Federal Agency for Education
State educational institution
Higher professional education.
Tula State University
Department of Physical Education and Sports.
abstract
Topic:
"Physical Rehabilitation in Peptic Ulcer".
Fulfilled
Student gr.XXXXXX
Checked:
Teacher
Simonova T.A.
Tula, 2006.
Ulcer disease. Facts. Manifestations.
Treatment of peptic ulcer.
Physical rehabilitation for peptic ulcer and complexes of gymnastic exercises.
List of used literature.
1) Peptic ulcer. Data. Manifestations.
Peptic ulcer disease (gastric ulcer, duodenal ulcer) is a disease, the main manifestation of which is the presence of an ulcer in the stomach or duodenum.
Among the population, the spread of peptic ulcer reaches 7-10%. The ratio of stomach ulcers and duodenal ulcers is 1:4. It is more common in men aged 25 - 50 years.
Etiology and pathogenesis
It is not possible to name any single cause of peptic ulcer disease.
Nevertheless, in the etiology, as recently considered, the following main factors play a role:
1. Neuropsychic stress and physical overload.
2. Malnutrition.
3. Biological defects inherited at birth.
4. Some drugs.
5. Smoking and alcohol.
The role of hereditary predisposition is undoubted.
Duodenal ulcers occur predominantly at a young age. Gastric ulcers - in the older.
There is a violation of the secretory and motor function of the stomach. Violation of nervous regulation is essential.
There are substances that also inhibit the function of parietal cells - gastrin and secretin.
These substances are of great importance in the recovery period after peptic ulcer. A large role is also given to the acid factor: an increase in the secretion of hydrochloric acid, which acts aggressively on the mucous membrane. An ulcer does not form without an increase in hydrochloric acid: if there is an ulcer, but there is no hydrochloric acid, it is practically cancer. But the normal mucosa is quite resistant to the action of damaging factors. Therefore, in the pathogenesis, it is also necessary to take into account the protective mechanisms that protect the mucosa from the formation of ulcers. Therefore, in the presence of etiological factors, an ulcer does not form in everyone.
External contributing factors:
1. Alimentary. Negative erosive effect on the mucosa and food that stimulates the active secretion of gastric juice (normally, mucosal injuries heal in 5 days). Spicy, spicy, smoked foods, fresh pastries (pies, pancakes), a large amount of food, most likely cold food, irregular meals, dry food, refined foods, coffee and various hard-to-digest foods that cause irritation of the gastric mucosa.
In general, irregular food intake (at different hours, at long intervals), disrupting the process of digestion in the stomach, can contribute to the development of peptic ulcer, since this excludes the neutralization of the acidic environment of the stomach by food.
2. Smoking - significantly contributes to the development of ulcers. In addition, nicotine causes vasospasm and impaired blood supply to the gastric mucosa.
Alcohol. Although the direct effect of alcohol has not been proven, it has a powerful cocaine effect.
Factors affecting pathogenesis
1. Acid - increased secretion of hydrochloric acid.
2. Reducing the intake of alkaline juice.
3. Violation of coordination between the secretion of gastric juice and alkaline contents.
4. Disturbed composition of the mucous membrane of the epithelium of the stomach (mucoglycoproteins that promote the repair of the mucosa. This substance covers the mucosa with a continuous layer, protecting it from burns).
Ulcer symptoms.
The main complaint of a patient with peptic ulcer is pain in the epigastric region, the appearance of which is associated with food intake: in some cases, pain occurs after half an hour - an hour, in others - 1.5 - 2 hours after eating or on an empty stomach. "Hungry" pains are especially characteristic of duodenal ulcers. They usually disappear after taking, sometimes even a small amount of food. The intensity of pain can be different; often the pain radiates to the back, or up into the chest. In addition to pain, patients are often worried about excruciating heartburn 2-3 hours after eating, due to the throwing of acidic stomach contents into the lower esophagus. Usually heartburn subsides after taking alkaline solutions and milk. Sometimes patients complain of belching, nausea, vomiting; vomiting usually brings relief. All these unpleasant sensations are also associated with eating. When the ulcer is located in the duodenum, "night" pains and constipation are characteristic.
Exacerbations of ulcers and the course of the disease.
Peptic ulcer is characterized by a chronic course with alternating periods of exacerbations and improvements (remissions). Exacerbations often occur in spring and autumn, usually last 1-2 months and are manifested by an increase in the described signs of the disease, often depriving the patient of his ability to work, and in some cases lead to complications:
* Bleeding - the most frequent and serious complications; occurs on average in 15-20% of patients with peptic ulcer and is the cause of almost half of all deaths in this disease. It occurs predominantly in young men. More often with peptic ulcer, so-called small bleeding occurs, massive bleeding is less common. Sometimes sudden massive bleeding is the first manifestation of the disease. Small bleeding is characterized by pallor of the skin, dizziness, weakness; with severe bleeding, melena is noted, single or repeated vomiting, vomit resembles coffee grounds;
* Perforation is one of the most severe and dangerous complications, which occurs in approximately 7% of peptic ulcer cases. It is more often observed with a duodenal ulcer. However, this complication of gastric ulcer is accompanied by higher mortality and a higher rate of postoperative complications. The vast majority of perforations of gastric and duodenal ulcers are so-called free perforations into the abdominal cavity. Often occurs after eating a large meal. It is manifested by a sudden sharp (dagger) pain in the upper abdomen. The suddenness and intensity of the pain is not so pronounced in any other condition. The patient takes a forced position with knees pulled up to the stomach, tries not to move;
* Penetrations are characterized by the penetration of an ulcer into the organs in contact with the stomach or duodenal bulb - the liver, pancreas, lesser omentum. The clinical picture in the acute period resembles perforation, but the pain is less intense. Soon, signs of damage to the organ into which the penetration occurred (girdle pain and vomiting with damage to the pancreas, pain in the right shoulder and in the back during penetration into the liver, etc.) join. In some cases, penetration occurs gradually;
* Stenosis of the gastrointestinal tract (as a result of cicatricial deformity);
* Degeneration into a malignant tumor or malignancy - observed almost exclusively in the localization of an ulcer in the stomach, malignancy of duodenal ulcers is very rare. With malignancy of the ulcer, pain becomes constant, loses connection with food intake, appetite decreases, exhaustion increases, nausea and vomiting become more frequent.
In this case, a change in the nature of pain can be a sign of the development of complications.
Peptic ulcer in adolescents and young adults usually occurs against the background of a pre-ulcerative condition (gastritis, gastroduodenitis), is characterized by more pronounced symptoms, a high level of acidity, increased motor activity of the stomach and duodenum, often the first sign of the disease is gastrointestinal bleeding.
Peptic ulcer in the elderly and senile age occurs against the background of an increasing decrease in the functions of the gastric mucosa, especially due to impaired blood circulation in the vessels. It is often preceded by chronic inflammatory processes in the stomach and duodenum. Ulcers in elderly and senile people are more often localized in the stomach. In persons older than 60 years, gastric localization of the ulcer occurs 3 times more often than in young and middle-aged patients.
Gastric ulcers that have arisen in the elderly and senile age are of considerable size (giant ulcers are often found), a shallow bottom covered with a gray-yellow coating, fuzzy and bleeding edges, edema, and slow healing of the ulcer.
Peptic ulcer in people in the elderly and senile age often proceeds according to the type of gastritis and is characterized by short duration, mild pain syndrome, and the absence of its clear connection with food intake. Patients complain of a feeling of heaviness, fullness in the stomach, diffuse aching pain in the epigastric region without a clear localization, radiating to the right and left hypochondrium, to the sternum, to the lower abdomen. Disorders are manifested by belching, nausea; heartburn and vomiting are less common. Characterized by constipation, loss of appetite and weight loss. The tongue is heavily coated. The course of the disease is characterized by monotony, the absence of a clear periodicity and seasonal exacerbation; in most patients, it is aggravated by other chronic diseases of the digestive system - cholecystitis, hepatitis, pancreatitis, enterocolitis, as well as chronic coronary heart disease, hypertension, atherosclerosis, cardiovascular insufficiency and pulmonary heart failure. In elderly and senile patients, there is a slowdown in the duration of ulcer scarring, and the frequency of complications increases. Bleeding occurs most frequently; perforation are much less common, and malignancy of the ulcer is much more common than in young and middle-aged people.
Some differences between gastric ulcer and duodenal ulcer.
Clinical signs
Duodenal ulcer
Over 40 years old
Male predominate
No gender differences
Night, hungry
Immediately after eating
normal, elevated
Anorexia
Body mass
COMPLEX PHYSICAL REHABILITATION OF PATIENTS WITH GASTRIC ULCER AND DUODENAL ULCER AT THE STATION STAGE
Introduction
Chapter 1. General characteristics of peptic ulcer of the stomach and duodenum
1.1 Anatomical and physiological features of the stomach and duodenum
1.2 Etiology and pathogenesis of peptic ulcer of the stomach and duodenum
1.3 Classification and clinical characteristics of peptic ulcer of the stomach and duodenum
Chapter 2. Comprehensive physical rehabilitation of patients with peptic ulcer of the stomach and duodenum
2.1 General characteristics of the means of physical rehabilitation for peptic ulcer of the stomach and duodenum
2.2 Exercise therapy in the physical rehabilitation of patients with gastric and duodenal ulcers
2.2.1 Mechanisms of the therapeutic effect of physical exercises in gastric and duodenal ulcers
2.2.2 Purpose, tasks, means, forms, methods and techniques of exercise therapy for peptic ulcer of the stomach and duodenum at the stationary stage
2.3 Therapeutic massage for peptic ulcer of the stomach and duodenum
2.4 Physiotherapy for this pathology
Chapter 3. Evaluation of the effectiveness of physical rehabilitation in gastric and duodenal ulcer
List of used literature
INTRODUCTION
The urgency of the problem. In the general structure of diseases of the digestive system, the pathology of the stomach and duodenum occupies a leading place. In about 60-70% of adults, the formation of peptic ulcer, chronic gastritis, duodenitis begins in childhood and adolescence, but they are especially common at a young age (20-30 years) and mainly in men.
Peptic ulcer is a chronic, relapsing disease prone to progression, with involvement in the pathological process along with the stomach and duodenum (in which ulcerative defects of the mucous membrane are formed during periods of exacerbation) of other organs of the digestive system, the development of complications that threaten the life of the patient.
Peptic ulcer of the stomach and duodenum is one of the most common diseases of the gastrointestinal tract. Available statistics indicate a high percentage of patients in all countries. Up to 20% of the adult population suffers from this disease throughout their lives. In industrialized countries, peptic ulcer affects 6-10% of the adult population, with duodenal ulcers predominating compared to gastric ulcers. About 5 million people are registered in Ukraine with gastric and duodenal ulcers. Peptic ulcer of the stomach and duodenum affects people in the most able-bodied age - from 20 to 50 years. The disease is more common in men than in women (the ratio of men and women is 4:1). At a young age, a duodenal ulcer is more common, at an older age - a stomach ulcer. Among urban residents, peptic ulcer is more common than among the rural population.
At present, given the urgency of the problem, its not only medical but also social significance, the pathology of the stomach and duodenum, pathogenesis, new methods of diagnosis, treatment and prevention of stomach diseases attract the attention of not only clinicians-therapists, but in connection with a significant "rejuvenation » diseases and pediatricians, and geneticists, pathophysiologists, immunologists, specialists in physical rehabilitation.
Significant experience has been accumulated in the study of peptic ulcer of the stomach and duodenum. Meanwhile, many aspects of this problem have not yet been resolved. In particular, the issues of using physical rehabilitation means in the complex treatment of this disease are very relevant. In this regard, there is a need for continuous improvement of the means, forms, methods and techniques of therapeutic physical culture and therapeutic massage, which led to the choice of this research topic.
Objective - to develop an integrated approach to the physical rehabilitation of patients with gastric and duodenal ulcers at the inpatient stage of rehabilitation treatment.
To achieve this goal, the following tasks:
1. To study and analyze the literature on the problem of physical rehabilitation of patients with gastric and duodenal ulcers.
2. To characterize the anatomical and physiological features of the stomach and duodenum.
3. To reveal the etiology, pathogenesis, classification and clinic of peptic ulcer of the stomach and duodenum.
4. Draw up a program of complex physical rehabilitation of persons with gastric and duodenal ulcers, taking into account the period of the course of the disease and the stage of rehabilitation.
5. Describe methods for evaluating the effectiveness of exercise therapy in gastric and duodenal ulcers.
The novelty of the work is that we have compiled a program of complex physical rehabilitation of persons with gastric and duodenal ulcers, taking into account the period of the course of the disease and the stage of rehabilitation.
Practical and theoretical significance. The program of complex physical rehabilitation of patients with peptic ulcer of the stomach and duodenum presented in the work can be used in medical institutions, as well as in the educational process for training specialists in physical rehabilitation in the discipline "Physical rehabilitation for diseases of internal organs".
Scope and structure of work. The work is written on 77 pages of computer layout and consists of an introduction, 3 chapters, conclusions, practical recommendations, a list of references (59 sources). In the work there is 1 table, 2 drawings and 3 sets of therapeutic exercises.
CHAPTER 1. GENERAL CHARACTERISTICS OF Peptic ulcer of the stomach and duodenum
1.1 Anatomical and physiological features of the stomach and duodenum
The stomach is the most important organ of the digestive system. It represents the widest part of the digestive tract. It is located in the upper abdomen, mainly in the left hypochondrium. Its initial section is connected to the esophagus, and the final section is connected to the duodenum.
Fig.1.1. Stomach
The shape, volume and position of the human stomach are highly variable. They can change at different times of the day and night, depending on the filling of the stomach, the degree of contraction of its walls, the phases of digestion, body position, individual structural features of the body, the state and effect of neighboring organs - the liver, spleen, pancreas and intestines. The stomach with increased contraction of the walls often has the shape of a bull's horn, or siphon, with reduced contractility of the walls and its omission - the shape of a bowl.
As food moves through the esophagus, the volume of the stomach decreases and its walls contract. Therefore, to fill the stomach during X-ray examination, it is enough to introduce 400-500 ml of a contrast suspension in order to get an idea of all its departments. The length of the stomach with an average degree of filling is 14-30, the width is from 10 to 16 cm.
Several sections are distinguished in the stomach: the initial (cardiac) - the place where the esophagus passes into the stomach, the body of the stomach - its middle part and the output (pyloric, or pylorus), adjacent to the duodenum. There are also anterior and posterior walls. The border along the upper edge of the stomach is short, concave. It is called the lesser curvature. On the lower edge - convex, more elongated. This is the greater curvature of the stomach.
In the wall of the stomach on the border with the duodenum there is a thickening of muscle fibers, circularly arranged in the form of a ring and forming a locking apparatus (pylorus), closing the exit from the stomach. The same, but less pronounced obturator apparatus (pulp) is present at the junction of the esophagus into the stomach. Thus, with the help of locking mechanisms, the stomach is limited from the esophagus and duodenum.
The activity of the locking apparatus is regulated by the nervous system. When a person swallows food, reflexively, under the influence of irritation of the walls of the esophagus by food masses passing through the throat, the pulp opens, located in the initial section of the stomach, and food passes from the esophagus to the stomach in a certain rhythm. At this time, the pylorus, located in the outlet section of the stomach, is closed, and food does not enter the duodenum. After the food masses stay in the stomach and are processed by gastric juices, the pylorus of the output section opens, and the food passes into the duodenum in separate portions. At this time, the pulp of the initial section of the stomach is closed. Such a harmonious activity of the pylorus and cardiac sphincter ensures normal digestion, and food intake causes pleasant sensations and pleasure.
If the gastric obturator apparatus is narrowed under the influence of cicatricial, ulcerative or tumor processes, a severe painful condition develops. With the narrowing of the pulp of the initial section of the stomach, the act of swallowing is disturbed. Food stays in the esophagus. The esophagus is stretched. Food is putrefied and fermented. When the pylorus narrows, food does not enter the duodenum, but stagnates in the stomach. It stretches, gases and other products of decay and fermentation accumulate.
In case of violation of the innervation of the stomach or damage to its muscular membrane, the sphincter ceases to fulfill its obturator role. They gape constantly. Acidic stomach contents can back up into the esophagus and cause discomfort.
The walls of the stomach consist of 3 membranes: external serous, middle muscular and internal mucosa. The mucous membrane of the stomach is the most important part of it, which plays a leading role in digestion. At rest, the mucous membrane is whitish, in the active state it is reddish. The thickness of the mucous membrane is not the same. It is maximum in the outlet section, gradually thins out and is equal to 0.5 mm in the initial part of the stomach.
The stomach is richly supplied with blood and innervated. The nerve plexuses are located in the thickness of its walls and outside the organ.
As noted, the stomach performs important functions for the body. Due to the presence of a developed muscular and mucous membranes, a closing apparatus and special glands, it plays the role of a depot, where food coming through the esophagus from the oral cavity accumulates, its initial digestion and partial absorption take place. In addition to the depositing role, the stomach performs other important functions. Of these, the main one is the physical and chemical processing of food and its gradual rhythmic transportation in small portions to the intestines. This is carried out by the coordinated motor and secretory activity of the stomach.
The stomach performs another important function. It absorbs water in small amounts, some soluble substances (sugar, salt, protein products, iodine, bromine, vegetable extracts). Fats, starch, etc. are not absorbed in the stomach.
The excretory function of the stomach has been known for a long time. In severe kidney disease, a large amount of waste accumulates in the blood. The gastric mucosa partially secretes them: urea, uric acid and other nitrogenous substances, as well as dyes alien to the body. It turned out that the higher the acidity of gastric juice, the faster the accepted dyes are released.
Therefore, the stomach is involved in the day-to-day metabolism. It partially removes from the body products formed as a result of the breakdown of proteins that are not used by the body and can cause poisoning. The stomach affects the water-salt metabolism, to maintain a constant acid-base balance, which is very important for the body.
The effect of the stomach on the functional state of other organs has been established. The reflex effect of the stomach on the gallbladder and bile ducts, intestines, kidneys, cardiovascular system and central nervous system has been proven. These organs also affect the function of the stomach. This relationship leads to dysfunction of the stomach in case of diseases of other organs, and vice versa, diseases of the stomach can cause diseases of other organs.
Thus, the stomach is an important organ for normal digestion and vital activity, which has a complex structure and performs numerous functions.
Such diverse functions provide the stomach with one of the leading places in the digestive system. On the other hand, violations of its function are fraught with serious diseases.
1.2 Etiology and pathogenesis of peptic ulcer of the stomach and duodenum
Currently, a group of factors has been identified that predispose to the development of gastric and duodenal ulcers.
I group associated with functional and morphological changes in the stomach and duodenum, leading to disruption of gastric digestion and a decrease in mucosal resistance, followed by the formation of a peptic ulcer.
II group includes disorders of regulatory mechanisms: nervous and hormonal.
III group - characterized by constitutional and hereditary features.
IV group - associated with the influence of environmental factors.
Group V - associated with comorbidities and drugs.
Currently, a number of exogenous and endogenous factors are known that contribute to the emergence and development of gastroduodenal ulcers.
To exogenous factors relate:
malnutrition;
Bad habits (smoking, alcohol);
Neuropsychic overstrain;
Occupational factors and lifestyle;
Medicinal effects (the following drugs have the greatest damaging effect on the gastric mucosa: nonsteroidal anti-inflammatory drugs - aspirin, indomethacin, corticosteroids, antibacterial agents, iron, potassium, etc.).
To endogenous factors relate:
genetic predisposition;
Chronic Helicobacter pylori gastritis;
Metaplasia of the gastric epithelium of the duodenum, etc.
Among them, the most significant is hereditary predisposition. It is detected in patients with duodenal ulcers in 30-40% and much less often in gastric ulcers. It has been established that the prevalence of peptic ulcer in relatives of probands is 5-10 times higher than in relatives of healthy people (FI Komarov, AV Kalinin, 1995). Hereditary ulcers are more likely to become aggravated and more likely to bleed. The predisposition to duodenal ulcer is transmitted through the male line.
There are the following peptic ulcer genetic markers:
An increased number of parietal cells in the glands of the stomach and, as a result, a persistently high level of hydrochloric acid in gastric juice; high serum levels of pepsinogens I, II and the so-called "ulcerogenic" fraction of pepsinogen in the gastric contents;
Increased release of gastrin in response to food intake; increased sensitivity of parietal cells to gastrin and disruption of the feedback mechanism between the production of hydrochloric acid and the release of gastrin;
The presence of O (I) blood types, which increases the risk of developing duodenal ulcers by 35% compared with individuals with other blood types;
Genetically determined deficiency in gastric mucus of fucoglycoproteins - the main gastroprotectors;
Violation of the production of secretory immunoglobulin A;
Absence of the intestinal component and a decrease in the alkaline phosphatase B index.
The main etiological factors of gastric ulcer and duodenal ulcer are the following:
infection helicobacteria. Currently, this factor is recognized by most gastroenterologists as the leading factor in the development of peptic ulcer. Helicobacter pylori infection is one of the most common infections. This microorganism is the cause of chronic Helicobacter pylori gastritis, as well as a leading factor in the pathogenesis of gastric and duodenal ulcers, low-grade gastric lymphoma and gastric cancer. Helicobacteria are considered class I carcinogens. The occurrence of duodenal ulcers in almost 100% of cases is associated with infection and colonization of Helicobacter pylori, and gastric ulcers are caused by this microorganism in 80-90% of cases
Acute and chronic psycho-emotional stressful situations. Domestic pathophysiologists have long paid great attention to this etiological factor in the development of peptic ulcer. With the clarification of the role of Helicobacter pylori, neuropsychic stressful situations began to be given much less importance, and some scientists began to believe that peptic ulcer disease was not associated with this factor at all. However, clinical practice knows many examples of the leading role of nervous shocks, psycho-emotional stress in the development of peptic ulcer and its exacerbations. The theoretical and experimental substantiation of the great importance of the neuropsychic factor in the development of peptic ulcer was made in the fundamental works of G. Selye on the general adaptation syndrome and the effect of "stress" on the human body.
Alimentary factor. At present, it is believed that the role of the alimentary factor in the development of gastric ulcer and duodenal ulcer is not only not decisive, but has not been strictly proven at all. However, irritating, very spicy, spicy, rough, too hot or cold foods are supposed to cause excessive gastric secretion, including excess production of hydrochloric acid. This may contribute to the implementation of the ulcerogenic action of other etiological factors.
Abuse of alcohol and coffee, smoking. The role of alcohol and smoking in the development of peptic ulcer has not been conclusively proven. The leading role of these factors in ulcerogenesis is problematic, if only because peptic ulcer disease is very common among people who do not drink alcohol and do not smoke, and, conversely, does not always develop in those who suffer from these bad habits.
However, it has been definitely established that in smokers, peptic ulcer of the stomach and duodenum occurs 2 times more often than in non-smokers. Nicotine causes vasoconstriction of the stomach and ischemia of the gastric mucosa, enhances its secretory capacity, causes hypersecretion of hydrochloric acid, increases the concentration of pepsinogen-I, accelerates the evacuation of food from the stomach, reduces pressure in the pyloric region and creates conditions for the formation of gastroduodenal reflux. Along with this, nicotine inhibits the formation of the main protective factors of the gastric mucosa - gastric mucus and prostaglandins, and also reduces the secretion of pancreatic bicarbonates.
Alcohol also stimulates the secretion of hydrochloric acid and disrupts the formation of protective gastric mucus, significantly reduces the resistance of the gastric mucosa and causes the development of chronic gastritis.
Excessive coffee consumption has an adverse effect on the stomach, due to the fact that caffeine stimulates the secretion of hydrochloric acid and contributes to the development of ischemia of the gastric mucosa.
Alcohol abuse, coffee and smoking may not be the root causes of gastric ulcer and duodenal ulcer, but undoubtedly predispose to its development and cause an exacerbation of the disease (especially alcohol excesses).
The influence of drugs. There is a whole group of drugs that can cause the development of an acute stomach ulcer or (less commonly) duodenal ulcer. These are acetylsalicylic acid and other non-steroidal anti-inflammatory drugs (primarily indomethacin), reserpine, glucocorticoids.
At present, a point of view has been formed that the above drugs cause the development of an acute stomach or duodenal ulcer or contribute to the exacerbation of a chronic ulcer.
As a rule, after discontinuation of the drug ulcerogenic drug, the ulcers heal quickly.
Diseases that contribute to the development of peptic ulcer. The following diseases contribute to the development of peptic ulcer:
Chronic obstructive bronchitis, bronchial asthma, pulmonary emphysema (with these diseases developing respiratory failure, hypoxemia, ischemia of the gastric mucosa and a decrease in the activity of its protective factors);
Diseases of the cardiovascular system, accompanied by the development of hypoxemia and ischemia of organs and tissues, including the stomach;
Cirrhosis of the liver;
Diseases of the pancreas.
Pathogenesis. Currently, it is generally accepted that peptic ulcer of the stomach and duodenum 12 develops as a result of an imbalance between the factors of aggression of gastric juice and the factors of protection of the mucous membrane of the stomach and duodenum 12 in the direction of the predominance of aggression factors (Table 1.1.). Normally, the balance between the factors of aggression and defense is maintained by the coordinated interaction of the nervous and endocrine systems.
Pathogenesis of peptic ulcer according to Ya. D. Vitebsky. The basis of the development of peptic ulcer according to Ya. D. Vitebsky (1975) is a chronic violation of duodenal patency and duodenal hypertension. There are the following forms of chronic violation of duodenal patency:
Arteriomesenteric compression (compression of the duodenum by the mesenteric artery or mesenteric lymph nodes);
Distal periduodenitis (as a result of an inflammatory and cicatricial lesion of the Treitz ligament);
Proximal periunit;
Proximal periduodenitis;
Total cicatricial periduodenitis.
With subcompensated chronic violation of duodenal patency (depletion of motility of the 12th intestine and an increase in pressure in it), functional insufficiency of the pylorus develops, antiperistaltic movements of the duodenum 12, episodic discharge of duodenal alkaline contents with bile into the stomach. In connection with the need to neutralize it, the production of hydrochloric acid increases, this is facilitated by the activation of gastrin-producing cells by bile and an increase in gastrin secretion. Acidic gastric contents enter the duodenum, causing the development of duodenitis first, then duodenal ulcers.
Table 1.1 The role of aggressive and protective factors in the development of peptic ulcer (according to E.S. Ryss, Yu.I. Fishzon-Ryss, 1995)
|
Protective factors: |
Aggressive factors: |
|
|
Resistance of the gastroduodenal system: Protective mucus barrier; Active regeneration of the surface epithelium; Optimal blood supply. 2. Antroduodenal acid brake. 3. Anti-ulcerogenic nutritional factors. 4. Local synthesis of protective prostaglandins, endorphins and enkephalins. |
1. Hyperproduction of hydrochloric acid and pepsin not only during the day, but also at night: Hyperplasia of parietal cells; Chief cell hyperplasia; Vagotonia; Increased sensitivity of the gastric glands to nervous and humoral regulation. 2. Helicobacter pylori infection. 3. Proulcerogenic alimentary factors. 4. Duodenogastric reflux, gastroduodenal dysmotility. 5. Reverse diffusion of H + . 6. Autoimmune aggression. |
|
|
Neuroendocrine regulation, genetic factors |
With decompensated chronic violation of duodenal patency (depletion of duodenal motility, duodenal stasis), constant gaping of the pylorus and reflux of duodenal contents into the stomach are observed. It does not have time to neutralize, alkaline contents dominate in the stomach, intestinal metaplasia of the mucous membrane develops, the detergent effect of bile on the protective layer of mucus is manifested and a stomach ulcer is formed. According to Ya. D. Vitebsky, a chronic violation of duodenal patency is present in 100% of patients with gastric ulcer, and in 97% of patients with duodenal ulcer.
1.3 Classification and clinical characteristics of peptic ulcer of the stomach and duodenum
Classification of peptic ulcer of the stomach and duodenum (P. Ya. Grigoriev, 1986)
I. Localization of the ulcer.
1. Gastric ulcer.
Cardiac and subcardiac parts of the stomach.
Mediogastric.
Antral department.
Pyloric canal and prepyloric section or lesser and greater curvature.
2. Duodenal ulcer.
2.1. Bulbar localization.
2.2 Postbulbar localization.
2.2.1. Proximal duodenum 12.
2.2.2. Distal duodenum 12.
II. The phase of the course of the disease.
1. Aggravation.
2. Relapse.
3. Decaying exacerbation.
4. Remission.
III. The nature of the flow.
1. First identified.
2. Latent flow.
3. Light flow.
Medium severity.
Severe or continuously relapsing course. IV. Ulcer sizes.
1. Small ulcer - up to 0.5 cm in diameter.
2. Large ulcer - more than 1 cm in the stomach and 0.7 cm in the duodenal bulb.
3. Giant - more than 3 cm in the stomach and more than 1.5-2 cm in the duodenum.
4. Superficial - up to 0.5 cm in depth from the level of the gastric mucosa.
5. Deep - more than 0.5 cm in depth from the level of the gastric mucosa.
V. Stage of ulcer development (endoscopic).
1. Stage of an increase in ulcers and an increase in inflammation.
The stage of the greatest magnitude and the most pronounced signs of inflammation.
Stage of subsidence of endoscopic signs of inflammation.
Ulcer reduction stage.
The stage of ulcer closure and scar formation.
Scar stage.
VI. The state of the mucous membrane of the gastroduodenal zone, indicating the location and degree of activity.
VII. Violation of the secretory function of the stomach.
VIII. Violation of the motor-evacuation function of the stomach and duodenum.
1. Hypertonic and hyperkinetic dysfunction.
2. Hypotonic and hypokinetic function.
3. Duodenogastric reflux.
IX. Complications of peptic ulcer.
1. Bleeding.
2.Perforation.
3. Penetration indicating the organ.
4. Perivisceritis.
5. Stenosis of the pylorus.
6. Reactive pancreatitis, hepatitis, cholecystitis.
7. Malignancy.
X. Timing of ulcer scarring.
1.Usual terms of scarring (duodenal ulcer - 3-4 weeks, gastric ulcer - 6-8 weeks).
2. Long-term non-scarring (duodenal ulcer - more than 4 weeks, gastric ulcer - more than 8 weeks).
The severity of the course of peptic ulcer.
1. Light form (mild severity) - characterized by the following features:
* exacerbation is observed 1 time in 1-3 years;
* the pain syndrome is moderate, the pain stops in 4-7 days;
* the ulcer is shallow;
*in the phase of remission, the ability to work is preserved.
2. The form of moderate severity has the following criteria:
* relapses (exacerbations) are observed 2 times a year;
* the pain syndrome is expressed, the pains are stopped in the hospital for
* characteristic dyspeptic disorders;
* the ulcer is deep, often bleeds, accompanied by the development
perigastritis, periduodenitis.
3. The severe form is characterized by the following features:
* relapses (exacerbations) are observed 2-3 times a year and more often;
* the pain is pronounced, it stops in the hospital in 10-14 days
(sometimes longer);
* sharply expressed dyspeptic phenomena, weight loss;
* the ulcer is often complicated by bleeding, the development of pyloric stenosis, perigastritis, periduodenitis.
Clinical characteristics of peptic ulcer of the stomach and duodenum.
Preulcer period. In most patients, the development of a typical clinical picture of the disease with a formed stomach and duodenal ulcer is preceded by a pre-ulcerative period (VM Uspensky, 1982). The pre-ulcerative period is characterized by the appearance of ulcer-like symptoms, however, during the endoscopic examination, it is not possible to determine the main pathomorphological substrate of the disease - an ulcer. Patients in the pre-ulcerative period complain of pain in the epigastric region on an empty stomach ("hungry" pains), at night ("night" pains) 1.5-2 hours after eating, heartburn, belching sour.
On palpation of the abdomen, there is local pain in the epigastrium, mainly on the right. A high secretory activity of the stomach (hyperaciditas), an increased content of pepsin in gastric juice on an empty stomach and between meals, a significant decrease in antroduodenal pH, accelerated evacuation of gastric contents into the duodenum (according to FEGDS and fluoroscopy of the stomach) are determined.
As a rule, such patients have chronic Helicobacter pylori gastritis in the pyloric region or gastroduodenitis.
Not all researchers agree with the allocation of the pre-ulcerative period (state). A. S. Loginov (1985) proposes to name patients with the above symptom complex as an increased risk group for peptic ulcer.
Typical clinical picture.
subjective manifestations. The clinical picture of peptic ulcer has its own characteristics associated with the localization of the ulcer, the age of the patient, the presence of concomitant diseases and complications. Nevertheless, in any situation, the leading subjective manifestations of the disease are pain and dyspeptic syndromes.
Pain syndrome. Pain is the main symptom of peptic ulcer and is characterized by the following features.
Localization of pain. As a rule, pain is localized in the epigastric region, and with a stomach ulcer - mainly in the center of the epigastrium or to the left of the midline, with a duodenal ulcer and prepyloric zone - in the epigastrium to the right of the midline.
With ulcers of the cardiac part of the stomach, atypical localization of pain behind the sternum or to the left of it (in the precordial region or the region of the apex of the heart) is quite often observed. In this case, a thorough differential diagnosis with angina pectoris and myocardial infarction should be carried out with the obligatory performance of an electrocardiographic study. When the ulcer is localized in the postbulbar region, pain is felt in the back or right epigastric region.
Time of onset of pain. In relation to the time of eating, pains are distinguished early, late, nocturnal and "hungry". Pain that occurs 0.5-1 hour after eating is called early, their intensity gradually increases; pains disturb the patient for 1.5-2 hours and then, as the gastric contents are evacuated, they gradually disappear. Early pain is characteristic of ulcers localized in the upper sections of the stomach.
Late pains appear 1.5-2 hours after eating, nocturnal - at night, hungry - 6-7 hours after eating and stop after the patient eats again, drinks milk. Late, nocturnal, hungry pains are most characteristic of the localization of the ulcer in the antrum and duodenum 12. Hunger pains are not observed in any other disease.
It should be remembered that late pain can also be with chronic pancreatitis, chronic enteritis, and nighttime pain with pancreatic cancer.
The nature of the pain. Half of the patients have pain of low intensity, dull, in about 30% of cases intense. Pain can be aching, boring, cutting, cramping. The pronounced intensity of the pain syndrome during exacerbation of peptic ulcer requires differential diagnosis with an acute abdomen.
Periodicity of pain. Peptic ulcer disease is characterized by periodic occurrence of pain. The exacerbation of peptic ulcer lasts from several days to 6-8 weeks, then the remission phase begins, during which the patients feel well, they do not worry about pain.
Relief of pain. Characterized by a decrease in pain after taking antacids, milk, after eating (“hungry” pains), often after vomiting.
Seasonality of pain. Exacerbations of peptic ulcer are more often observed in spring and autumn. This "seasonality" of pain is especially characteristic of duodenal ulcers.
The appearance of pain in peptic ulcer is due to:
irritation with hydrochloric acid of sympathetic nerve endings in the bottom of the ulcer;
motor disorders of the stomach and duodenum (pylorospasm and duodenospasm are accompanied by increased pressure in the stomach and increased contraction of its muscles);
vasospasm around the ulcer and the development of mucosal ischemia;
Decrease in the threshold of pain sensitivity in case of inflammation of the mucous membrane.
dyspeptic syndrome. Heartburn is one of the most common and characteristic symptoms of peptic ulcer. It is caused by gastroesophageal reflux and irritation of the esophageal mucosa by gastric contents rich in hydrochloric acid and pepsin.
Heartburn can occur at the same time after a meal as the pain. But in many patients it is not possible to note the connection of heartburn with food intake. Sometimes heartburn may be the only subjective manifestation of peptic ulcer disease.
Therefore, with persistent heartburn, it is advisable to do FEGDS to exclude peptic ulcer. However, we must remember that heartburn can be not only with peptic ulcer, but also with calculous cholecystitis, chronic pancreatitis, gastroduodenitis, isolated insufficiency of the cardiac sphincter, diaphragmatic hernia. Persistent heartburn can also occur with pyloric stenosis due to increased intragastric pressure and the manifestation of gastroesophageal reflux.
Belching is a fairly common symptom of peptic ulcer disease. The most characteristic eructation is sour, more often it occurs with mediogastric than with duodenal ulcer. The appearance of belching is due to both insufficiency of the cardia and antiperistaltic contractions of the stomach. It should be remembered that belching is also extremely characteristic of diaphragmatic hernia.
Vomiting and nausea. As a rule, these symptoms appear in the period of exacerbation of peptic ulcer. Vomiting is associated with increased vagal tone, increased gastric motility and gastric hypersecretion. Vomiting occurs at the “height” of pain (during the period of maximum pain), vomit contains acidic gastric contents. After vomiting, the patient feels better, the pain is significantly weakened and even disappear. Repeatedly repeated vomiting is characteristic of pyloric stenosis or severe pylorospasm. Patients often induce vomiting themselves to alleviate their condition.
Nausea is characteristic of mediogastric ulcers (but usually associated with concomitant gastritis), and is also often observed with postbulbar ulcers. At the same time, nausea, as E. S. Ryss and Yu. I. Fishzon-Ryss (1995) point out, is completely “uncharacteristic of a duodenal ulcer and rather even contradicts such a possibility.”
Appetite in peptic ulcer is usually good and may even be increased. With a pronounced pain syndrome, patients try to eat rarely and even refuse to eat because of the fear of pain after eating. Decreased appetite is much less common.
Violation of the motor function of the large intestine.
In half of patients with peptic ulcer, constipation is observed, especially during the period of exacerbation of the disease. Constipation is due to the following reasons:
* spastic contractions of the colon;
* diet, poor vegetable fiber and the absence, as a result, of intestinal stimulation;
* decrease in physical activity;
* taking antacids calcium carbonate, aluminum hydroxide.
Data from an objective clinical study. On examination, asthenic (more often) or normosthenic body type attracts attention. Hypersthenic type and overweight are not typical for patients with peptic ulcer.
Signs of autonomic dysfunction with a clear predominance of the vagus nerve tone are extremely characteristic: cold, wet palms, marbling of the skin, distal extremities; tendency to bradycardia; tendency to arterial hypotension. The tongue of patients with peptic ulcer is usually clean. With concomitant gastritis and severe constipation, the tongue may be lined.
Palpation and percussion of the abdomen with uncomplicated peptic ulcer reveals the following symptoms:
Moderate, and in the period of exacerbation, severe pain in the epigastrium, as a rule, localized. With a stomach ulcer, pain is localized in the epigastrium along the midline or on the left, with a duodenal ulcer - more on the right;
percussion tenderness - a symptom of Mendel. This symptom is detected by jerky percussion with a finger bent at a right angle along symmetrical parts of the epigastric region. According to the localization of the ulcer with such percussion, local, limited soreness appears. Sometimes the pain is more pronounced on inspiration. Mendel's symptom usually indicates that the ulcer is not limited to the mucous membrane, but is localized within the wall of the stomach or duodenum with the development of the periprocess;
local protective tension of the anterior abdominal wall, more characteristic of a duodenal ulcer during an exacerbation of the disease. The origin of this symptom is explained by irritation of the visceral peritoneum, which is transmitted to the abdominal wall by the mechanism of the viscero-motor reflex. As the exacerbation stops, the protective tension of the abdominal wall progressively decreases.
Diagnostics. To make a correct diagnosis, the following signs must be considered.
Main:
1) characteristic complaints and a typical ulcer history;
2) detection of an ulcer during gastroduodenoscopy;
3) identification of the "niche" symptom during X-ray examination.
Additional:
1) local symptoms (pain points, local muscle tension in the epigastrium);
2) changes in basal and stimulated secretion;
3) "indirect" symptoms during X-ray examination;
4) hidden bleeding from the digestive tract.
Treatment of peptic ulcer. The complex of rehabilitation measures includes medicines, motor regimen, exercise therapy and other physical methods of treatment, massage, therapeutic nutrition. Exercise therapy and massage improve or normalize neuro-trophic processes and metabolism, helping to restore the secretory, motor, absorption and excretory functions of the digestive canal.
Conservative treatment of peptic ulcer is always complex, differentiated, taking into account the factors contributing to the disease, pathogenesis, localization of the ulcer, the nature of clinical manifestations, the degree of dysfunction of the gastroduodenal system, complications and concomitant diseases.
During the period of exacerbation, patients should be hospitalized as early as possible, since it has been established that with the same treatment method, the duration of remission is higher in patients treated in a hospital. Treatment in a hospital should be carried out until the ulcer is completely scarred. However, by this time, gastritis and duodenitis still persist, and therefore treatment should be continued for another 3 months on an outpatient basis.
The antiulcer course includes: 1) elimination of factors contributing to the recurrence of the disease; 2) medical nutrition; 3) drug therapy; 4) physical methods of treatment (physiotherapy, hyperbaric oxygen therapy, acupuncture, laser therapy, magnetotherapy).
Elimination of factors contributing to the recurrence of the disease provides for the organization of regular meals, optimization of working and living conditions, a categorical prohibition of smoking and alcohol consumption, and a prohibition of taking medications with an ulcerogenic effect.
Therapeutic nutrition is provided by the appointment of a diet that should contain the physiological norm of protein, fat, carbohydrates and vitamins. Provision is made for compliance with the principles of mechanical, thermal and chemical sparing (table No. 1A, diet No. 1 according to Pevzner).
Drug therapy has as its goal: a) suppression of excess production of hydrochloric acid and penim or their neutralization and adsorption; b) restoration of the motor-evacuation function of the stomach and duodenum; c) protection of the mucous membrane of the stomach and duodenum and treatment of helicobacteriosis; d) stimulation of the processes of regeneration of cellular elements of the mucous membrane and relief of inflammatory-dystrophic changes in it.
Physical methods of treatment - thermal procedures during the period of exacerbation subsiding (applications of paraffin, ozocerite) with an uncomplicated course of the disease and no signs of hidden bleeding.
With long-term non-scarring ulcers, especially in elderly and senile patients, laser irradiation of the ulcer defect is used (through a fibrogastroscope), 7-10 irradiation sessions significantly shorten the scarring time.
In some cases, there is a need for surgical treatment. Surgical treatment is indicated for patients with peptic ulcer disease with frequent relapses with continuous therapy with maintenance doses of antiulcer drugs.
During the period of remission of peptic ulcer, it is necessary: 1) exclusion of ulcerogenic factors (cessation of smoking, drinking alcohol, strong tea and coffee, drugs from the group of salicylates and pyrazolone derivatives); 2) compliance with the regime of work and rest, diet; 3) sanatorium treatment; 4) dispensary observation with secondary prevention
Patients with newly diagnosed or rarely recurrent peptic ulcer should undergo seasonal (spring-autumn) prophylactic courses of treatment lasting 1-2 months.
Prevention. Distinguish between primary and secondary prevention of peptic ulcer disease. Primary prevention is aimed at active early detection and treatment of pre-ulcerative conditions (functional indigestion of hypersthenic type, antral gastritis, duodenitis, gastroduodenitis), identification and elimination of risk factors for the disease. This prevention includes sanitary-hygienic and sanitary-educational measures to organize and promote rational nutrition, especially among persons working on the night shift as transport drivers, adolescents and students, to combat smoking and alcohol consumption, to create favorable psychological relationships in the work team and at home, explaining the benefits of physical culture, hardening and organized recreation.
The task of secondary prevention is to prevent exacerbation and recurrence of the disease. The main form of prevention of exacerbation is clinical examination. It includes: registration of persons with peptic ulcer in the clinic, constant medical supervision over them, prolonged treatment after discharge from the hospital, as well as spring-autumn courses of anti-relapse therapy and, if necessary, year-round treatment and rehabilitation.
CHAPTER 2. COMPREHENSIVE PHYSICAL REHABILITATION OF PATIENTS WITH GASTRIC AND DUODENAL Peptic Ulcers at the Stationary Stage
2.1 General characteristics of the means of physical rehabilitation of patients with peptic ulcer of the stomach and duodenum
An integrated approach with the obligatory consideration of the individual characteristics of the course of the process is an unshakable principle for the treatment and rehabilitation of peptic ulcer. The most effective treatment for any disease is the one that most effectively eliminates the cause that causes it. In other words, we are talking about a targeted impact on those changes in the body that are responsible for the development of an ulcerative defect in the mucous membrane of the stomach and duodenum.
The peptic ulcer treatment program includes a complex of diverse activities, the ultimate goal of which is the normalization of gastric digestion and the correction of the activity of regulatory mechanisms responsible for the disorganization of the secretory and motor functions of the stomach. This approach to the treatment of the disease provides a radical elimination of the changes that have occurred in the body. The treatment of patients with peptic ulcer should be comprehensive and strictly individualized. During the period of exacerbation, treatment is carried out in a hospital.
Comprehensive treatment and rehabilitation patients with peptic ulcer of the stomach and duodenum include: drug treatment, diet therapy, physiotherapy and hydrotherapy, drinking mineral water, exercise therapy, therapeutic massage and other therapeutic agents. The antiulcer course also includes the elimination of factors contributing to the recurrence of the disease, provides for the optimization of working and living conditions, the categorical prohibition of smoking and alcohol consumption, the prohibition of taking medications with an ulcerogenic effect.
Drug therapy has as its purpose:
1. Suppression of excess production of hydrochloric acid and pepsin or their neutralization and adsorption.
2. Restoration of the motor-evacuation function of the stomach and duodenum.
3. Protection of the mucous membrane of the stomach and duodenum and treatment of helicobacteriosis.
4. Stimulation of the processes of regeneration of cellular elements of the mucous membrane and relief of inflammatory-dystrophic changes in it.
The basis of drug treatment of exacerbations of peptic ulcer is the use of anticholinergics, ganglioblockers and antacids, with the help of which the effect on the main pathogenetic factors is achieved (decrease in pathological nervous impulses, inhibitory effect on the pituitary-adrenal system, decrease in gastric secretion, inhibition of the motor function of the stomach and duodenum, etc. .).
Alkalizing agents (antacids) are widely included in the medical complex and are divided into two large groups: soluble and insoluble. Soluble antacids include: sodium bicarbonate, as well as magnesia oxide and calcium carbonate (which react with hydrochloric acid of gastric juice and form soluble salts). Alkaline mineral waters (Borjomi, Jermuk springs, etc.) are widely used for the same purpose. Reception of antacids should be regular and repeated during the day. The frequency and timing of admission are determined by the nature of the violation of the secretory function of the stomach, the presence and time of occurrence of heartburn and pain. Most often, antacids are prescribed an hour before a meal and 45-60 minutes after a meal. The disadvantages of these antacids include the possibility of changing the acid-base state with prolonged use in large doses.
An important therapeutic measure is diet therapy. Therapeutic nutrition in patients with gastric ulcer must be strictly differentiated depending on the stage of the process, its clinical manifestations and associated complications. The basis of dietary nutrition in patients with peptic ulcer of the stomach and duodenum is the principle of sparing the stomach, that is, creating maximum rest for the ulcerated mucosa. It is advisable to use products that are weak stimulants of sap secretion, quickly leave the stomach and slightly irritate its mucous membrane.
Currently, special anti-ulcer rations for therapeutic nutrition have been developed. The diet must be followed for a long time and after discharge from the hospital. During the period of exacerbation, products that neutralize hydrochloric acid are prescribed. Therefore, at the beginning of treatment, a protein-fat diet, restriction of carbohydrates is needed.
Meals should be fractional and frequent (5-6 times a day); diet - complete, balanced, chemically and mechanically sparing. Diet food consists of three successive cycles lasting 10-12 days (diet No. 1a, 16, 1). With severe neuro-vegetative disorders, hypo- and hyperglycemic syndromes, the amount of carbohydrates in the diet is limited (up to 250-300 g), with trophic disorders, concomitant pancreatitis, the amount of protein increases to 150-160 g, with severe acidism, preference is given to products with antacid properties : milk, cream, soft-boiled eggs, etc.
Diet number 1a - the most sparing, rich in milk. Diet No. 1a includes: whole milk, cream, cottage cheese steam soufflé, egg dishes, butter. As well as fruits, berries, sweets, kissels and jelly from sweet berries and fruits, sugar, honey, sweet berry and fruit juices mixed with water and sugar. Sauces, spices and appetizers are excluded. Drinks - rosehip broth.
Being on a diet number 1a, the patient must comply with bed rest. She is kept for 10 - 12 days, then they switch to a more stressful diet No. 1b. On this diet, all dishes are cooked pureed, boiled in water or steamed. Food is liquid or mushy. It contains various fats, chemical and mechanical irritants of the gastric mucosa are significantly limited. Diet No. 1b is prescribed for 10-12 days, and the patient is transferred to diet No. 1, which contains proteins, fats and carbohydrates. Dishes that stimulate gastric secretion and chemically irritate the gastric mucosa are excluded. All dishes are prepared boiled, mashed and steamed. Diet No. 1 for a patient with a stomach ulcer should receive a long time. You can switch to a varied diet only with the permission of a doctor.
Application of mineral waters occupies a leading place in the complex therapy of diseases of the digestive system, including peptic ulcer.
Drinking treatment is practically indicated for all patients with peptic ulcer in remission or unstable remission, without a sharp pain syndrome, in the absence of a tendency to bleeding and in the absence of persistent narrowing of the pylorus.
Assign mineral waters of low and medium mineralization (but not higher than 10-12 g / l), containing no more than 2.5 g / l of carbon dioxide, bicarbonate sodium, bicarbonate-sulphate sodium water, as well as water with a predominance of these ingredients, but more complex cationic composition, pH from 6 to 7.5.
Drinking treatment should be started already from the first days of the patient's admission to the hospital, however, the amount of mineral water for admission during the first 2-3 days should not exceed 100 ml. In the future, with good tolerance, the dose can be increased to 200 ml 3 times a day. With increased or normal secretory and normal evacuation function of the stomach, water is taken in a warm form 1.5 hours before meals, with reduced secretion - 40 minutes -1 hour before meals, with a slowdown in evacuation from the stomach 1 hour 45 minutes - 2 hours before food.
In the presence of pronounced dyspeptic symptoms, mineral water, especially hydrocarbonate, can be used more often, for example 6-8 times a day: 3 times a day 1 hour 30 minutes before meals, then after meals (after about 45 minutes) at the height of dyspeptic symptoms and, Finally, before bed.
In some cases, when taking mineral water before meals, heartburn intensifies in patients, and pain appears. Such patients sometimes well tolerate the intake of mineral water 45 minutes after a meal.
Often, this method of drinking treatment has to be resorted to only in the first days of the patient's admission, in the future, many patients switch to taking mineral water before meals.
Persons with peptic ulcer in the stage of remission or unstable remission of the disease, in the presence of dyskinesia and concomitant inflammatory phenomena from the large intestine are shown: microclysters and cleansing enemas from mineral water, intestinal douches, siphon lavages of the intestines.
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Page 17 of 18
Clinical examination and principles of rehabilitation treatment of patients with peptic ulcer at the stages of medical rehabilitation
The general direction of healthcare development in our country has been and remains preventive, providing for the creation of favorable healthy living conditions for the population, the formation of a healthy lifestyle for each person and the whole society, and active medical monitoring of the health of each person. The implementation of preventive tasks is associated with the successful solution of many socio-economic problems and, of course, with a radical restructuring of the activities of health authorities and institutions, primarily with the development and improvement of primary health care. This will effectively and fully ensure the medical examination of the population, create a unified system for assessing and systematic monitoring of the state of human health, the entire population as a whole.
Medical examination issues require in-depth study and improvement, because its traditional methods are ineffective and do not allow for a full-fledged early diagnosis of diseases, clearly identify groups of people for differentiated observation, and fully implement preventive and rehabilitation measures.
The methodology for preparing and conducting preventive examinations under the program of general medical examination needs to be improved. Modern technical means make it possible to improve the diagnostic process, providing for the participation of a doctor only at the final stage - the stage of making a formed decision. This makes it possible to increase the efficiency of the work of the prevention department, to reduce the time of medical examination to a minimum.
Together with E. I. Samsoi and co-authors (1986, 1988), M. Yu. Kolomoets, V. L. Tarallo (1989, 1990) we have improved the method of early diagnosis of diseases of the digestive system, including peptic ulcer, using automated complexes. Diagnosis consists of two stages - non-specific and specific.
At the first stage (non-specific), an initial expert assessment of the state of health of those undergoing medical examination is given, dividing them into two streams - healthy and subject to further examination. This stage is implemented by preliminary interviewing the population according to the indicative questionnaire (0-1) * in preparation for a preventive examination. The prophylactic patients, answering the questions of the indicative questionnaire (0-1), fill out the technological interview card (TKI-1). Then its machine processing is carried out, according to the results of which individuals of risk groups are distinguished according to the pathology of individual nosological units.
* The indicative questionnaire is based on the anamnestic questionnaire "Complex of programs" ("Basic examination") for solving the problems of processing the results of mass dispensary screening examinations of the population using the micro-computer "Iskra-1256" of the RIVC of the Ministry of Health of Ukraine (1987) with the inclusion of specially developed methods for self-examination of the patient , additions and changes that ensure the conduct of mass self-interviewing of the population and filling out maps at home. The medical questionnaire is intended for territorial-district certification of the health of the population with the allocation of risk groups for diseases and lifestyle using a computer.
The issue of allocation of two streams of subjects (healthy and those in need of further examination) is decided on the basis of the conclusion of the computer on TKI-1 and the results of mandatory studies.
Persons in need of additional examination are sent for further examination under screening targeted programs. One of these programs is the targeted mass medical examination program for the early detection of common diseases of the digestive system (including peptic ulcer and pre-ulcerative conditions). Clinical patients according to a specialized questionnaire (0-2 "p") fill out the technological card TKI-2 "p", after which they are automatically processed according to the same principle. The computer suggests a probable
diagnosis (diagnoses) and a list of additional methods for examining the digestive organs (laboratory, instrumental, radiological). The participation of the general practitioner of the prevention department is provided for at the final stage of the preventive examination - the stage of making a formed decision, determining the group for dispensary observation. During a preventive examination, a medical specialist is examined on the recommendation of a computer.
The questionnaires were tested by conducting preventive medical examinations of 4217 people. According to the results of machine processing, only 18.8% of the interviewees made a presumptive diagnosis of "healthy", the conclusion "needs further examination" - 80.9% (among them, 77% of those undergoing medical examinations needed consultations from therapeutic specialists). Analysis of the final results of preventive examinations showed that the computer gave a true positive response in 62.9% of cases, a true negative - in 29.1%, a false positive - in 2.4%, a false negative - in 5.8%.
When identifying gastroenterological pathology, the sensitivity of the specialized screening questionnaire turned out to be very high - 96.2% (with a predictive coefficient of the result of 0.9), since in the indicated percentage of cases the machine gives the correct answer with a positive decision "sick". At the same time, with a negative answer, the error is 15.6% (with a prediction coefficient of 0.9). As a result, the coefficient of conformity of the diagnostic conclusion is 92.1%, t. out of 100 people, in 8, the decision of the computer to identify gastroenterological pathology based on the survey data may be incorrect.
The given data convinces of a high degree of reliability of the developed criteria and allows us to recommend a specialized questionnaire for widespread use in a screening target program at the stage of preparation for a preventive medical examination.
As you know, the order of the Ministry of Health of the USSR No. 770 dated May 30, 1986 provides for the allocation of three dispensary groups: healthy (DO; prophylactically healthy (Dg); patients in need of treatment (Dz). Our experience shows that, in relation to patients with peptic ulcer, their with pre-ulcerative conditions, as well as to persons with risk factors for the occurrence of these diseases, a more differentiated division of those undergoing medical examination into the second and third health groups is justified (in each of them it is advisable to single out 3 subgroups) in order to ensure a differentiated approach to the implementation of preventive and therapeutic measures.
II group:
On - increased attention (persons who do not complain, without deviations from the norm according to the results of additional studies, but exposed to risk factors);
II b - persons with latent current pre-ulcerative conditions (no complaints, but having deviations from the norm in additional studies);
c - patients with obvious pre-ulcerative conditions, peptic ulcer who do not need treatment.
Group:
IIIa - patients with obvious pre-ulcerative conditions in need of treatment;
III b - patients with uncomplicated peptic ulcer in need of treatment;
III c - patients with severe peptic ulcer disease, complications and (or) concomitant diseases.
Peptic ulcer is one of the diseases in the fight against which preventive rehabilitation measures are of decisive importance.
Without belittling the importance of the inpatient stage of treatment, it should be recognized that it is possible to achieve a stable and long-term remission, to prevent the recurrence of peptic ulcer disease through a long (at least 2 years) and successive restorative staged treatment of the patient after discharge from the hospital. This is evidenced by our own research and the work of a number of authors (E. I. Samson, 1979; P. Ya. Grigoriev, 1986; G. A. Serebrina, 1989, etc.).
We distinguish the following stages of post-hospital rehabilitation treatment of patients with peptic ulcer:
a rehabilitation department for gastroenterological patients of a hospital for rehabilitation treatment (usually in a suburban area using natural healing factors);
a polyclinic (including a day hospital of a polyclinic, a department or an office for rehabilitation treatment of a polyclinic or a rehabilitation center at a polyclinic);
sanatorium-dispensary of industrial enterprises, institutions, collective farms, state farms, educational institutions;
Spa treatment.
We combine all of the above stages of post-hospital rehabilitation treatment in the period of late rehabilitation, and in general, the process of medical rehabilitation can be divided into three periods:
- early rehabilitation (timely diagnosis in the clinic, early intensive treatment);
- late rehabilitation (postoperative stages of treatment);
- Dispensary observation in the clinic.
In the system of medical rehabilitation of patients with peptic ulcer, the polyclinic stage plays a decisive role, since it is in the polyclinic that continuous, consistent monitoring and treatment of the patient is carried out for a long time, and the continuity of rehabilitation is ensured. The effectiveness of the rehabilitation of patients in the clinic is due to the complex effect of various means and methods of rehabilitation treatment, including therapeutic nutrition, herbal and physiotherapy, acupuncture, exercise therapy, balneotherapy, psychotherapy with very restrained, maximally differentiated and adequate pharmacotherapy (E. I. Samson, M Yu. Kolomoets, 1985; M, Yu. Kolomoets et al., 1988, etc.).
A correct assessment of the role and significance of the outpatient stage in the rehabilitation treatment of patients has contributed to the further improvement in recent years of the organizational forms of rehabilitation of patients at the outpatient stage (OP Shchepin, 990). One of them is a polyclinic day hospital (DSP). An analysis of our observations on day hospitals at the polyclinics of the Central Republican Clinical Hospital of the Minsk region of Kyiv, the polyclinic of the 3rd city hospital of Chernivtsi, as well as the data of A. M. Lushpa (1987), B. V. Zhalkovsky, L. I. Leibman (1990) show that that DSP is most effectively used for the rehabilitation of gastroenterological patients, constituting 70-80% of the total number of patients treated. Among patients with diseases of the digestive system, about half were patients with peptic ulcer. Based on the experience of the DSP, we determined the indications for referring patients with peptic ulcer to a day hospital. These include:
Uncomplicated peptic ulcer in the presence of a peptic ulcer 2 weeks after the start of treatment in a hospital after relief of pain.
Exacerbation of uncomplicated peptic ulcer disease without a peptic ulcer (from the beginning of an exacerbation), bypassing the stationary stage.
Long-term non-scarring ulcers in the absence of complications 3-4 weeks after the start of inpatient treatment.
Due to the rather long stay of patients in the DSP during the day (6-7 hours), we consider it appropriate to organize one or two meals a day (diet No. 1) in the DSP.
The duration of treatment of patients with peptic ulcer at various stages of medical rehabilitation depends on the severity of the course, the presence of complications and concomitant diseases, and a number of other clinical features in a particular patient. At the same time, our many years of experience allows us to recommend the following terms as optimal: in a hospital - 20-30 days (or 14 days, followed by referral of the patient to a day hospital or a rehabilitation department for gastroenterological patients of a rehabilitation treatment hospital); in the rehabilitation department of a rehabilitation treatment hospital - 14 days; in a day hospital - from 14 to 20 days; in the rehabilitation treatment department of a polyclinic or a rehabilitation center at a polyclinic - 14 days; in a sanatorium-dispensary - 24 days; in a sanatorium in a resort - 24-26 days.
In general, prolonged treatment should be continued for at least 2 years in the absence of new exacerbations and relapses. A practically healthy patient can be considered in those cases if within 5 years he had no exacerbations and relapses of peptic ulcer.
In conclusion, it should be noted that the problem of treating peptic ulcer goes far beyond the scope of medicine and is a socio-economic problem that requires a set of measures on a nationwide scale, creating conditions for reducing psychogenic factors, normal nutrition, hygienic working conditions, life, rest.
Introduction
1. Anatomical, physiological, pathophysiological and clinical features of the course of the disease
1.1 Etiology and pathogenesis of gastric ulcer
1.2 Classification
1.3 Clinical picture and provisional diagnosis
2. Methods of rehabilitation of patients with gastric ulcer
2.1 Therapeutic exercise (LFK)
2.2 Acupuncture
2.3 Acupressure
2.4 Physiotherapy
2.5 Drinking mineral waters
2.6 Balneotherapy
2.7 Music therapy
2.8 Mud treatment
2.9 Diet therapy
2.10 Phytotherapy
Conclusion
List of used literature
Applications
Introduction
In recent years, there has been a tendency towards an increase in the incidence of the population, among which gastric ulcer has become widespread.
According to the traditional definition of the World Health Organization (WHO), peptic ulcer(ulcus ventriculi et duodenipepticum, morbus ulcerosus)- a common chronic relapsing disease, prone to progression, with a polycyclic course, the characteristic features of which are seasonal exacerbations, accompanied by the appearance of an ulcerative defect in the mucous membrane, and the development of complications that threaten the life of the patient. A feature of the course of gastric ulcer is the involvement of other organs of the digestive apparatus in the pathological process, which requires timely diagnosis for the preparation of medical complexes for patients with peptic ulcer, taking into account concomitant diseases. Peptic ulcer of the stomach affects people of the most active, able-bodied age, causing temporary and sometimes permanent disability.
High morbidity, frequent relapses, long-term disability of patients, as a result of which significant economic losses - all this makes it possible to classify the problem of peptic ulcer as one of the most urgent in modern medicine.
A special place in the treatment of patients with peptic ulcer is rehabilitation. Rehabilitation is the restoration of health, functional state and ability to work, disturbed by diseases, injuries or physical, chemical and social factors. The World Health Organization (WHO) gives a very close definition of rehabilitation: “Rehabilitation is a set of activities designed to enable people with impaired functions as a result of illness, injury and birth defects to adapt to the new conditions of life in the society in which they live” .
According to WHO, rehabilitation is a process aimed at comprehensive assistance to the sick and disabled in order to achieve the maximum possible physical, mental, professional, social and economic usefulness for this disease.
Thus, rehabilitation should be considered as a complex socio-medical problem, which can be divided into several types or aspects: medical, physical, psychological, professional (labor) and socio-economic.
As part of this work, I consider it necessary to study the physical methods of rehabilitation for gastric ulcers, focusing on acupressure and music therapy, which determines the purpose of the study.
Object of study: gastric ulcer.
Subject of research: physical methods of rehabilitation of patients with gastric ulcer.
Tasks are directed to consideration:
Anatomical, physiological, pathophysiological and clinical features of the course of the disease;
Methods of rehabilitation of patients with gastric ulcer.
1. Anatomical, physiological, pathophysiological and clinical features of the course of the disease
1.1 Etiology and pathogenesis of gastric ulcer
Gastric ulcer is characterized by the formation of an ulcer in the stomach due to a disorder of the general and local mechanisms of the nervous and humoral regulation of the main functions of the gastroduodenal system, trophic disorders and activation of proteolysis of the gastric mucosa and often the presence of Helicobacter pylori infection in it. At the final stage, an ulcer occurs as a result of a violation of the ratio between aggressive and protective factors with a predominance of the former and a decrease in the latter in the stomach cavity.
Thus, the development of peptic ulcer, according to modern concepts, is due to an imbalance between the impact of aggressive factors and defense mechanisms that ensure the integrity of the gastric mucosa.
Aggression factors include: an increase in the concentration of hydrogen ions and active pepsin (proteolytic activity); Helicobacter pylori infection, the presence of bile acids in the cavity of the stomach and duodenum.
The protective factors include: the amount of protective mucus proteins, especially insoluble and premucosal, the secretion of bicarbonates (“alkaline flush”); mucosal resistance: proliferative index of the mucosa of the gastroduodenal zone, local immunity of the mucosa of this zone (the amount of secretory IgA), the state of microcirculation and the level of prostaglandins in the gastric mucosa. With peptic ulcer and non-ulcer dyspepsia (gastritis B, pre-ulcerative condition), aggressive factors sharply increase and protective factors in the stomach cavity decrease.
Based on currently available data, the main and predisposing factors of the disease have been identified.
The main factors include:
Violations of humoral and neurohormonal mechanisms that regulate digestion and tissue reproduction;
Disorders of local digestive mechanisms;
Changes in the structure of the mucous membrane of the stomach and duodenum.
Predisposing factors include:
Hereditary-constitutional factor. A number of genetic defects have been established that are realized in various links in the pathogenesis of this disease;
Helicobacter pylori invasion. Some researchers in our country and abroad attribute Helicobacter pylori infection to the main cause of peptic ulcer;
Environmental conditions, first of all, neuropsychic factors, nutrition, bad habits;
medicinal effects.
From a modern point of view, some scholars consider peptic ulcer as a polyetiological multifactorial disease. However, I would like to emphasize the traditional direction of the Kyiv and Moscow therapeutic schools, which believe that the central place in the etiology and pathogenesis of peptic ulcer belongs to disorders of the nervous system that occur in its central and vegetative sections under the influence of various influences (negative emotions, overstrain during mental and physical work , viscero-visceral reflexes, etc.).
There are a large number of works testifying to the etiological and pathogenetic role of the nervous system in the development of peptic ulcer. The first was created spasmogenic or neurovegetative theory.
Works by I.P. Pavlova about the role of the nervous system and its higher department - the cerebral cortex - in the regulation of all vital functions of the body (the ideas of nervism) are reflected in new views on the development of peptic ulcer: this cortico-visceral theory K.M. Bykova, I.T. Kurtsina (1949, 1952) and a number of works pointing to the etiological role of disorders of neurotrophic processes directly in the mucous membrane of the stomach and duodenum in peptic ulcer.
According to the cortico-visceral theory, peptic ulcer is the result of disturbances in the cortico-visceral relationship. Progressive in this theory is the evidence of a two-way connection between the central nervous system and internal organs, as well as the consideration of peptic ulcer from the point of view of a disease of the whole organism, in the development of which a violation of the nervous system plays a leading role. The disadvantage of the theory is that it does not explain why the stomach is affected when the cortical mechanisms are disturbed.
Currently, there are several fairly convincing facts showing that one of the main etiological factors in the development of peptic ulcer is a violation of nervous trophism. An ulcer arises and develops as a result of a disorder of biochemical processes that ensure the integrity and stability of living structures. The mucous membrane is most susceptible to dystrophies of neurogenic origin, which is probably due to the high regenerative capacity and anabolic processes in the gastric mucosa. The active protein-synthetic function is easily disturbed and may be an early sign of dystrophic processes aggravated by the aggressive peptic action of gastric juice.
It was noted that in gastric ulcer, the level of secretion of hydrochloric acid is close to normal or even reduced. In the pathogenesis of the disease, a decrease in the resistance of the mucous membrane is of greater importance, as well as the reflux of bile into the stomach cavity due to insufficiency of the pyloric sphincter.
A special role in the development of peptic ulcer is assigned to gastrin and cholinergic postganglionic fibers of the vagus nerve involved in the regulation of gastric secretion.
There is an assumption that histamine is involved in the implementation of the stimulating effect of gastrin and cholinergic mediators on the acid-forming function of parietal cells, which is confirmed by the therapeutic effect of histamine H2 receptor antagonists (cimetidine, ranitidine, etc.).
Prostaglandins play a central role in protecting the epithelium of the gastric mucosa from the action of aggressive factors. The key enzyme for prostaglandin synthesis is cyclooxygenase (COX), present in the body in two forms, COX-1 and COX-2.
COX-1 is found in the stomach, kidneys, platelets, endothelium. Induction of COX-2 occurs under the action of inflammation; the expression of this enzyme is carried out predominantly by inflammatory cells.
Thus, summarizing the above, we can conclude that the main links in the pathogenesis of peptic ulcer are neuroendocrine, vascular, immune factors, acid-peptic aggression, a protective muco-hydrocarbonate barrier of the gastric mucosa, helicobacter pylori and prostaglandins.
1.2 Classification
Currently, there is no generally accepted classification of peptic ulcer disease. A large number of classifications based on various principles have been proposed. In foreign literature, the term "peptic ulcer" is more often used and a peptic ulcer of the stomach and duodenum is distinguished. The abundance of classifications emphasizes their imperfection.
According to the WHO classification of the IX revision, gastric ulcer (heading 531), duodenal ulcer (heading 532), ulcer of unspecified localization (heading 533) and, finally, gastrojejunal ulcer of the resected stomach (heading 534) are distinguished. The WHO International Classification should be used for the purpose of accounting and statistics, however, for use in clinical practice, it should be significantly expanded.
The following classification of peptic ulcer is proposed.
I. General characteristics of the disease (WHO nomenclature)
1. Stomach ulcer (531)
2. Peptic ulcer of the duodenum (532)
3. Peptic ulcer of unspecified localization (533)
4. Peptic gastrojejunal ulcer after gastric resection (534)
II. Clinical form
1. Acute or newly diagnosed
2. Chronic
III. Flow
1. Latent
2. Mild or rarely recurrent
3. Moderate or recurrent (1-2 relapses per year)
4. Severe (3 or more relapses within a year) or continuously relapsing; development of complications.
1. Aggravation (relapse)
2. Fading exacerbation (incomplete remission)
3. Remission
V. Characteristics of the morphological substrate of the disease
1. Types of ulcers a) acute ulcer; b) chronic ulcer
2. Dimensions of the ulcer: a) small (less than 0.5 cm); b) medium (0.5-1 cm); c) large (1.1-3 cm); d) giant (more than 3 cm).
3. Stages of ulcer development: a) active; b) scarring; c) the stage of the "red" scar; d) the stage of the "white" scar; e) long-term scarring
4. Localization of the ulcer:
a) stomach: A: 1) cardia, 2) subcardial region, 3) body of the stomach, 4) antrum, 5) pyloric canal; B: 1) anterior wall, 2) posterior wall, 3) lesser curvature, 4) greater curvature.
b) duodenum: A: 1) bulb, 2) postbulbar part;
B: 1) anterior wall, 2) posterior wall, 3) lesser curvature, 4) greater curvature.
VI. Characteristics of the functions of the gastroduodenal system (only pronounced violations of the secretory, motor and evacuation functions are indicated)
VII. Complications
1. Bleeding: a) mild, b) moderate, c) severe, d) extremely severe
2. Perforation
3. Penetration
4. Stenosis: a) compensated, b) subcompensated, c) decompensated.
5. Malignancy
Based on the presented classification, as an example, the following formulation of the diagnosis can be proposed: gastric ulcer, first detected, acute form, large (2 cm) ulcer of the lesser curvature of the body of the stomach, complicated by mild bleeding.
1.3 Clinical picture and provisional diagnosis
The judgment about the possibility of peptic ulcer should be based on the study of complaints, anamnestic data, physical examination of the patient, assessment of the functional state of the gastroduodenal system.
For typical The clinical picture is characterized by a clear connection between the occurrence of pain and food intake. There are early, late and "hungry" pains. Early pain appears 1/2-1 hour after eating, gradually increases in intensity, lasts 1 1/2-2 hours and subsides as the gastric contents are evacuated. Late pain occurs 1 1/2-2 hours after eating at the height of digestion, and "hungry" pain - after a significant period of time (6-7 hours), i.e. on an empty stomach, and stops after eating. Close to "hungry" night pain. The disappearance of pain after eating, taking antacids, anticholinergic and antispasmodic drugs, as well as the subsidence of pain during the first week of adequate treatment is a characteristic sign of the disease.
In addition to pain, a typical clinical picture of gastric ulcer includes various dyspeptic phenomena. Heartburn is a common symptom of the disease, occurs in 30-80% of patients. Heartburn may alternate with pain, precede it for a number of years, or be the only symptom of the disease. However, it should be borne in mind that heartburn is very often observed in other diseases of the digestive system and is one of the main signs of insufficiency of cardiac function. Nausea and vomiting are less common. Vomiting usually occurs at the height of pain, being a kind of culmination of the pain syndrome, and brings relief. Often, to eliminate pain, the patient himself artificially induces vomiting.
Constipation is observed in 50% of patients with gastric ulcer. They intensify during periods of exacerbation of the disease and are sometimes so persistent that they disturb the patient even more than pain.
A distinctive feature of peptic ulcer is the cyclical course. Periods of exacerbation, which usually last from several days to 6-8 weeks, are replaced by a remission phase. During remission, patients often feel practically healthy, even without following any diet. Exacerbations of the disease, as a rule, are seasonal in nature; for the middle zone, this is mainly the spring or autumn season.
A similar clinical picture in individuals with a previously undiagnosed diagnosis is more likely to suggest peptic ulcer disease.
Typical ulcer symptoms are more common when the ulcer is localized in the pyloric part of the stomach (pyloroduodenal form of peptic ulcer). However, it is often observed with an ulcer of the lesser curvature of the body of the stomach (mediogastric form of peptic ulcer). Nevertheless, in patients with mediogastric ulcers, the pain syndrome is less defined, pain can radiate to the left half of the chest, lumbar region, right and left hypochondrium. In some patients with mediogastric peptic ulcer, a decrease in appetite and weight loss are observed, which is not typical for pyloroduodenal ulcers.
The greatest clinical features occur in patients with localized ulcers in the cardiac or subcardial regions of the stomach.
Laboratory studies have a relative, indicative value in the recognition of peptic ulcer.
Study gastric secretion It is necessary not so much for the diagnosis of the disease, but for the detection of functional disorders of the stomach. Only a significant increase in acid production detected during fractional gastric probing (the rate of basal secretion of HCl over 12 mmol/h, the rate of HCl after submaximal stimulation with histamine over 17 mmol/h and after maximum stimulation over 25 mmol/h) should be taken into account as a diagnostic sign of peptic ulcer .
Additional information can be obtained by examining intragastric pH. Peptic ulcer, especially pyloroduodenal localization, is characterized by pronounced hyperacidity in the body of the stomach (pH 0.6-1.5) with continuous acid formation and decompensation of alkalization of the medium in the antrum (pH 0.9-2.5). The establishment of true achlorhydria practically excludes this disease.
Clinical Analysis blood in uncomplicated forms of peptic ulcer, it usually remains normal, only a number of patients have erythrocytosis due to increased erythropoiesis. Hypochromic anemia may indicate bleeding from gastroduodenal ulcers.
positive reaction stool for occult blood often observed with exacerbations of peptic ulcer. However, it should be borne in mind that a positive reaction can be observed in many diseases (tumors of the gastrointestinal tract, nosebleeds, bleeding gums, hemorrhoids, etc.).
To date, it is possible to confirm the diagnosis of gastric ulcer using X-ray and endoscopic methods.
2. Methods of rehabilitation of patients with gastric ulcer
2.1 Therapeutic exercise (LFK)
Physiotherapy exercises (exercise therapy) for peptic ulcer disease contributes to the regulation of excitation and inhibition processes in the cerebral cortex, improves digestion, blood circulation, respiration, redox processes, positively affects the neuropsychic state of the patient.
When performing physical exercises, the stomach area is spared. In the acute period of the disease in the presence of pain exercise therapy is not indicated. Physical exercises are prescribed 2-5 days after the cessation of acute pain.
During this period, the procedure of therapeutic exercises should not exceed 10-15 minutes. In the prone position, exercises for the arms and legs with a limited range of motion are performed. Exercises that actively involve the abdominal muscles and increase intra-abdominal pressure are excluded.
With the cessation of acute phenomena, physical activity is gradually increased. To avoid exacerbation, do it carefully, taking into account the patient's response to exercise. Exercises are performed in the initial position lying, sitting, standing.
To prevent adhesions against the background of general strengthening movements, exercises for the muscles of the anterior abdominal wall, diaphragmatic breathing, simple and complicated walking, rowing, skiing, outdoor and sports games are used.
Exercises should be done carefully if they aggravate the pain. Complaints often do not reflect the objective state, and the ulcer can progress with subjective well-being (disappearance of pain, etc.).
In this regard, in the treatment of patients, the abdominal area should be spared and very carefully, gradually increase the load on the abdominal muscles. It is possible to gradually expand the patient's motor mode by increasing the total load when performing most exercises, including exercises in diaphragmatic breathing and exercises for the abdominal muscles.
Contraindications to the appointment of exercise therapy are: bleeding; generating ulcer; acute perivisceritis (perigastritis, periduodenitis); chronic perivisceritis, subject to the occurrence of acute pain during exercise.
The exercise therapy complex for patients with gastric ulcer is presented in Appendix 1.
2.2 Acupuncture
Gastric ulcer from the point of view of its occurrence, development, as well as from the standpoint of the development of effective methods of treatment is a major problem. Scientific searches for reliable methods of treating peptic ulcer are due to the insufficient effectiveness of known methods of therapy.
Modern ideas about the mechanism of action of acupuncture are based on somato-visceral relationships, carried out both in the spinal cord and in the overlying parts of the nervous system. The therapeutic effect on the reflexogenic zones, where the acupuncture points are located, contributes to the normalization of the functional state of the central nervous system, the hypothalamus, maintaining homeostasis and faster normalization of the disturbed activity of organs and systems, stimulates oxidative processes, improves microcirculation (by synthesizing biologically active substances), blocks pain impulses. In addition, acupuncture increases the adaptive capacity of the body, eliminates prolonged excitation in various centers of the brain that control smooth muscles, blood pressure, etc.
The best effect is achieved if acupuncture points located in the zone of segmental innervation of the affected organs are irritated. Such zones for peptic ulcer disease are D4-7.
The study of the general condition of patients, the dynamics of indicators of laboratory, radiological, endoscopic studies give the right to objectively evaluate the applied method of acupuncture, its advantages, disadvantages, develop indications for differentiated treatment of patients with peptic ulcer. They showed a pronounced analgesic effect in patients with persistent pain symptoms.
An analysis of the parameters of the motor function of the stomach also revealed a clear positive effect of acupuncture on tone, peristalsis and gastric evacuation.
Introduction
Anatomical, physiological, pathophysiological and clinical features of the course of the disease
1 Etiology and pathogenesis of gastric ulcer
2 Classification
3 Clinical picture and preliminary diagnosis
Methods of rehabilitation of patients with gastric ulcer
1 Therapeutic exercise (LFK)
2 Acupuncture
3 point massage
4 Physiotherapy
5 Drinking mineral waters
6 Balneotherapy
7 Music therapy
8 Mud treatment
9 Diet therapy
10 Phytotherapy
Conclusion
List of used literature
Applications
Introduction
In recent years, there has been a tendency towards an increase in the incidence of the population, among which gastric ulcer has become widespread.
According to the traditional definition of the World Health Organization (WHO), peptic ulcer (ulcus ventriculi et duodenipepticum, morbus ulcerosus) is a common chronic relapsing disease, prone to progression, with a polycyclic course, the characteristic features of which are seasonal exacerbations, accompanied by the appearance of an ulcer in the mucous membrane, and the development of complications that threaten the life of the patient. A feature of the course of gastric ulcer is the involvement of other organs of the digestive apparatus in the pathological process, which requires timely diagnosis for the preparation of medical complexes for patients with peptic ulcer, taking into account concomitant diseases. Peptic ulcer of the stomach affects people of the most active, able-bodied age, causing temporary and sometimes permanent disability.
High morbidity, frequent relapses, long-term disability of patients, as a result of which significant economic losses - all this makes it possible to classify the problem of peptic ulcer as one of the most urgent in modern medicine.
A special place in the treatment of patients with peptic ulcer is rehabilitation. Rehabilitation is the restoration of health, functional state and ability to work, disturbed by diseases, injuries or physical, chemical and social factors. The World Health Organization (WHO) gives a very close definition of rehabilitation: “Rehabilitation is a set of activities designed to enable people with impaired functions as a result of illness, injury and birth defects to adapt to the new conditions of life in the society in which they live” .
According to WHO, rehabilitation is a process aimed at comprehensive assistance to the sick and disabled in order to achieve the maximum possible physical, mental, professional, social and economic usefulness for this disease.
Thus, rehabilitation should be considered as a complex socio-medical problem, which can be divided into several types or aspects: medical, physical, psychological, professional (labor) and socio-economic.
As part of this work, I consider it necessary to study the physical methods of rehabilitation for gastric ulcers, focusing on acupressure and music therapy, which determines the purpose of the study.
Object of study: gastric ulcer.
Subject of research: physical methods of rehabilitation of patients with gastric ulcer.
Tasks are directed to consideration:
Anatomical, physiological, pathophysiological and clinical features of the course of the disease;
Methods of rehabilitation of patients with gastric ulcer.
1. Anatomical, physiological, pathophysiological and clinical features of the course of the disease
.1 Etiology and pathogenesis of gastric ulcer
Gastric ulcer is characterized by the formation of an ulcer in the stomach due to a disorder of the general and local mechanisms of the nervous and humoral regulation of the main functions of the gastroduodenal system, trophic disorders and activation of proteolysis of the gastric mucosa and often the presence of Helicobacter pylori infection in it. At the final stage, an ulcer occurs as a result of a violation of the ratio between aggressive and protective factors with a predominance of the former and a decrease in the latter in the stomach cavity.
Thus, the development of peptic ulcer, according to modern concepts, is due to an imbalance between the impact of aggressive factors and defense mechanisms that ensure the integrity of the gastric mucosa.
Aggression factors include: an increase in the concentration of hydrogen ions and active pepsin (proteolytic activity); Helicobacter pylori infection, the presence of bile acids in the cavity of the stomach and duodenum.
The protective factors include: the amount of protective mucus proteins, especially insoluble and premucosal, the secretion of bicarbonates (“alkaline flush”); mucosal resistance: proliferative index of the mucosa of the gastroduodenal zone, local immunity of the mucosa of this zone (the amount of secretory IgA), the state of microcirculation and the level of prostaglandins in the gastric mucosa. With peptic ulcer and non-ulcer dyspepsia (gastritis B, pre-ulcerative condition), aggressive factors sharply increase and protective factors in the stomach cavity decrease.
Based on currently available data, the main and predisposing factors of the disease have been identified.
The main factors include:
Violations of humoral and neurohormonal mechanisms that regulate digestion and tissue reproduction;
Disorders of local digestive mechanisms;
Changes in the structure of the mucous membrane of the stomach and duodenum.
Predisposing factors include:
Hereditary-constitutional factor. A number of genetic defects have been established that are realized in various links in the pathogenesis of this disease;
Helicobacter pylori invasion. Some researchers in our country and abroad attribute Helicobacter pylori infection to the main cause of peptic ulcer;
Environmental conditions, first of all, neuropsychic factors, nutrition, bad habits;
medicinal effects.
From modern positions, some scientists consider peptic ulcer as a polyetiological multifactorial disease. . However, I would like to emphasize the traditional direction of the Kyiv and Moscow therapeutic schools, which believe that the central place in the etiology and pathogenesis of peptic ulcer belongs to disorders of the nervous system that occur in its central and vegetative sections under the influence of various influences (negative emotions, overstrain during mental and physical work , viscero-visceral reflexes, etc.).
There are a large number of works testifying to the etiological and pathogenetic role of the nervous system in the development of peptic ulcer. The spasmogenic or neurovegetative theory was first created .
Works by I.P. Pavlov about the role of the nervous system and its higher department - the cerebral cortex - in the regulation of all vital functions of the body (the ideas of nervism) are reflected in new views on the development of peptic ulcer: this is the cortico-visceral theory of K.M. Bykova, I.T. Kurtsina (1949, 1952) and a number of works pointing to the etiological role of disorders of neurotrophic processes directly in the mucous membrane of the stomach and duodenum in peptic ulcer.
According to the cortico-visceral theory, peptic ulcer is the result of disturbances in the cortico-visceral relationship. Progressive in this theory is the evidence of a two-way connection between the central nervous system and internal organs, as well as the consideration of peptic ulcer from the point of view of a disease of the whole organism, in the development of which a violation of the nervous system plays a leading role. The disadvantage of the theory is that it does not explain why the stomach is affected when the cortical mechanisms are disturbed.
Currently, there are several fairly convincing facts showing that one of the main etiological factors in the development of peptic ulcer is a violation of nervous trophism. An ulcer arises and develops as a result of a disorder of biochemical processes that ensure the integrity and stability of living structures. The mucous membrane is most susceptible to dystrophies of neurogenic origin, which is probably due to the high regenerative capacity and anabolic processes in the gastric mucosa. The active protein-synthetic function is easily disturbed and may be an early sign of dystrophic processes aggravated by the aggressive peptic action of gastric juice.
It was noted that in gastric ulcer, the level of secretion of hydrochloric acid is close to normal or even reduced. In the pathogenesis of the disease, a decrease in the resistance of the mucous membrane is of greater importance, as well as the reflux of bile into the stomach cavity due to insufficiency of the pyloric sphincter.
A special role in the development of peptic ulcer is assigned to gastrin and cholinergic postganglionic fibers of the vagus nerve involved in the regulation of gastric secretion.
There is an assumption that histamine is involved in the implementation of the stimulating effect of gastrin and cholinergic mediators on the acid-forming function of parietal cells, which is confirmed by the therapeutic effect of histamine H2 receptor antagonists (cimetidine, ranitidine, etc.).
Prostaglandins play a central role in protecting the epithelium of the gastric mucosa from the action of aggressive factors. The key enzyme in the synthesis of prostaglandins is cyclooxygenase (COX), with
