.
3. More than 1.0 cm - giant.
E) BY THE PRESENCE OF COMPLICATIONS
1. Bleeding (15-20%).
2. Perforation (4-10%).
3. Pyloroduodenal (bulbar) stenosis (5-10%).
4. Penetration (often combined with other complications).
Malignancy (20%, with true malignancy less common, but often a primary ulcerative form of gastric cancer).
G) CLASSIFICATION OF GASTRIC ULCERS BY JOHNSON, 1965
Type I - mediogastric ulcer (60%).
Type II - combined peptic ulcer of the stomach and 12 duodenal ulcer (20%).
Type III - pyloroduodenal ulcer (20%).
H) SYMPTOMATIC GASTRODUODENAL ULCERS
I. Medicinal ulcers.
II. "Stress" ulcers.
With widespread burns (Curling's ulcers).
With craniocerebral injuries, hemorrhages in the brain, neurosurgical operations (Cushing's ulcers).
In other "stressful" situations - myocardial infarction, sepsis, severe injuries and abdominal operations.
III. Endocrine ulcers:
1. Zollinger-Ellison syndrome.
2. Gastroduodenal ulcers in hyperparathyroidism.
IV. Gastroduodenal ulcers in some diseases of internal organs (dyscirculatory-hypoxic)
In chronic nonspecific lung diseases.
With rheumatism, hypertension and atherosclerosis.
With liver diseases ("hepatogenic" ulcers).
In diseases of the pancreas ("pancreatogenic" ulcers).
With chronic renal failure.
With rheumatoid arthritis.
In other diseases (diabetes mellitus, erythremia, carcinoid syndrome, Crohn's disease, etc.).
Indications for surgical treatment of peptic ulcer
Absolute
1. Urgent
Ulcer perforation
Profuse ulcer bleeding
2. Planned
Pyloroduodenal stenosis
Malignant gastric ulcer
Penetration of the ulcer with the formation of an interorgan fistula
relative
1. Peptic ulcer of the stomach
the ineffectiveness of conservative therapy for 68 weeks with a newly diagnosed ulcer;
recurrence of a stomach ulcer;
combined ulcer (type II according to Johnson)
Peptic ulcer of the duodenum 12:
- stressful (causes blood from the site of the ulcer and occurs against the background of severe experiences);
- medicinal (damage to the stomach due to drugs harmful to health);
- endocrine (due to calcium and phosphorus deficiency).
- defect of the intestine, localized in the region of the bulb. As well as the defeat of the intestinal section in the area followed by the duodenum;
- destruction of various gastric areas;
- combined - an ulcer of the stomach and duodenum, which is simultaneously located in several places.
- The acute form is the formation of an ulcer in the gastric zone, which is formed within a short time. This peptic ulcer of the stomach is usually diagnosed in young men.
- An uncomplicated stomach ulcer is a disease that does not pose a threat to human life, but also reduces performance. If you ignore the treatment of this form of the disease, it can flow into an exacerbated pathology.
- Acute peptic ulcer - has symptoms such as: stomach or intestinal bleeding, nausea, heartburn, severe pain and tingling in the right rib area. Requires immediate medical attention.
- Pentrating ulcerative form - the ulcer enters the tissues and organs that are in the neighborhood. The first stage is the ulceration of all layers that make up the organ. The second is the connection with the underlying tissues. And the last - the stage of penetration, which is at the final stage.
- Pyloric stenosis of the stomach is a disease that impairs the entry of food into the stomach and intestines, and also makes the lumen of the digestive tract narrower.
- small in diameter (up to 50 mm);
- medium (from 50 to 200 mm);
- large in size (200–300 mm);
- giant (from 300 mm and more).
- Increased acid content in gastric juice. This is evidenced by the occurrence of a burning sensation in the esophagus, loss of appetite, irritability and other symptoms.
- Decrease in acid concentration. It causes the appearance of fermentation processes in the stomach, unfavorable breath, a large number of gases in the intestines.
- Increased speed of intestinal wall movements and transport of contents through it.
- Slow intestinal motility.
- loss of the ability of the kidneys to produce and excrete urine, which leads to secondary damage to all body systems;
- the death of liver tissue, which causes nodes from scar tissue, and a change in its structure;
- viral inflammatory lesions of the liver;
- diseases of the pancreas, high blood pressure and narrowing of the lumen of the arteries.
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severe variant of the clinical course;
Today, peptic ulcers are getting in the way of more and more people, and the issue of their treatment is even more relevant. But the main factor in the successful cure of the disease is the correct definition of the type of disease. Therefore, the topic of this article is the types of ulcers. And also what species are dangerous to life.
In the most general concept, an ulcer is a scar that is purulent or inflammatory in nature, and is located on the skin or mucous membrane.
In the case of the stomach, an ulcer is a disease that is chronic, with damage to the mucous walls of the stomach.
Breakdown of the disease by common features
Medicine has stepped far in its development and has studied peptic ulcers quite deeply. At the moment, there are many classifications of this disease.
Before moving on to the detailed division, let's highlight the main groups:
Separation of peptic ulcers according to the localization of inflammatory processes
In the most general approach, two types of ulcers can be distinguished according to the place of localization. This is external, located on the body, which can be visually identified, and internal, which is found in the stomach or duodenum. A more detailed distribution of the internal ulcer into subspecies is as follows:
Grouping of ulcers depending on the nature of their manifestation:
Subdivision on the basis of size, formed defects
The classification of peptic ulcer according to the size factor is as follows:
Distinctions on the activity of the stomach and duodenum in case of illness
The concept of an ulcer is similar in essence to the term wound, but the ulcer defect deeply affects the stomach and duodenum, disrupting their performance. A peptic ulcer heals only with the formation of a scar, unlike a wound. There are a number of ulcers, each of which leads to different consequences:
Other varieties
An ulcer is also characterized by individual sensitivity of the patient. Having identified certain pain sensations and symptoms, it is necessary to consult a specialist, since some types of ulcers are unsafe for human life.
Perforated gastric ulcer is a dangerous complication that occurs when a deep hole forms in the wall of the esophagus. The abdominal cavity is significantly inflamed. Such an ailment is dangerous with the possibility of a breakthrough of an ulcer outside the stomach into the abdominal cavity and is accompanied by the release of contents.
The main symptoms are severe pain in the abdominal area, combined with a simultaneous drop in blood pressure, and then vomiting. It occurs due to the general infection of the body with pathogenic microbes that have entered the bloodstream.
The callous variety, as a rule, does not cause scarring for a long time and is extremely dangerous for humans, as it is the cause of stomach cancer. It is characterized by constant pain, increased gastric secretion, nausea and vomiting, weight loss, slowing down of metabolic processes, pallor.
It is impossible to do without surgical intervention for a callous ulcer. If you do not resort to it, then at best it will be possible to eliminate the symptoms only for a short period of time. The callous ulcer is a continuation of the acute one.
Mirror view - the inflammatory process touches the mucous membrane and causes a deepening, which includes several layers of the digestive canal. In this case, there are no symptoms and there are two sources of damage, one on top of the other. At the same time, the right and left walls of the muscle bag are inflamed, which is very risky for life.
Chronic type - the transition from an aggravated form, if scarring does not occur for a long time, it is rather difficult to identify the chronic form. This is possible only with systematic examinations by a doctor.
For functional indigestion, nausea, intense abdominal pain, bad breath and heartburn, think about the possibility of a chronic type of ulcer.
Gastric ulcers resulting from various diseases
The most diverse types of ulcers receive a permanent residence permit in the human body as a result of these pathologies:
Do not forget about these ailments, which are the cause of ulcers. If they are diagnosed in a timely manner and measures are taken, then the treatment of various types of peptic ulcer will not come in handy.
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