PEPTIC ULCER

From Big Medical Encyclopedia

PEPTIC ULCER. With about d

e p-and N and e:

Classification............ 460

Aetiology and pathogeny........ 461

Pathological anatomy...... 463

Clinical picture and current... 465

Complications............. 467

Diagnosis............... 468

Treatment............... 472

Rehabilitation............ 478

Forecast............... 478

Prevention............

Children have 479 Features of a peptic ulcer 479

Peptic ulcer — the chronic recurrent disease which is characterized by ulceration in a stomach or in a duodenum owing to frustration of the general and local mechanisms of nervous and hormonal regulation of the main functions of gastroduodenal system, disturbance of a trophicity and development of proteolysis of a mucous membrane.

Mentioning of stomach ulcer and bleeding as a result of «corrosion» of a blood vessel meets in «A canon of medical science» of Ibn-Sina (Avicenna). The Russian scientist Fedor Uden in the treatise «The Academic Readings about Chronic Diseases» (1816) called this disease of «a gastric tuberculosis» and described a wedge, a picture of perforated stomach ulcer. The first description of anatomic features and typical a wedge, symptoms of a disease belongs to Zh. Kryuvelje (1829), to-ry gave it the name of simple chronic stomach ulcer.

Modern scientific representation about I. as a disease of all organism it developed thanks to works in the field of physiology of digestion of I. P. Pavlov and his pupils — I. P. Razenkova, K. M. Bykov, etc., the c which proved the leading role. N of page in regulation of the main functions of a stomach. Big contribution to development of clinical, pathogenetic and social aspects I. domestic clinical physicians M. P. Konchalovsky, R. A. Luriya, M. I. Pevzner, H brought. N. Burdenko, S. S. Yudin, V. S. Mayat, M. I. Kuzin, N. D. Strazhesko, N. I. Lepor-sky, V. of X. Vasilenko, I. M. Fle-kel, G. I. Burchinsky, S. M. Ryss, F. I. Komarov, pathomorphologists I. V. Davydovsky, S. S. Vail, Yu. M. Lazovsky, etc.

The peptic ulcer is eurysynusic around the world, but especially in the countries of Europe and in Japan where it occurs at 2 — 3% of adult population, and at city dwellers approximately twice more often than at rural. In recent years the tendency to increase in cases of primary registration of a disease was outlined that it is in no small measure connected with improvement of diagnosis thanks to wide use rentgenol. researches and to implementation in practice of a gastroduodenofibrosko-piya. In 1973, by data A. G. Safonova, in the USSR on the dispensary account apropos I. 1 million people consisted. At endoscopic inspection of the persons with dispeptic frustration who were not seeing earlier a doctor, I. is registered approximately in 12% of cases. During the opening of the dead from other diseases or injuries quite often find ulcers or the cicatricial changes in a stomach and a duodenum which are not distinguished at life (so-called mute ulcers). It follows from this that I. meets more often than it is diagnosed.

Men, especially young age, are ill a peptic ulcer by 4 times more often than women. Approximately in half of cases the disease arises at children's or teenage age; at adults — is more often at the age of 25 — 40 years. According to G. I. Dorofeyev and V. M. Uspensky (1984), at every third woman with I. the disease arises after approach of a menopause. According to the same researchers, localization of an ulcer in a duodenum is observed preferential at teenagers and at persons at the age of 30 — 40 years, stomach ulcer meets at persons at the age of 50 — 60 years more often; among all patients there are I. the relation of number of cases with localization of an ulcer in a stomach to number of cases with localization of an ulcer in a duodenum equals 1:7 (1:13 at patients up to 25 years, 1:8 at sick 25 — 44 years, 1:3 at sick 45 — 59 years, 1:2 at sick 60 years and is more senior). According to Yu. E. Lapina (1969), among the persons which are on disability concerning diseases of the digestive system, I. is the reason of disability at 68,4% of men and 30,9% of women.

Mortality in connection with I. on 100 000 population in a number of foreign countries, according to S. M. Rys-s and E. S. Ryss (1968), makes from 0,6 to 7,1 at localization of an ulcer in a stomach and from 0,2 to 9,7 at its localization in a duodenum. A proximate cause of a lethal outcome at I. in most cases complications (a helcomenia and a perforation of a wall of a stomach or duodenum) are.

Classification

of the Conventional classification I. does not exist. According to the ninth review by the International statistical classification of diseases, injuries and causes of death (WHO), allocate stomach ulcer, an ulcer of a duodenum, a round ulcer of not specified localization and a gastrojejunal ulcer. Depending on sharpness and features of a course of process of an ulcer subdivide on acute with bleeding, acute with a perforation, acute with bleeding and a perforation, acute without mentioning of bleeding or a perforation, chronic or not - specified with bleeding, chronic or not specified with a perforation, chronic or not specified with bleeding and a perforation, chronic without mentioning of bleeding or a perforation, not specified both acute, and chronic without mentioning of bleeding or a perforation. The peptic ulcer of a stomach along with an erosion (acute) of a stomach and an ulcer (peptic) peloric part of a stomach is included in the heading «stomach ulcer», a peptic ulcer of a duodenum — in the heading «ulcer of a duodenum».

In the USSR on the basis of the international classification by a number of clinical physicians — M. I. Pevzner (1946), I. M. Fleke Lem (1958), A. P. Peleshchuk with sotr. (1974), M. Yu. Melikova (1976), by F. I. Komarov (1976) — developed classifications of a peptic ulcer taking into account features of clinical implication, the course of a disease, localization of an ulcer and other factors.

The kliniko-morphological picture of a disease is most in detail reflected in the classification offered by F. I. Komarov. On features a wedge, manifestations I. divide into several types — neurovegetative, gastritichesky and trophic. On localization allocate stomach ulcer (small curvature, big curvature, a front wall, a back wall, peloric, prepyloric, subkardi-alny, fundal), an ulcer of a duodenum (a bulb, extra bulbous), and also the ulcers located both in a stomach, and in a duodenum. By quantity of an ulcer can be single and multiple.

On a current the disease is divided on acute (a fresh ulcer) and chronic (seldom recurrent, often recurrent), allocate stages of an aggravation, remission, incomplete remission (the calming-down aggravation). On a condition of secretory function allocate a hyperacidity, a normo-hlorgidriya, an achlorhydria, an akhiliya; on a condition of motor function of a stomach and duodenum allocate the most expressed disturbances — a pylorospasm, a cardiospasm, hypotonia (atony) of a stomach, a ventroptosis, bulbostaz, duodeno-staz. Besides, classification included complications — bleeding, a penetration, a perforation, cicatricial changes (deformation of a bulb of a duodenum or stomach, a pyloric stenosis), a malignancy.

Depending on morfol. features of ulcer defect and dynamics of reparative processes allocate the cicatrizing ulcer (in case of reduction of its sizes), it is long not cicatrizing ulcer (in the absence of signs of scarring within 30 days and more), a huge ulcer (diameter more than 30 mm), a kallez-ny (calloused) ulcer with dense edges and a bottom owing to snowballing of cicatricial fabric, the migrating ulcer (emergence of an ulcer in other department of a stomach or duodenum) and the complicated ulcer (bleeding penetrating, perforated, malignizi-rovanny).

The etiology and a pathogeny

Exists a set of theories of development I., however any of them to a crust, time completely does not open all mechanisms of ulceration.

In a basis of the first theory of developing of a disease — vascular, formulated by R. Virkhov in the middle of 19 century, anatomic changes of blood vessels in a zone of an ulcer (thrombosis, an embolism, an arteriolosclerosis) were put. According to the mechanical theory of L. Ashoff developing of an ulcer is connected with traumatizing by rough food of a mucous membrane of a stomach in the field of small curvature («a gastric path»). G. E. Konjetzny which offered the inflammatory theory assumed that ulcer process develops against the background of inflammatory changes of a mucous membrane of a stomach and is a consequence of gastritis or erosion. Considering frequent formation of an ulcer in the places which are most affected by a gastric juice, E. R. Rie-gel proved the peptic theory. P. Balint on the basis of the revealed shifts of acid-base equilibrium in the acid party at patients I. put forward the theory of «acidosis». According to the neurovegetative theory offered by G. Bergmann, hypersecretion of a gastric juice, hyper motility of a stomach and vascular disorders in it at persons with konstitutsionalno the caused dominance of a tone of a parasympathetic nervous system are the reason of ulceration. Neuroreflex theory of I. I. Grekova and

N. D. Strazhesko explains developing of an ulcer with reflex influences on a stomach, napr, at hron. appendicitis, colitis, cholelithiasis. According to the reflux theory the throwing of bile in a bulb of a duodenum and the stomach arising at increase in intra duodenal pressure or insufficiency of a peloric sphincter can serve one of factors of a yazvoobrazovaniye (in connection with destruction by bile acids and lysolecithin of protective slime).

The most reasonable remains the corticovisceral theory offered in 1952 by K. M. Bykov and I. T. Kurtsin, underlining the leading role of c. N of page and the subcrustal centers in disturbance of regulation of functions of a stomach and duodenum.

In a crust, time consider that formation of an ulcer both in a stomach, and in a duodenum results from the arising changes in the ratio of factors of «aggression» and «protection». Refer increase in acidity and peptic activity of a gastric juice in the conditions of disturbance of motility of a stomach and a duodenum to factors of «aggression», reduction of protective properties is caused by decrease in products of slime, delay of process fiziol. regenerations of a superficial epithelium, disturbance of local blood circulation and nervous trophicity of a mucous membrane. The long or often repeating psychoemotional overstrain, as a rule, of negative character (negative emotions, conflict situations, feeling of constant alarm, overfatigue, etc.) is the main reason for these changes. This concept combines views of clinical physicians, physiologists and pathomorphologists of a pathogeny of a peptic ulcer.

Defined etiol. a role is played by heredity that is confirmed rather high (40 — 60%) by the frequency of a disease at parents and relatives of patients, especially young age. It is established that at patients with the burdened heredity in a mucous membrane of a stomach is 1V2 — 2 times more than parietal glandulotsit (obkladoch-ny cells), than at healthy. Signs of genetic predisposition are 0(1) blood group which is often found at patients I., lack of AVO antigen (see. Group-specific substances, Blood groups), deficit of a ^-anti-tripsin and fukoglikoproteid, and also decrease in quantity T-lim-fotsitov, increase in number of V-lymphocytes and undifferentiated lymphocytes (see. Immunocompetent cells).

The factors contributing to developing of a disease, especially at hereditary burdeness, errors in food (e.g., food with no drink, irregular meal, the use of rough or spicy food, its bad chewing, bystry food, lack of teeth), insufficient contents in foodstuff of proteins and vitamins are. Impact smoking and alcohol intake that is connected with increase in gastric secretion and peptic activity of a gastric juice under the influence of nicotine and ethanol, and also with ability of ethanol to destroy a proteinaceous and lipidic complex of an apical membrane of cells of a superficial epithelium of a mucous membrane and to induce back diffusion of hydrogen ions exerts on development of a disease. Increase at nek-ry patients I. immunoglobulins of a class A (see Immunoglobulins) and existence in blood of antibodies to certain antigens of tissues of stomach allowed to assume a role of autoimmune aggression in emergence and development of a disease, however in a crust, time of convincing data for justification of the autoimmune nature I. does not exist.

At the heart of formation of ulcer defect of a mucous membrane of a stomach or a duodenum process of proteolytic destruction of fabric a gastric juice lies in places with the broken trophicity. The probability of ulceration significantly increases at decrease in an alkaline component in a gastric secret and more long contact of an acid gastric juice with a mucous membrane both at a spasm of the gatekeeper, and at bystry evacuation of acid contents from a stomach in a duodenum.

Along with increase in activity of an acid and peptic factor the importance in formation of an ulcer belongs to decrease in a protective barrier of a mucous membrane that is shown by reduction of content of mucin (see) in gastric and duodenal slime, destruction of an apical membrane of a superficial epithelium, and also frustration of a neurovascular trophicity of a mucous membrane of bodies. Normal mucin thanks to being its part sialine to - there is exclusively steady against proteolytic effect of pepsin (see) and trypsin (see); besides, it has ability to connect salt to - that and to adsorb pepsin, and also to inhibit peptic digestion that is caused by action mucoitinsulphuric to - you, the slime which is formed as a result of hydrolysis.

At destruction of a mucous barrier and proteinaceous and lipidic complex of an apical membrane of epithelial cells back diffusion of hydrogen ions in a mucous membrane considerably increases. At the same time in cases of disturbance of a local blood-groove (a spasm of arterioles, venous staz, development of a fabric hypoxia and acidosis) there is an activation of kallikrein-kinin system here (see Kinina) that, in turn, promotes increase in permeability of capillaries, disorder of microcirculation, release of products of peroxide oxidation of lipids and damage of lysosomic structures of cellular elements. At destruction of cellular membranes of the ferruterous device it is possible to allow a possibility of activation of a pepsinogen of the main glandulotsit salt to - that, developed by parietal glandulotsita, directly in a submucosa (see. Gastric juice). More frequent formation of an ulcer in antral department of a stomach and in a bulb of a duodenum is explained by relative poverty of vascular network in these departments of gastroduodenal system, a large number of trailer arteries and arteriovenous shunts in the field, more dense network of nerve terminations and quite powerful muscular layer demanding more than oxygen for ensuring propulsive ability of a peloric press and a duodenum.

The realization of adverse neuroemotional influences on gastroduodenal system is enabled through the forefront of a hypothalamus, branch of a vagus nerve, atsetilkholinovy, histamine and tastrinovy receptors of the main and parietal glandulotsit. Along with it stimulation of a kislotoob-razovaniye and proteolytic activity of gastric glands happens under the influence of thyritropic and adrenocorticotropic hormones. The last raises glucocorticoid and reduces mineralokortikoid-ny activity of bark of adrenal glands. At the same time ulcerogenic action of cortisol is connected with the fact that under its influence products salt to - you raise and protective and reparative properties of a mucous membrane of a stomach and duodenum decrease. Decrease in synthesis of cortexone (see) leads to increase in the content in blood of potassium ions stimulating through cyclic 3', 5' - AMF — µАМФ (see Adenozinfosforny acids) products salt to - you in parietal glandulotsita. Along with disturbances in the central link of neurohumoral regulation of the main functions of a stomach and duodenum in development I. more important also local mechanisms matter. In particular, at disturbances in food there is a hyperplasia gastrinprodutsiruyushchy cells of a mucous membrane of antral department of a stomach and increase in products of gastrin (see). Increase in its activity can arise also at reduction of products of the gastrointestinal hormones inhibiting a kislotoobrazovaniye in a stomach — secretin (see), cholecystokinin (see), a gastron and urogastrone (see the Stomach, physiology), enteroanthelone (see), gastric inhibitory hormone (Gip), and also sex hormones (see) and a calcitonin of a thyroid gland (see Kaljtsitonin). The modulator of secretory and endocrine functions of a stomach, intestines and pancreas is the somatostatin (see) which is contained in cells of a stomach and a pancreas (see. And POOD system, t. 20, additional materials).

Final stage in increase in activity of an acid and peptic factor is excitement of histamine receptors of the main and parietal glandulotsit, increase in products of tsAMF from ATP (see. Adenosine triphosphoric acid) of I, stimulation of enzymatic processes of oxidizing phosphorylation in synthesis salt to - you and a pepsinogen. Effect of a histamine (see) both in parietal, and in the main glandulotsita substantially decides by its interaction on H2 receptors of a mucous membrane of a stomach, stimulation adenilatsshchk-manholes (see Adenozinfosforny acids) and accumulation of tsAMF — the major intracellular factor realizing neurohumoral influences by sharp increase in metabolic activity of cells of a mucous membrane. These data are confirmed by the fact that after introduction of a histamine by the patient I. with localization of an ulcer in a duodenum substantial increase of the tsAMF level in a mucous membrane of a stomach and in a gastric juice is noted, and increase in level of a histamine in blood is followed by simultaneous decrease of the activity of a histaminase. Along with a histamine increase in maintenance of tsAMF in cells of a mucous membrane of a stomach is caused also by all other substances stimulating products salt to - you (acetylcholine, gastrin, sweep l xanthines, glyukokortiko ides, drugs of potassium and calcium), however on the mechanism of action they differ from each other. Ions of magnesium suppress secretion salt to - you, brake activity of tsiklazny system. The important role in protection of a mucous membrane of a stomach against influence salt to - you and pepsin belongs to regenerator abilities of an epithelium, full substitution to-rogo happens within 4 — 6 days. Intracellular regulation of proliferation and differentiation of cells of a mucous membrane of a stomach and duodenum irrespective of character of a mitogenetic incentive is carried out by calcium ions, tsAMF gastrin, cyclic 3', the 5th '-guanozinmonofos-fathom — tsGMF (see. Guanylic acid) and acetylcholine (see), and it is supposed that gastrin and acetylcholine promote increase in content of calcium in proliferating cells of a mucous membrane of a stomach and duodenum, and also stimulate a regenerator cycle. There are also local regulators of cellular updating of a mucous membrane in the form of the chalones (see) having ability to inhibit mitoses by impact on C2 phase of a cellular cycle, at the same time more expressed inhibitory effect is observed at localization of an ulcer in a bulb of a duodenum.

Thus, the high risk of developing of an ulcer (a so-called ulcerogenic situation), especially at patients with the burdened heredity, arises only in case of decrease in a protective barrier as a result of deficit of glikozaminoglikan (see Mucopolysaccharides) and the glycoproteins which are especially containing a fukoza, decreases of the activity of regeneration of a mucous membrane at changes in the ratio of tsAMF and tsGMF and also disturbance of local blood circulation and a nervous trophicity mainly in places with the developed reflexogenic zone and with rather small vascularization (antral department of a stomach and a bulb of a duodenum). In disturbance of microcirculation, permeability of capillaries and cellular membranes, a nervous trophicity and metabolism of a mucous membrane of a stomach and duodenum during the formation of an ulcer the important role belongs to a local circulator hypoxia, acidosis, and also the factors participating in increase in kislotnopeptichesky activity of a gastric juice (a histamine, acetylcholine, gastrin, glucocorticoid hormones, kinina, products of peroxide oxidation of lipids), especially in the conditions of decrease in level of inhibitors of a kislotoobrazovaniye and proteolysis.

Taking into account all features of a pathogeny it is possible to allocate three stages of formation of an ulcer: a stage neuro vaskulyatornoy dystrophies, a stage of a necrobiosis in a submucosa and a stage of ulcer destruction of a mucous membrane as a result of proteolysis. At the same time at the beginning of development I. functional gastric disturbances or a duodenum (hypersthenic type) are of great importance, and also antral gastritis and a duodenitis (with the increased and normal secretion), to-rye are characterized as «predjyazvenny states» and the same as I., are shown by a hyperplasia of gastrinprodutsiruyushchy and mast cells, a hyperplasia and hyperfunction of own glands of a stomach, decrease in products of mucin. Confirmation to it is «the gastritichesky anamnesis» at 60 — 70% of patients I.

On the basis of the above it is possible to mark out the following risk factors of emergence I.: the long or often repeating neuroemotional overstrain (stress), genetic predisposition, including long and permanent increase in gastric acidity of constitutional character, hron. gastritis and a duodenitis with hypersecretion, functional gastric disturbances and a duodenum of hypersthenic type, disturbance in food, smoking and abuse of hard alcoholic beverages. At persons of young age with the specified risk factors the peptic ulcer arises much more often.

Experimental ulcer. Models of stomach ulcer or a duodenum are developed on different types of animals (the highest primacies, dogs, rats, mice, rabbits, Guinea pigs, hamsters, polecats, etc.). However to a crust, time at animals did not manage to reproduce the model of a disease completely corresponding I. the person, in the mechanism of development a cut an important role is played by neurohormonal factors. The created pilot models reproduce preferential one or several links of a pathogeny of a disease; they are used for studying of mechanisms of ulceration. The majority of pilot models corresponds not to initial, but final stages of formation of ulcer process at the person. By means of a number of models it is possible to study nervous or hormonal mechanisms of development I. Pilot models depending on a method of reproduction of a disease can be conditionally divided into four groups: the ulcers got by impact on these or those structures of a nervous system; «hormonal» experimental ulcers; «pharmacological» experimental ulcers; ulcers, ulcerations got by impact on local mechanisms., the First group of models can be received by their reproduction by the principle of the corticovisceral pathology developed by K. M. Bykov and I. T. Kurtsin or is reproduced by means of impact on various structures of the central and peripheral nervous system. The most reasonable are models with damage or stimulation of the centers of a hypothalamus. One of the first works on studying of a role of the hypothalamic centers in the mechanism of ulceration was executed in 1926

by H. N. Burdenko and B. N. Mogilnitsky, to-rye got multiple gastroduodenal ulcers and a hyperemia of a mucous membrane of a stomach and duodenum at dogs at damage of a hypothalamus by the metal probe. A. D. Speransky and sotr. (1937) got ulcers preferential in peloric department of a stomach and a bulb of a duodenum after the room of a glass ball in the basis of the Turkish saddle. P. G. Bogach,

A. F. Kosenko (1956, 1977), Martin, Shne-dorf (J. Martin, J. G. Schnedorf, ■ 1938), etc. caused formation of ulcers in went. - kish. a path by implantation of microelectrodes in the centers of a hypothalamus and irritation their electric current. These models are very difficult, but are most adequate I. the person also allow to study a role salt to - you, enzymes, components of slime (glycoproteins and glikozamino-glycanes) in yazvoobrazovaniya, regulation of products of these substances at the different levels, involvement in process of ulceration of hormonal mechanisms, a role in their development for century of N of page. It is necessary to refer also «stressful» defeats reproduced on small animals by creation of hypermotility to model of a peptic ulcer of the neurogenic nature (run in a squirrel wheel, continuous swimming), or by their immobilization in special metal or plastic cylinders.

E. A. The bug (1972), Robert, Nezamis, Stou (A. Robert, J. E. Nezamis, D. F. Stowe, 1975), etc. for receiving a canker of a stomach at rats used «hormonal» model; at the same time ulcers at animals formed at hypodermic administration of steroid hormones by it in a daily dose of 3 — 5 mg and more within 3 — 4 days.

Pilot models of a canker of a stomach or duodenum are reproduced often by means of various pharmakol. means of the non-hormonal nature, first of all stimulators of gastric secretion. Hay, Varko, Koud (L. J. Hay, R. L. Varco, Page F. Code, 1942) entered an experimental animal intramusculary a histamine in wax. Slow long absorption of a histamine continuously supported the increased gastric secretion that led to formation of ulcers in a bulb of a duodenum, is more rare in a stomach. Later Robert, Nezamis, Stou (1975); Hosoda, Ikedo, Saito (S. Hosoda,

H. Ikedo, T. Saito, 1981), etc. suggested to use the automatic pump for ensuring the continuous dosed receipt in an organism of the animal this or that stomach of means stimulating secretion. Mann (N. S. Mann, 1977) was hit erosive damages of a mucous membrane of a stomach at rats at introduction by it in a stomach quadruple with a one-hour break acetilsalicylic to - you, an ibuprofen, Naproxenum, indometacin, phenylbutazone, L-DOFA, etc. Ulcerogenic effect of the specified medicines is mediated and also is caused by stimulation of histamine receptors. The proof of it is absence of the erosion at preliminary introduction by an animal of a metiamid and Cimetidinum blocking H2 receptors of a mucous membrane. The model of tsinkofenovy stomach ulcer at dogs offered by Cherchill and Van-Vagoner is very widespread (T. P. Churchill, R. N. of Van Wagoner, 1931), in formation a cut a certain role belongs to steroid hormones and proteolytic enzymes of a mucous membrane of a stomach.

It is necessary to carry the ulcers of a duodenum reproduced by Mann and Vilyamson to model of the fourth group (F. Ch. Mann, Page S. Williamson, 1923) at dogs by change of the site of a duodenum in terminal department of an ileal gut. In a pathogeny of such ulcers an essential role is played by the developing gastric hypersecretion and lack of neutralized effect of bile and a secret of a pancreas. In offered in 1945 by Shay (N. of Shay) models of the ulcer at rats got by deligation on area of the gatekeeper, an essential role are played by stimulation of cholinergic processes. Because of simplicity of reproduction the «acetate» model of stomach ulcer offered by Okabe, Pfeyffe-rom was widely adopted (S. Okabe, Page J. Pfeiffer, 1971), at a cut receive ulcer process by short-term application ice acetic to - you on the site of a serous cover of a stomach. The choice of model of cankers of a stomach and duodenum depends on desire of the experimenter and is defined by need to investigate these or those mechanisms of development patol. process.

Development of pilot models of a peptic ulcer serves for studying of a pathogeny of a disease and searches of effective methods of treatment.

Pathological anatomy

Morfol. substrate Ya. is hron. the ulcer located in a stomach or a duodenum. In 85,3% of cases of stomach ulcer are single and in 14,7% — multiple. Single ulcers of a duodenum meet in 94,5% of cases. In 2,9% of cases the combination of stomach ulcer and a duodenum is noted.

Stomach ulcers in most cases are located on its small curvature in prepyloric and peloric departments, is much more rare in cardial and subcardial departments. The majority of ulcers of a duodenum is localized in its upper part, rather seldom they are found in other departments of a gut (so-called out of bulbous ulcers). According to Oi (M. of Oi), etc. (1959), 94% of all stomach ulcers are located on border between zones of actually gastric and peloric glands, usually on the party of peloric glands, i.e. on the site of a wall of a stomach limited to front and back slanting fibers and a circular layer of a muscular coat of a stomach where at its movements the greatest stretching is noted. Duodenal ulcers are usually located in a transition range of a mucous membrane of a duodenum in a mucous membrane of a stomach, over a zone where the sphincter of the gatekeeper separates from circular muscles of a duodenum a connective tissue layer, i.e. in the zone which is also exposed to stretching during peristaltic movements.

The sizes of ulcers at I. can be various and fluctuate from several millimeters to 5 — 6 cm in the diameter and more. According to Thomas (J. Thomas, 1980), etc., average area hron. stomach ulcers makes 49 mm2, and depth — from 5 to 20 mm. Ulcers can have the round, oval or irregular form. Their vertical axis (in relation to a wall of a stomach or duodenum) is displaced to a cardial part of body and therefore takes place in the slanting direction. The edge of the ulcer turned to an entrance to a stomach, podryt and a mucous membrane hangs over ulcer defect. The opposite edge of an ulcer flat, terrasovidny that, according to I. V. Davydovsky, is connected with the shift of a mucous membrane as a result of the hyperperistalsis directed towards the gatekeeper. Folds of a mucous membrane on the periphery of an ulcer are thickened and meet (converge) to edges of ulcer defect. The serous cover in a zone of an ulcer is sharply thickened.

The microscopic picture of edges and a bottom of an ulcer depends on a stage of a disease. In a stage of an aggravation the bottom of an ulcer consists of four layers. The first, surface layer,

1 — 2 mm thick is formed by the unstructured necrotic masses, slime, fibrin, a deskvamirovanny epithelium, leukocytes and erythrocytes. In this layer fungi in the form of a mycelium often meet, colonies of microorganisms are more rare (at patients with hyposecretion of a gastric juice). Among necrotic masses in deep ulcer defects food particles can be found. The second layer — a zone of a fibrinoid necrosis (see. Fibrinoid transformation) — often discontinuous 1 — 1,5 mm thick. At quickly progressing process the layer of a fibrinoid necrosis is sharply thickened. Assume that formation of this layer is connected with treatment of collagenic fibers fibrinogen of plasma. The layer of a fibrinoid necrosis interferes with penetration of a «aggressive» gastric juice into deeper layers of a bottom of an ulcer. The third layer of a bottom of an ulcer comes to light not always. It is formed by granulyatsionny fabric with a large number of vessels, in a cut the limfoplazmotsitarny infiltration expressed in various degree and a sclerosis is noted. During the progressing of process this layer is exposed to a fibrinoid necrosis, and during the healing — to scarring. The fourth layer is presented by connecting fabric of different degree of a maturity, edges extends far for limits of macroscopically visible ulcer defect.

Blood vessels are exposed to considerable changes in area of a bottom and edges of an ulcer. In arteries and to a lesser extent in the veins located in a zone of a necrosis or near it inflammatory infiltration and a fibrinoid necrosis of walls, fibrinferments of gleams is noted. Often in arteries the picture of productive arteritis develops (see) with damage of all layers of a vascular wall, a considerable thickening of an internal cover, an obliteration of a gleam. At the same time in an internal cover of vessels smooth muscle cells form and glikozaminoglikana collect, the hyperelastosis due to growth of fibers is noted inner elastic membrane. In an average cover of arteries hypertrophic and atrophic changes are observed. In sites of an atrophy of an average cover merge of internal and outside elastic membranes can be noted. The described changes quite often are followed by mural or occlusive thrombosis (see) with the subsequent organization and a rekanalization of blood clots. In rekanali-zuyushchikhsya blood clots and a muscular coat of arteries vessels are formed, to-rye can connect to vasa vasorum that provides collateral circulation. In veins the sclerosis and a hyperelastosis of walls which is followed by narrowing of gleams is expressed. Quite often in a wall of a stomach in the field of an ulcer an arteriovenous anastomosis forms. At advanced and senile age similar changes of vessels come to light also in other departments of a stomach. Along with them in large arteries, it is preferential in the left gastric, symptoms of atherosclerosis are noted. Changes of vessels in a zone of an ulcer are the reason of further deterioration in blood supply of affected areas that complicates healing of an ulcer and promotes its recurrent current.

In intramural neuroplexes vacuolation of cytoplasm and pycnosis of kernels of ganglionic cells, lymphoid and cellular infiltration is noted. In the field of an ulcer the growths of nerve fibrils creating large amputating neuromas constantly are found.

Edges of an ulcer are characterized by flattening of a superficial epithelium, its cells are rich with RNA, in them synthesis of DNA is increased, symptoms of a dysplasia are quite often noted.

Progressing hron. ulcer process it is shown by expansion and uglubleyiy ulcer defect. Increase in the sizes of an ulcer happens due to destruction of its edges (is centrifuge) or formations of erosion and acute ulcers close hron. ulcers with the subsequent their merge (tsentripetalno). Depth yaz you increases as a result of a necrosis in the field of its bottom. The necrosis can be focal or takes all bottom of an ulcer, quite often extends in the parties from its center, stratifying edges of an ulcer.

Healing of an ulcer begins with sloughing and epithelization of the cleared bottom. Sloughing can be promoted by the active growth of the epithelium getting under a layer of a necrosis. The regenerating epithelium is flattened, basphilic, cytoplasm of its cells is rich with RNA. Further the epithelium becomes higher, begins to cosecrete slime. Gradually gastric poles, and then and glands form, to-rye, however, have simpler structure, than inherent to the relevant department of a mucous membrane. Also the muscular plate of a mucous membrane can be exposed to regeneration. At the same time the large smooth muscle cells forming in places uneven thickenings form. In the regenerating sites elastic fibers do not come to light that allows even to find the place of the former ulceration after a complete recovery of a mucous membrane. The muscular coat of a stomach in the field of an ulcer is not recovered, and replaced with fibrous fabric, in a cut it is possible to find groups of muscle cells. Thus, the term «hem after an ulcer», eurysynusic in clinic, is related to a submucosa and a muscular coat, and the mucous membrane regenerates without formation of a hem.

At an endoscopic research on site of ulcer defect in the course of scarring the palisadoobrazny regenerating epithelium, in the regenerating fabric — a hyperplasia of capillaries (a stage of a red hem) is defined. At gistol. a research emergence in a neogenic mucous membrane unripe is noted psevdopit richesky glands. Further the mucous membrane regenerating on site ulcer defect takes a form of «cobblestone road», capillaries zapustevat, the quantity them considerably decreases that leads to decolourization of a hem (a stage of a white hem). At a histologic research in these sites a large amount of psevdopilorichesky glands is defined. After healing of ulcers of a duodenum hems can not be formed.

Characteristic changes at I. are observed as well in the zones remote from an ulcer. So, at duodenal ulcers the mucous membrane of a stomach contains giperplazirovan-ny actually gastric glands, increase in number of the main glandulotsit, and also considerable (almost double in comparison with norm) increase in quantity of parietal glandulotsit is noted. By means of electronic microscopic examination it is established that along with a hyperplasia of glands there is their accelerated differentiation, thanking a cut the number of the mature functionally active cells developing salt to - that increases. At patients with a duodenal ulcer many researchers note also a hyperplasia of the cells producing gastrin, number to-rykh almost twice surpasses their quantity at stomach ulcers. In a zone of actually gastric glands (in the field of a greater cul-de-sac) change-types hron prevail. gastritis (see), in distal departments of a stomach symptoms of atrophic gastritis with the phenomena of an intestinal metaplasia (enteroliza-tion) quite often come to light. At advanced and senile age in all departments of a stomach atrophic gastritis develops. In comparison with norm at I. with localization of an ulcer lymphoid and cellular infiltration of own plate increases in a stomach in its antral department and in the field of edges of an ulcer, the number of the cells cosecreting immunoglobulins, preferential a class G increases. Accumulations of the cells cosecreting IgG come to light in connecting fabric of a bottom of ulcers. These data confirm activation of immune system at I., what is caused by antigenic properties of decomposition products of a bottom of an ulcer, viruses and microorganisms, and also formation of autoantibodies.

Certain changes come to light also in a submucosa and a muscular coat of a lesser cul-de-sac. According to Libermann-Meffert (D. Liebermann-Meffert, 1979), etc., thickness of a submucosal layer can increase twice, and a muscular coat — by 3 times.

Complications I., according to the offer B. And. Samsonova (1975), divide into ulcer and destructive — a penetration (distribution of in-filtrativno-ulcer process to thickness of the next body), a perforation (see), bleeding (see. Gastrointestinal bleeding), inflammatory — a perigastritis (see), a periduodenitis (see), ulcer and cicatricial — a stenosis (see Pilor about a stenosis), deformation; the complications connected with a malignancy of an ulcer (see the Stomach, tumors) and combined.

The penetration most often occurs in a pancreas and an omentulum. In some cases at bystry progressing of process fatty tissue of an omentulum with large blood vessels appears a bottom of an ulcer. The penetration in a pechenochnodvenadtsatiperstny sheaf and a liver is much less often observed. At a penetration of stomach ulcer or a duodenum in a lean or cross colon, in a gall bladder, a diaphragm or in an aorta internal fistulas are formed. The penetration of an ulcer (in case of its arrangement on the wrinkled and shortened small curvature of a stomach) in an initial part of a duodenum leads to formation of gastroduodenal fistula. In extremely exceptional cases the penetration of an ulcer in a front abdominal wall with formation of outside fistula is possible. The perforation of a wall of a stomach or duodenum occurs at bystry destruction of a bottom of an ulcer and leads to development of peritonitis (see).

Bleeding is the most frequent complication of a peptic ulcer and the most frequent cause of death of patients. It arises owing to an arrosion of walls of the vessels located in day of an ulcer (see the Arrosion). Weight of bleeding depends on caliber of an arrozirovanny artery and on expressiveness of perivascular fibrosis. Heavy profuse bleedings arise at the ulcers located in 3 — 4 cm from small and big curvature of a stomach — in places where branches of gastric arteries pass, without being divided, through a muscular coat in a submucosa. Quite often deadly, the helcomenia, penetrating in an omentulum, as a result of destruction of the large arteries passing in it can be profuse. The spontaneous stop of bleeding is promoted by a peculiar invagination of vascular walls with narrowing of its gleam. The vessels located in a zone of a hem lose ability to fall and invagination in connection with fixing of their walls perivascular growths of fibrous fabric.

The cicatricial gastrostenosis is caused by excess growth of connecting fabric during the healing of the ulcer located in peloric department of a stomach. Hems in a middle part of a stomach lead to its deformation as hourglasses.

The clinical picture and a current

the Main symptom of a disease in typical cases is a colicy pain in epigastric or piloro duodenal area. Pain is characterized by frequency and rhythm (communication with meal), can irradiate in interscapular space and usually abates after reception of a small amount of food, milk, hydrosodium carbonate, use of heat. At height of a painful attack quite often there is single vomiting acid contents, after a cut there can occur improvement of health (often for the purpose of reduction of pain patients cause vomiting); heartburn, locks of spastic type are observed. For I. seasonality of aggravations (more often in the spring and in the fall), and also their communication with a nervnoemotsionalny overstrain, a heavy exercise stress, the use of rough and spicy food, with big breaks in meal, with alcohol intake is characteristic. Increased fatigue, irritability, frustration of a dream, perspiration is noted. Language is laid over at a root. At a palpation and percussion in epigastric area and in a zone of a projection of a bulb of a duodenum (a piloroduodenal-ny zone) morbidity, and also a moderate muscle tension comes to light. In an initial stage of a disease the tendency to arterial hypotension and bradycardia, the passing phenomena of a cholestasia (see), signs of dysfunction of a pancreas, dyskinesia of a large intestine of spastic type (see Intestines, functional diseases) and different neurotic symptoms are observed (see the Neurasthenia). Approximately at a half of patients the hyperacidity is defined (see).

Features a wedge, manifestations and courses of a disease depend on localization of ulcer defect, existence of associated diseases, a condition of nervous and endocrine systems, a sex, age of the patient, prescription of a disease and other factors.

At localization of an ulcer in a bulb of a duodenum or antral department of a stomach of pain arise on an empty stomach more often (hungry pains), at night (night pains) or in 1 — 2 hour after food (late pains). Pains, as a rule, abate after meal, especially milk, or hydrosodium carbonate. Patients often complain of the persistent heartburn (see) arising usually later i1/2 — 3 hours after food (heartburn can be considered as an equivalent of late pains), and also an eructation acid. Gastric acidity is increased (see. Gastric juice). At a palpation morbidity in epigastric or piloroduodenalny area is noted.

At patients with localization of an ulcer in cardial department of a stomach (it is rare in abdominal department of a gullet) pain arises right after food (early pains), especially after reception of spicy or hot food, happens aching, pressing or holding apart, the hypochondrium is localized under a xiphoidal shoot or in left (the ulcer is closer to cardial department of a stomach, the pains are projected above). Here the burning sensation is quite often noted during meal. Pain irradiates up the course of a gullet and to the area of heart; abates after reception of hydrosodium carbonate or milk. Persistent heartburn and an eructation is noted by food. At a palpation morbidity under a xiphoidal shoot is defined, and also during the pressing on it. Gastric acidity is more often lowered, sometimes normal, changes at sub maximum stimulation by a histamine a little. The ulcer is often combined with an incompetence of cardia, a gastroesophagal reflux (see).

Wedge, picture Ya. with localization of an ulcer in a body and a greater cul-de-sac it is characterized by the dull aching ache in an anticardium more often on an empty stomach or in 20 — 30 min. after food, occasionally at night. Pain abates after reception of hydrosodium carbonate or any food, especially milk. Are characteristic an eructation the eaten food, nausea. Heartburn happens seldom. Appetite is kept or lowered. Language is laid over by a dense gray-white plaque, morbidity at a palpation of a front abdominal wall in mezogastralny area is noted and in left hypochondrium; there is pain at percussion of a front abdominal wall, the muscle tension is quite often observed. Secretory function of a stomach is increased, gastric acidity normal or is lowered. In gastric contents a lot of slime, the increased content of gastromucoprotein, fukopro-theines, sialic acids and a lactate dehydrogenase is defined. The ulcers which are located in the field of big curvature of a stomach are inclined to a malignancy.

The special attention is deserved by me. with localization of an ulcer in the channel of a pylorus. Klien, signs remind it a duodenal ulcer (see above), however the pain syndrome differs in intensity and duration. Frequent aggravations, irradiation of pain in the right hypochondrium, in a back and for a breast, persistent vomiting in the large volume of acid contents of a stomach, a lose of weight of a body, hypersecretion and a hyperacidity are characteristic. Scarring of ulcers often leads to a stenozi-rovaniye of the channel of the gatekeeper. The malignancy of process is quite often observed.

I. with localization of an ulcer in post-bulbar area occurs preferential at persons of middle and advanced age. It is shown by heartburn, an eructation, persistent pains in mezogastralny area and in drank-roduodenalnoy to a zone with irradiation of pain in the right or left hypochondrium, the right shoulder or a shovel, in a back that demonstrates involvement in patol. process of biliary tract and pancreas. Vomiting, often repeated, arising at height pains, as a rule, does not give relief. Gastric acidity normal or raised. Signs of a cholestasia are characteristic. Intestinal bleedings can be frequent the first symptom of a disease. The correct diagnosis is possible only at careful purposeful radiological and endoscopic researches.

I. meets double ulcer defect rather seldom. There is a formation of stomach ulcer at patients to a duodenal ulcer more often, however also the return sequence can meet. In the first case against the background of a wedge, pictures, characteristic of a duodenal ulcer, early pains, feeling of weight in an anticardium develop, the eructation air and the eaten food, stops seasonality of aggravations; there is a tendency to hypo - and achlorhydrias (see the Achlorhydria, the Hypochlorhydria).

Current I., as a rule, chronic, characterized by the gradual beginning, increase of symptomatology, recurrence of process. However also the acute form Ya is possible., at a cut duration of a disease makes no more than 1 year from the moment of detection of an ulcer. The wedge, pictures at an acute form of a disease is feature rather bystry disappearance of symptoms and scarring under the influence of treatment, and also frequent development of complications (bleeding, a perforation).

Depending on sharpness and dynamics patol. process distinguish the following stages I.: an aggravation

(recurrence), the calming-down aggravation, remission. Allocate a peptic ulcer with often recurrent and continuously recurrent current.

Depending on features the wedge, pictures mark out three severity I.: easy, moderately severe and heavy. At the easy course of a disease of an aggravation are observed 1 — 2 time a year, the arising dispeptic frustration and a pain syndrome are stopped during 1 — 2 week; weight reduction (weight) of a body, complications and disturbances from other bodies and systems is not observed. At I. moderately severe aggravations are noted 1 — 3 time a year; the wedge, a picture is characterized by considerable expressiveness * a pain syndrome and dispeptic frustration, weight reduction, signs of a periprotsess (see the Periduodenitis, the Perigastritis); deformation of a bulb of a duodenum, partial steno-zirovaniye of the gatekeeper, associated diseases of other digestive organs and gastrointestinal bleedings in the anamnesis come to light.

Heavy degree I. the znachitel is characterized by continuously recurrent current and the expressed symptomatology,the ny weight loss, complications (bleedings, perforations and a penetration) expressed by cicatricial changes of a stomach or duodenum, damage of other digestive organs, persistent disbolism.

Terms of scarring of an ulcer quite often have accurate communication of the patient, prescription and disease severity, the size of an ulcer, existence of the previous chronic gastritis with age (see), a duodenitis, (see), a gastroduodenita, associated diseases, and also depend on timely hospitalization and efficiency of therapy. Disappearance of a niche is noted on average through 30 — 32 in the afternoon, and formation of a dense hem at an endoscopic research — through-48 — 50 days.

Women have a current I. more favorable, differs in rare aggravations, moderation of a pain syndrome, weak expressiveness of dispeptic frustration, insignificant гип^рхлоргидрией. Approach of remission pregnancies and increase of aggravations after the delivery and in a climacteric is characteristic in time.

I. at persons of youthful and young age arises usually against the background of a predjyazvenny state (gastritis, a gastroduodenit), differs in more expressed symptomatology, Torahs-pidnostyyu of a current, in a high level of acidity and proteolytic activity of a gastric juice, increase in a physical activity of a stomach and duodenum; quite often first symptom of a disease happens went. - kish. bleeding (see below).

I. at advanced and senile age arises against the background of relative increase of glucocorticoid activity of adrenal glands in the conditions of the progressing fading of function of gonads, and also the accruing decrease in a trophicity of a mucous membrane of a stomach, special owing to disturbance of blood circulation at atherosclerosis of mezenterialny vessels. It is often preceded hron. inflammatory processes of century

to a .zheludka and duodenum. Ulcers at people of advanced and senile age are more often localized in a stomach. At persons is more senior 60 gastric localization of an ulcer .lt meets by 3 times more often than at patients of young and middle age.

The stomach ulcers which arose at advanced and senile age differ in the considerable sizes { huge ulcers), the superficial bottom covered with a gray-yellow plaque, an illegibility and bleeding of edges, hypostasis, a hyperemia and an atrophy of the mucous membrane surrounding an ulcer, slow healing of ulcer defect quite often meet.

I. at people at advanced and senile age proceeds as gastritis more often and differs in short duration, weak expressiveness of a pain syndrome, lack of its accurate communication with meal. Patients show complaints to feeling of weight, completeness in a stomach, the diffuse aching ‘pain in an anticardium without accurate localization irradiating in the right and left hypochondrium under a xiphoidal shoot, to the area of a breast, to the bottom of a stomach. Dispepsichesky frustration are shown by an eructation, nausea; heartburn and vomiting are observed less often. Locks, a loss of appetite and weight loss are characteristic. Language is laid densely over. At a palpation morbidity in an anticardium, in the area ^проекции a gall bladder, a pancreas, capotement, signs of a ventroptosis (see) and an enteroptosia (cm, the Splanchnoptosia) is noted. Decrease in acid-forming and pepsinoobrazuyushchy function of a stomach is often noted, positive reaction a calla on the occult blood comes to light (see Kal, a chemical research); gradually hypochromia anemia develops (see. Iron deficiency • anemia). Disease differs in monotony, lack of accurate frequency and seasonality of aggravations; at most of patients it is burdened by others hron. diseases of system of digestion — cholecystitis (see), hepatitis (see), pancreatitis (see), a coloenteritis (see Colitis, Enteritis), and also hron. coronary heart disease (see), an idiopathic hypertensia (see), atherosclerosis (see), cardiovascular insufficiency (see) and a pulmonary heart (see. Pulmonary heart). At persons of advanced and senile age delay of terms of scarring of an ulcer is observed, the frequency of complications increases. Most often there are bleedings; the penetration and a perforation meet much less often, and malignancies of an ulcer considerably more often than at persons of young and middle age.

At associated diseases, such as gastritis, a duodenitis, pancreatitis, a coloenteritis, cholecystitis, hron. coronary heart disease, is observed an atypical current I.: the characteristic day-night rhythm of pain (it becomes frequent it a constant) disappears, seasonality of aggravations is lost, the nature of pain changes (aching, pressing), appear feeling of completeness and weight in an anticardium, nausea, an eructation, are noted hypo-or an achlorhydria, decrease in a tone of a stomach. At a combination I. about a reflux esophagitis (see the Esophagitis) pain of burning character arises after reception of spicy, greasy, cold food, and also at hasty food. It is localized behind a breast, irradiates up a gullet, in a neck and in both shoulders, heartburn becomes constant and painful, amplifies at a sharp inclination of a trunk forward and in a prone position. The loud eructation and vomiting of food are characteristic.

Considerably the current I changes. in the conditions of wartime. In a wedge, a picture heartburn, hungry and late pains without accurate localization prevail, the hyperacidity and hyper motor dyskinesia of all are noted went. - kish. path; increase of a recurrence and complications is observed (bleedings and perforations).

Complications

Complications I. bleeding, a perforation, a penetration of an ulcer, a cicatricial pyloric stenosis, a malignancy of an ulcer, and also a perigastritis and a periduodenitis are.

Bleeding — the most frequent and serious complication; it occurs on average at 15 — 20% of patients I. is also the reason of nearly a half of all lethal outcomes at this disease. It is observed preferential at men of young age. More often at I. there are so-called small bleedings, massive bleedings meet less often. Sometimes sudden massive bleeding happens the first display of a disease. Bleeding results from an arrosion of a vessel in an ulcer, a venous staz and a vein thrombosis. It also various disturbances of a hemostasis can be the cause (see), at the same time a certain part is assigned to the gastric juice possessing anti-coagulating by properties. So, ability of a gastric juice to extend a calcium clotting time of plasma, a prothrombin time, to reduce concentration fibrinstabiliziruyushche-go a factor and to slow down transformation of fibrinogen into fibrin is noted; duodenal contents influence activation of plasmin and an inactivation V, VIII and IX blood-coagulation factors (see. Coagulant system of blood). According to A.S. Belousov, patients have Me. there is a certain dependence of a «local» hemostasis on acid and peptic activity of a gastric juice: the acidity of juice and activity of pepsin is higher, the coagulative properties of blood are less expressed. The symptomatology of bleeding depends on the volume of blood loss. Small bleeding is characterized by pallor of skin, dizziness, weakness; at the expressed bleeding the melena is noted (see), single or repeated vomiting, emetic masses remind a coffee thick (in detail see. Gastrointestinal bleeding).

Perforation (perforation) of an ulcer — one of the heaviest and dangerous complications which meets approximately in 7% of cases I. The perforation of ulcers of a duodenum that makes, according to separate surgical clinics, to 80% and more from total number of perforations is more often noted. However the perforation of the ulcer of a stomach is followed by higher lethality and more high frequency of postoperative complications. Overwhelming number of perforations of the ulcer of a stomach and duodenum represent so-called free perforations in an abdominal cavity. Approximately in 20% of cases (as a rule, at ulcers of a back wall of a stomach or duodenum) the «covered» perforations caused by bystry development of a fibrinous inflammation and cover of a perforated opening by an omentulum, the left hepatic lobe or a pancreas are observed. The perforation of the ulcer in a free abdominal cavity meets at men of young age also more often; quite often arises after reception of plentiful food. It is shown by sudden sharpest (knife-like) pain in an upper part of a stomach. Suddenness and intensity of pain do not happen so expressed at any other state. The patient accepts forced situation with the knees tightened to a stomach, tries not to move. At a palpation sharply expressed muscle tension of a front abdominal wall is noted. The perforation of the ulcer of antral department of a stomach or duodenum, at Krom occurs running off of gastric contents on the right channel of an abdominal cavity, is followed by sharp pain and in the right ileal area (as at appendicitis). During the first hours after a perforation patients have a vomiting, edges in the subsequent, at development of diffuse peritonitis (see), becomes repeated; bradycardia is replaced by tachycardia, pulse is characterized by weak filling. Appear fever, a leukocytosis, ROE is accelerated. At percussion of a stomach (definition of hepatic dullness) and at rentgenol. a research in an abdominal cavity under a diaphragm gas comes to light. During the developing of the so-called covered perforation, to-rogo does not result from penetration of a large number of gastric contents into an abdominal cavity, after violently developing symptomatology, in the next 2 — 3 hours, the health of the patient considerably improves, pains abate. However the muscular tension of a front abdominal wall in the field of an upper third of the right direct muscle of a stomach remains expressed during 2 — 3 days. The similar clinical picture is observed at a perforation of the ulcer not in a free abdominal cavity, and in the space limited to the commissures formed as a result of the previous inflammatory processes.

The penetration is characterized by penetration of an ulcer into the bodies adjoining to a stomach or a bulb of a duodenum — a liver, a pancreas, an omentulum. Klien, a picture in the acute period reminds a perforation, but pain happens less intensive. Soon signs of defeat of that body join, in to-ry there was a penetration (a girdle pain and vomiting at damage of a pancreas, pain in right hypochondrium to irradiation in the right shoulder and in a back at a penetration in a liver, etc.). In some cases the penetration occurs gradually. At diagnosis it is necessary to consider existence of a constant pain syndrome, a leukocytosis, subfebrile condition and restriction smeshchaye-pave a stomach or a duodenum at rentgenol. research.

A cicatricial pyloric stenosis at I. develops gradually. Cicatricial narrowing of the channel of the gatekeeper has circular character, and in an initial part of a duodenum process extends excentricly. The symptomatology of this complication depends on extent of narrowing of the gatekeeper and duration of gastric emptying. In a phase of compensation (a relative stenosis) there can be a feeling of weight, overflow in a stomach, especially after reception of plentiful food; the eructation acid, vomiting is sometimes observed. In a phase of subcompensation strengthening of pain, increase of vomiting is noted, emetic masses quite often contains the remains of food eaten the day before. Heavy disturbances in the form of falloff of body weight, dehydration of an organism, a hypoproteinemia, a hypopotassemia, an azotemia, etc. are characteristic of a phase of a decompensation. In detail — see the Pylorostenosis.

The malignancy of process is observed almost only at localization of an ulcer in a stomach, the malignancy of ulcers of a duodenum meets very seldom. At a malignancy of an ulcer of pain become constants, lose touch with meal, appetite decreases, exhaustion accrues, nausea, vomiting become frequent; subfebril-ny temperature, the anemia accelerated by ROE, with firmness positive benzidine test (see) are noted. In detail tumors of a stomach and a duodenum — see the Duodenum, tumors; Stomach, tumors.

To complications I. carry also a perigastritis (see) and a periduodenitis (see).

Diagnosis

Diagnosis I. put on the basis of carefully collected anamnesis, characteristic a wedge, pictures, data of laboratory, radiological and endoscopic researches. During the collecting the anamnesis it is necessary to pay attention to the previous diseases, a neuroemotional overstrain, disturbances in food, smoking, abuse of hard alcoholic beverages, seasonality of aggravations, especially at persons with the burdened heredity. At assessment of complaints of the patient crucial importance has a pain syndrome with a characteristic rhythm, frequency of pain. At diagnosis local morbidity and a muscle tension of a front abdominal wall in a piloro-duoden to a lny zone or under a xiphoidal shoot has a certain value, symptoms of dyskinesia went. - kish. path of spastic type.

In blood the insignificant hyperglobulia, sometimes a hypoproteinemia or a disproteinemia are noted (reduction of content of albumine and increase a2-and R-globulins), the content of gastrin, a histamine, acetylcholine, ki-nin, and also activity of proteolytic enzymes can increase. Along with it increase in level of protein nitrogen, immunoglobulins of a class A is defined. At localization of an ulcer in a duodenum and antral department of a stomach at a research of gastric secretion increase in contents free salt to - you in a gastric juice on an empty stomach and educations salt to - you in a stomach in a stimulated phase (is observed especially at an ulcer of a duodenum). Rather reliable symptom of a disease is increase in basal secretion salt to - you to 15 — 20 mmol/l and more, and against the background of stimulations to 45 — 60 mmol/l and more. Long decrease in pH in a bulb of a duodenum and increase in activity of pepsin and gastricsin, especially in basal fraction of a gastric juice is of great importance.

The crucial role in diagnosis of a disease is played by a X-ray and endoscopic inspection.

Radiodiagnosis I. is based on direct (morphological) and indirect (functional) signs. The major diagnostic importance gets identification of straight lines rentgenol. signs — niches (see) and cicatricial and ulcer deformation of the struck wall of a stomach or a duodenum. The niche is rentgenol. the image of ulcer defect in a wall of the hollow body filled with a contrast agent and the regional shaft around an ulcer caused by inflammatory and functional changes of fabrics, adjacent to an ulcer. Distinguish ulcer niches small (from 0,5 X 0,5 to 0,5 X 0,8 cm), averages (

from 0,5 X 0,8 to 0,5 X 1,5 cm) and big (to several centimeters) the sizes. The last can have three-layered STRUK-TURA? caused by the image contained in a large ulcer of a baric suspension, liquid and gas

(fig. 1). The niche can have an appearance of a ledge on a contour of a shadow of a stomach or duodenum (profile, or planimetric, a niche) or a contrast spot (depot of a baric suspension against the background of a relief of a mucous membrane — a niche of a relief, or a fasny niche).

Indirect rentgenol. signs I. are caused generally by disturbance of a tone, secretory and motor and evacuation function of a stomach and duodenum. Also carry to them the manifestation accompanying I. gastritis (gastroduodenit) and existence of local morbidity (a painful point) at a palpation.

At stomach ulcer the profile niche has usually geometrically regular shape (funnels, a cone), accurate outlines and a symmetric infiltrative (inflammatory) shaft at the basis, and also equal and accurate contours of the basis. Outlines of a niche can become uneven and indistinct in the presence at the bottom of an ulcer crater of clots, lumps of slime, necrotic masses or the remains of food. In krayeobrazuyushchy situation the niche supports limits of a contour of a stomach and is usually separated from its gleam narrow (apprx. 1 mm) by the cross accurately outlined strip of an enlightenment (Hampton's line) which is the image of the mucous membrane hanging over a crater of an ulcer (fig.


of Fig. 2. Roentgenogram of a stomach of the patient with a peptic ulcer (direct projection):

the arrow specified a big ulcer niche on small curvature of a stomach which longitudinal extent exceeds depth; at the basis of ulcer defect light clearly is visible strip — Hampton's line.


Fig. 1. The roentgenogram of a stomach of the patient with a peptic ulcer executed in vertical position (a direct projection): the arrow specified the big ulcer niche on small curvature of a stomach containing barium, liquid and gas (three-layered structure).


2). At deeper ulcers, especially in a stage of an aggravation in connection with inflammatory changes, hypostasis and rigidity of sites of a wall, adjacent to a crater, and also as a result of a muscular spasm the thickening of a wall around an ulcer having on roentgenograms an appearance of a transparent collar, a tape or the shaft located between an ulcer and a gleam of a stomach is formed various degree. At the dosed compression of an abdominal wall (a hand or special adaptation) the form and the size of a niche do not change.

The sizes of a niche can change depending on the size of an inflammatory shaft that is connected with expressiveness of hypostasis of a mucous membrane at the basis of an ulcer crater, extent of spastic reduction of muscles of a wall of a stomach and cicatricial changes. At reduction of hypostasis and elimination of spastic reduction of muscles depth of a niche sharply decreases, increase in hypostasis and strengthening of a muscular spasm lead to «deepening» of a niche up to formation of «ulcer regional defect of the filling» caused by adhesion of sharply edematous edges of a shaft. At very big sizes of an inflammatory shaft the niche at a research in a side projection can not go beyond a shadow of a stomach, however and in these cases the ulcer crater is located in in the center of an inflammatory shaft, to-ry has a smooth surface, accurate outlines, and edges it on border with not changed wall of a stomach form an obtuse angle. After disappearance of the inflammatory phenomena the niche gets a typiform again.

Fig. 3. Roentgenogram of a stomach of the patient with a peptic ulcer (direct projection):

the ulcer is localized on small curvature of a stomach; the arrow specified retraction of a contour of big curvature of a body of a stomach (de Querven's symptom),


Nisha of a relief at stomach ulcer has the rounded or oval shape, smooth, smooth edges. Around it there is a defect of filling in the form of the aura caused by an inflammatory shaft, to an outer edge to-rogo converge the folds of a mucous membrane which are not reaching a crater of an ulcer; borders of an inflammatory shaft at the same time gradually pass into intact fabrics. At kal-lezny (calloused) ulcers the shaft at the basis of a crater is caused not so much by an inflammation or a spasm, how many connective tissue growths; it has the considerable height, borders more accurately outlined, big density. Because of existence of an infiltrative shaft at the basis of an ulcer crater the true depth of an ulcer does not correspond (always less!) to depth of the niche defined in time rentgenol. researches. At kallezny chronic recurrent ulcers important rentgenol. a sign is also convergence of folds of a mucous membrane towards a niche. However folds, partially passing to a big regional shaft, do not reach the ulcer crater having, as a rule, big than at usual ulcers, the sizes. Deep niches come to light at the penetrating ulcers usually getting out of limits of a wall of a stomach into the next body soldered to it — a liver, a pancreas, an omentulum, a gastrohepatic sheaf, a spleen or in an abdominal wall. Such niches get out of the correct conical shape, clearness of contours. At the same time the trekhsloynost of contents of a niche, lack of its smeshchayemos-ta and existence of considerable consolidation of the fabrics surrounding a niche, and also a long delay of contrast weight in an ulcer crater are quite often noted, the most part to-rogo yakho-ditsya usually outside a wall of a stomach. At superficial ulcers, and also the ulcers which are localized in a prepyloric zone of a stomach, a niche at rentgenol. a research often does not come to light.

Indirect rentgenol. symptoms of stomach ulcer are caused by disturbance of a tone, secretory and motor evakuatornoy functions of a stomach and a duodenum, and also existence of the accompanying gastritis (gastroduodenit) and local morbidity at a palpation. Increase in a tone of a stomach in a phase of an aggravation leads to change of its form, the horn can remind edges.

Strengthening of a vermicular movement, the deep, sometimes segmenting waves is noted. At localization of an ulcer on small curvature of a body of a stomach there is a local spasm in the form of retraction of a contour of big curvature at the level of a niche — de Querven's (fig. 3) symptom. At ulcers of antral department of a stomach the circular spasm is possible. At the ulcers located in subcardial department, the stomach owing to a spasm of preferential oblique muscles can have an appearance of hourglasses. Retraction on big curvature is located usually at the level or is slightly lower than the ulcer crater which is localized on small curvature of a stomach or near it. Contours of an ulcer crater accurate, equal, transition to the neighboring sites smooth. The relief of a mucous membrane is not changed. At the dosed compression of an abdominal wall, and also under the influence of antispasmodics the form and the amount of retraction change. At hron. to a form of a disease deformation of body is caused not only functional, but also organic changes of a stomach. Strengthening of secretion taking place at I., radiological it is shown by existence of a nappe and slime over the contrast weight (an intermediary layer); at the same time the amount of liquid in the course of the research can increase considerably. Gastric emptying at I. it is more often slowed down owing to hypersecretion and a spasm of the gatekeeper. Bystry evacuation of contents of a stomach and a gaping of the gatekeeper is sometimes observed. Speed of gastric emptying in the course of the research can change: the evacuation which is slowed down in the beginning is replaced by bystry gastric emptying or, on the contrary, the accelerated emptying is succeeded by its sharp delay. The accompanying antral gastritis and a duodenitis which are most expressed in a phase of an aggravation I., are shown by a sharp thickening, tortuosity and disorder of an arrangement of folds of a mucous membrane, to-rye sometimes take a form of pillows or big platforms. Diagnostic value has existence of a constant painful point in the certain zone of a stomach moving together with body at a palpation or change of position of the patient. Value of this indirect symptom increases at its combination to other radiological signs — a regional spasm, signs of disturbance of secretory and motor functions.

Radiological diagnosis of «senile» ulcers in view of their preferential high arrangement is accompanied by great difficulties.


They come to light at a research of patients in vertical position in slanting better and side projections, often are followed by the deformation of a stomach in the form of hourglasses caused by a spasm of circular muscles differ in the big sizes of a niche, considerable inflammatory and cicatricial changes of fabrics. Due to slower healing of ulcers at persons of advanced and senile age symptoms of such ulcer can be defined also several months later after its identification that shall not be regarded as a sign of a malignancy.

Rentgenol. the picture of stomach ulcer of any localization allows to judge the nature of process to some extent. At high-quality process of an ulcer are located near small curvature of a stomach more often, in krayeobrazuyushchy situation the ulcer crater goes beyond a shadow of a stomach. The shaft surrounding an ulcer symmetrically covers it, has equal outlines, with the healthy not changed wall of a stomach forms an obtuse angle. In favor of high-quality process the correct rounded or oval shape of a niche of a relief, and also lack of destruction of folds of a mucous membrane in sites, adjacent to an ulcer, testifies. The malignancy of an ulcer is characterized by emergence in earlier being defined typical ulcer niche of new signs: roughnesses of edges of an ulcer crater, increase in its sizes, asymmetry of a dense hilly shaft, especially on the site turned to escaping of a stomach, break of folds of a mucous membrane on border with this site, rigidities of sites of a wall of a stomach, adjacent to a niche. These signs come to light in the conditions of a double contrast study of a stomach at stretching its gas entered via the probe better.

At ulcers of a duodenum the niche has usually small sizes, the irregular conical, oblong or star-shaped (angular) shape. The big penetrating ulcers of this localization meet seldom. Sometimes double ulcers (fig. 4) located on opposite walls of a gut (the «kissing» ulcers) are found. Most often ulcers are located on small curvature of a bulb. At the same time the type of an ulcer is defined by its situation in relation to the course of X-ray. At its fasny arrangement (fig. 5, a) the ulcer has an appearance of a contrast spot (depot of a baric suspension) surrounded with an inflammatory shaft of a mucous membrane in the form of an enlightenment (a niche of a relief, or a fasny niche); at a profile arrangement (fig. 5, b)



fig. 4. Aim roentgenogram of a bulb of a duodenum of the patient with a peptic ulcer: shooters specified

two niches located on opposite walls of a bulb of a duodenum (the «kissing» ulcers).


the ulcer has the form of a conic ledge on a contour of a bulb of a duodenum (a profile niche). At children and at persons of supernutrition the stomach is more often located highly and almost cross therefore to receive at them the image of a bulb of a duodenum in the second slanting projection and to distinguish an ulcer of a front or back wall very difficult. Quite often discrepancy of results of radiological and endoscopic researches is explained by it. Ulcer process in a bulb, as a rule, is followed by its deformation. However lack of deformation of a bulb does not exclude an opportunity in it ulcer process, is even long existing. In similar cases the ulcer crater remains within a mucous membrane and does not get into a muscular layer of a bulb. Deformation of a bulb of a duodenum in many respects is defined by cicatricial retractions and protrusions of its wall, shortening of one of walls, lengthening or expansion of its torsions, and also existence of a local spasm and swelling of a mucous membrane in a zone of an arrangement of an ulcer.

Post-bulbar ulcers meet more often at men. Usually they are localized on an inner edge of the upper horizontal or descending part of a duodenum. The sizes of a niche at a post-bulbar ulcer fluctuate over a wide range, clearly are expressed an inflammatory shaft around a niche and a game -



Fig. 5. Aim roentgenograms of a bulb of a duodenum of the patient with a peptic ulcer in various projections: and — the fasny image of an ulcer in the form of depot of a baric suspension (it is specified by an arrow) with convergence of folds of a mucous membrane to it (a niche of a relief, or a fasny niche); — the profile image of an ulcer (it is specified by an arrow) with an inflammatory shaft on its edges (profile, or planimetric, a niche).


vergention of folds of a mucous membrane, outside contour of a duodenum it is involved. In the course of healing of post-bulbar ulcers the cicatricial stenosis can develop, for to-rogo asymmetry of a form, small extent (1 — 1,5 cm), clearness and roughness of contours of the narrowed site, and also deformation of a relief of a mucous membrane with convergence of folds to the cicatrizing ulcer are characteristic.

To indirect rentgenol. to symptoms of an ulcer of a duodenum the spasm or a gaping of the gatekeeper, strengthening of a vermicular movement of a gut, acceleration or delay of a passage of a baric suspension belong; at considerable changes of a tone of a gut of a duo-denostaz, local morbidity at a palpation, during the periods of aggravations — signs of a gastroduodenit. At post-bulbar ulcers disturbance of tonic and motor function of a duodenum (dystonia and dyskinesia), a spasm of the gatekeeper, and also a duodenum in a zone of an arrangement of an ulcer, local morbidity are observed at a palpation of this area. During remission functional disturbances are absent or are expressed moderately.

The endoscopic research (see Gastroscopy) allows to reveal a disease, to establish a stage of process, to control efficiency of treatment, to carry out differential diagnosis between symptomatic (acute) ulcers



and a peptic ulcer, to reveal a malignancy of process. In the presence of a dysplasia in the field of edges of an ulcer it is necessary to carry out an aim biopsy and tsitol. a research of the received material.

At an endoscopic research stomach ulcer has oval or roundish, is more rare an ellipse or slit-like form. Its bottom is executed by fibrinous imposings, has yellowish color. Edges of an ulcer tower in the form of a shaft. The mucous membrane of a stomach around an ulcer is hyperemic and edematous, temperature in the field of a bottom and edges of an ulcer is lower, than in the unimpaired sites of a mucous membrane of a stomach. At gistol. a research of the material received at a biopsy signs of an acute inflammation in the field of edges or a bottom of an ulcer come to light: hypostasis, limfoplazmotsitarny infiltration, a hemostasis and a lymphostasis, quite often an atrophy of glands with substitution by their connective tissue fibers. Ulcers of a bulb of a duodenum have irregular shape more often (polygonal, slit-like or linear), the superficial, covered with a yellow plaque bottom, edematous edges, easily bleed at a touch. The mucous membrane around an ulcer is sharply hyperemic. At gistol. a research of a mucous membrane of a bulb of a duodenum signs of a duodenitis (without atrophy or atrophic) are found, and at gistokhy. a research — reduction of keeping of pussycats


of ly mucopolysaccharides, sialomu-tsin and sulfamutsin. On the color table (Art. 400, fig. 3 — 14) presented an endoscopic picture of stomach ulcers and a duodenum of various localization at various stages of ulcer process.

Apply an elektrogastrografiya to identification of disturbances of motor function of a stomach (see). A sign of disturbance of motor function of a stomach is change of amplitude of waves on an elektrogastrogramma.

Differential diagnosis. Differential diagnosis is carried most often out with hron. cholecystitis (see) and hron. pancreatitis (see). At hron. cholecystitis of pain arise, as a rule, after reception of greasy, fried food, are localized in right hypochondrium, have no accurate frequency, do not decrease after reception of hydrosodium carbonate, milk, etc.; there is no seasonality of aggravations. At hron. pancreatitis of pain are usually localized in left or right hypochondrium in the form of «half ring», in epigastric area, or happen surrounding; more often they constants (sometimes pristupoobrazny), amplify soon after food, are combined with disorders of function of intestines (tendency to a diarrhea, a steatorrhea, etc.); seasonality of aggravations is absent. Besides, I. differentiate with functional gastric disturbances (see the Stomach), gastritis (see), a duodenitis (see), gastroduodenity, proceeding with normal or hypersecretion, and also about a reflux esophagitis (see the Esophagitis), a trance - verzity (see Colitis), a tubercular or nonspecific mesadenitis (see), acute and an appendicism (see). However in all cases the main differentsialnodiagnostichesky criterion is detection of an ulcer or rubtsovoyazvenny deformation of a stomach or duodenum at a X-ray or endoscopic inspection.

Great difficulties arise at differential diagnosis I. with an ulcer and infiltrative form of cancer. At detection of stomach ulcer it is necessary to conduct careful examination of the patient for an exception of a tumor. Existence of a malignant new growth can be suspected at decrease at sick appetite, emergence of disgust for meat, a lose of weight, increase supraclavicular limf, nodes and a liver, at emergence of ascites, an achlorhydria or akhiliya (at cancer of antral department of a stomach quantity salt to - you can be normal or even raised), strengthening ane-


Mia, acceleration of ROE, hypoproteinemia, increase in content of fibrinogen of blood, tendency to a thrombogenesis; and also at characteristic change of a X-ray and endoscopic pattern (see above). The final diagnosis is established on the basis of detection of cells of a tumor at a cytologic research of the material taken at an aim biopsy.

At detection of ulcer defect in a stomach or a duodenum, especially at patients with the combined diseases of internals, endocrine and a nervny system, there is a need to exclude existence of symptomatic ulcers (see Ulcers symptomatic). At the same time it is necessary to consider the anamnesis (associated diseases, the postponed injuries, reception of medicines, etc.), the sequence of involvement of bodies in patol. process, seasonality of aggravations, features wedge, pictures and condition of gastric secretion and motility. The special attention is required by differential diagnosis with gast-rinomy, shown Zollinger's syndrome — Ellisona (see Zollinger — Ellisona a syndrome), for to-rogo sharply expressed hyperacidity, existence of often multiple ulcers in a stomach and a duodenum, developing of bleeding, perforation, continuation of ulcer process even after a resection of a stomach are characteristic. In favor of a gastrinoma also lack of decrease in gastric secretion after intravenous administration of secretin and reception under language of an anaprilin (Obsidanum, propranolol) testifies.

Treatment

At for the first time revealed I., a recurrence of an ulcer with the expressed and resistant pain syndrome, persistent heartburn, frequent vomiting and weight loss treatment in a hospital is shown. At suspicion of bleeding, a penetration, a perforation or a malignancy of patients hospitalize in surgical department. At emergence of symptoms I. without recurrence of an ulcer, and also at the favorable course of a disease and existence of appropriate house conditions perhaps out-patient treatment. Duration of treatment in a hospital at uncomplicated I. averages 4 — 5 weeks. During the subsiding of process within 1 — 1112 month treatment is continued on an outpatient basis (the so-called prolonged treatment), further conduct courses of proti-voretsidivny therapy.

Treatment I. complex, is directed to an exception of disturbing factors, normalization of the main functions of a stomach and duodenum, increase in protective properties of an organism, strengthening of reparative processes in a mucous membrane went. - kish. path. It includes elimination of irritants, the rational mode, to lay down. food, medicamentous means, physiotherapeutic procedures, LFK, sanatorium treatment.

Conservative treatment includes basic and individual therapy. Basic therapy provides restriction of a physical activity, purpose of a diet, antiacid, the sedatives, drugs normalizing secretory and motor functions of a stomach and duodenum, and also stimulating processes of healing. Individual therapy is appointed depending on features of a course of a disease (e.g., at it is long to not healing ulcer use laser therapy, at elderly people — solkoserit or the drugs improving microcirculation).

At an aggravation I. within one week the bed rest promoting decrease in intra belly pressure and peristaltic activity of a stomach, disappearance of venous stagnation, improvement of inflow of an arterial blood to a zone of an ulcer is shown. One of the most important methods of therapy I. the clinical nutrition (see clinical nutrition) based on the principles of a mechanical, chemical and thermal shchazheniye is. The patient in the period of an aggravation within the first week appoint a diet No. 1A, within the second week — a diet No. 1B, since third week during all course of treatment, during the prolonged treatment, and also during the periods of antirecurrent therapy — a diet No. 1. Food fractional (5 — 6 times a day). Milk and dairy products are considered as the most preferable. Meat and fish dishes are steamed. Every morning the patient is recommended to eat 150 — 200 g of oat or semolina porridge and one soft-boiled egg. Apples, currant, beet, carrots are used only in the wiped look. The amount of protein in a daily diet, according to a number of researchers, shall not be less than 120 — 130 g. Food shall contain enough vitamins, especially Vkh, B2, B6, A and C. The use of sodium chloride is limited to 10 g a day. Exclude the fried dishes, crude vegetables and fruit containing a rough cellulose (turnip, cabbage, pears, peaches, a persimmon, a gooseberry, etc.), marinades, a pickles, smoked products, strong beef-infusion and fish broths, spices (mustard, pepper, vinegar), carbonated drinks, coffee, cocoa, alcohol.

Drug treatment is appointed taking into account features of a clinical picture, localization of an ulcer, existence of associated diseases.

As the antiacid means possessing kislotosvyazyvayushchy and buffer action apply Almagelum, fosfalugel, gastrofarm, Vicalinum, Vicairum, hydrosodium carbonate, calcium carbonate, magnesium oxide, aluminum hydroxide, Burzhe's mix (water solution of a hydrocarbonate, sulfate and sodium phosphate). All antiacid means appoint in 30 min. prior to food and through 1 — lVa of hour after food. At emergence of alkali reaction of urine they are cancelled. For extension of kislotosvyazyvayushchy action of antiacid means in 30 min. prior to food, and to the persons having night pains also before going to bed subcutaneously enter 0,5 ml of 0,1% of solution of Atropini sulfas.

Inhibition the kislotoobrazova-niya and normalization of a tone of a stomach are reached by purpose of peripheral m cholinolytics: pay-fidlina, atropine, Fubromeganum and antispasmodics (Nospanum, Halidorum). With the same purpose use ganglioblokiruyushchy means: petrolhexonium, Dimecolinum, Quateronum. Good effect blockers of H2-histamine receptors, in particular Cimetidinum (Tagametum, it is white mt), in a daily dose to 1 g have, to-ruyu divide into 4 receptions (3 times on 0,2 g and before going to bed 0,4 g). Stop administration of drug, gradually reducing a dose, in connection with a possibility of development of a withdrawal. After the termination of a course of treatment (28 — 30 days) within 1 — 2 years appoint maintenance doses of Cimetidinum on 0,2 — 0,4 g to night. At prolonged use of Cimetidinum and its analogs there can be a leukopenia, thrombocytopenia, diarrhea, impotence, osteoporosis, etc. Potato and cabbage juice has the braking influence on gastric secretion (on V2 of a glass before food).

For suppression of proteolytic activity of pepsin, gastricsin and trypsin according to indications, especially at threat of bleeding, intravenously kapelno enter aminocaproic to - that (100 ml of 5% of solution), Gordoxum (500 000 PIECES) or a kontrika of l (20 000 PIECES into 300 ml of isotonic solution of sodium chloride).

For strengthening of processes of regeneration in a zone of an ulcer appoint redoxons, Wb, B12, U, biogenic stimulators (extract of an aloe), metronidazole (see). According to indications apply intravenous injections

of plasma, albumine, the mixes prepared on the basis of amino acids (casein, Aminopeptidum, etc.), appoint nucleinate of sodium (barmy RNA) in a daily dose of 1,5 — 3 g, inosine of 600 mg a day, Etadenum, solko-serit, anabolic hormones (Nerobolum, retabolil, etc.). Possesses a certain reparative action pentoksifillin (trental), improving microcirculation and rheological properties of blood, and also alpha adrenoblockers (phentolamine) and beta adrenoblockers — anaprilin, etc. At often recurrent current I. apply Prodectinum (Parmidinum) on 0,25 g 3 times a day during 3 — 4 weeks. Good to lay down. the effect is noted during the use of hyperbaric oxygenation (see).

At the expressed pain syndrome enter Atropini sulfas (subcutaneously), Baralginum (intramusculary) or, according to indications, Promedolum (subcutaneously). At the persistent heartburn and disks-netichesky frustration leading to throwing of acid contents from a stomach in a gullet and to receipt of contents from a duodenum in a stomach appoint Metoclopramidum (a raglan, cerucal), anaesthesin, 0,25% solution of novocaine.

For the purpose of recovery of immune balance by the patient with I. appoint immunomodulators Thymalinum (0,005 g of 1 times a day at a course dose of 0,1 — 0,14 g), levamisole (decarice) on 0,05 g a day during 2 — 3 weeks. For treatment I. use the antioxidants (Dibunolum) blocking peroxide oxidation of lipids and stabilizing cellular membranes of a mucous membrane of a stomach and duodenum. In the course of treatment of a peptic ulcer appoint the means normalizing functions of other bodies and systems (cholagogue, fermental, the purgatives, drugs expanding coronary vessels, etc.).

In complex treatment of patients I. normalization of a functional condition of the central nervous system is of great importance. For this purpose appoint Elenium, Meprotanum (meprobamate), Nozepamum (Tazepamum), amitriptyline, eglonyl (Sulpiridum), infusions of a valerian, motherwort, widely apply psychotherapy (see).

Use of physiotherapeutic procedures is defined by features a wedge, pictures and currents I. Since 2 — the 3rd week appoint an electrophoresis of Dicainum, Methacinum, novocaine and other medicines to an abdominal wall in epigastric area; apply also mud cure, applications of paraffin, ozokerite, a diathermy, ultrasound, variation magnetic field, UVCh, microwave therapy, an inductothermy, the harmonic modulated currents, balneotherapy, reflexotherapy and an electrosleep. And also at suspicion of a perforation and a penetration of an ulcer thermal procedures are contraindicated to the patients who had gastrointestinal bleeding.

In case of absence within

1 month of scarring of an ulcer, despite active treatment, for the purpose of dissolution of blood clots in microvessels, improvements of microcirculation and strengthening of reparative processes by means of the endoscope make an obkalyvaniye of edges of an ulcer solkoserily (1 ml), heparin (5000 PIECES) or chymotrypsin (mg in i of ml of isotonic solution of sodium chloride). Radiation of an ulcer helium - the neon or argon laser (see), imposing on it a protective film from medical glue (MK-6, MK-7), irrigation by sea-buckthorn oil after clarification of a bottom of an ulcer is effective.

Great value in complex therapy I. has LFK. Physical exercises are directed to strengthening and normalization of activity of c. N of page, recovery of its regulatory function, increase in body resistance, improvement and normalization of exchange processes; they also promote improvement of blood supply of a stomach and duodenum that creates necessary conditions for healing of an ulcer, normalization of gastric secretion, reduction of pains and elimination of dispeptic frustration. LFK is appointed in the absence of suspicions of bleeding or a perforation during subsiding of the acute phenomena. At the expressed pain syndrome use of LFK is contraindicated. Appoint to lay down. gymnastics, massage, later — pedestrian walks. During observance of a bed rest, lying on spin and sitting, carry out exercises for hands, legs and a trunk; bending of legs in hip and knee joints should be carried out without tearing off a foot from a bed. Physical exercises shall not cause pain. Exercises with involvement of muscles of a prelum abdominale and increasing intra belly pressure are excluded. Exercises carry out slowly and smoothly within 8 — 10 min. At expansion of the mode duration of occupations is increased up to 15 — 20 min., raise loading; exercises carry out in initial positions lying on spin, on one side, sitting, being kneeling at slow and average speed; also exclude the exercises promoting substantial increase of intra belly pressure. Further intensity of loading increases, gradually include exercises for muscles of a prelum abdominale in a set of exercises, and also with various objects (dumbbells of 1 — 2 kg, inflatable balls, etc.), walking, elements of games, self-massage of muscles of an abdominal wall on the course of a large intestine. Duration of occupations increases up to 20 — 25 min.

After the termination of a basic course of therapy carry out the prolonged treatment. Patients keep to a diet No. 1, receiving 5 — 6-times food, it appoint antiacid, antispasmodics, vitamins. In the spring and in the fall, even in the absence of complaints, during 6 — 7 weeks carry out antirecurrent therapy in volume of the prolonged treatment. By the patient with frequent (

2 — 3 times a year) aggravations and a recurrence of a disease the antirecurrence-noye treatment is held all the year round.

In a stage of remission by the patient with I. it is shown a dignity. - hens. treatment in specialized balneological sanatoria — Yessentuki, Zheleznovodsk, Borjomi, Staraya Russa, Feodosiy, Darasun, Jurmala, Odessa, etc. The basic to lay down. a factor is drinking mineral water (see Mineralnye Vody). Gidrokarbonatno - sulfatno - sodium, gidrokarbonatno-sodium and hydro - carbonate hloridno-sodium mineral waters promote more bystry evacuation of food from a stomach, cause braking of secretion of a gastric juice, possess alkalizing action. At a hyperacidity water should be drunk in a warm look, small drinks within 5 — 7 min. on 200 ml in 30 min. prior to food and through 1V2 — 2 hour after food. Cool water in 10 — 25 min. prior to food is recommended to patients with a hypochlorhydria and an achlorhydria. Apply also intestinal washings (see), climate treatment (see the Climatotherapy). In the spring and in the fall dignity. - hens. treatment should be combined with antirecurrent therapy. Dignity. - hens. treatment is contraindicated in the presence in the anamnesis of bleedings, at a pyloric stenosis, suspicion on a malignancy of process.

Operational treatment. Indications to operational treatment at uncomplicated and complicated I. are various. At uncomplicated I., not giving in to conservative treatment, indications to operation are relative and shall be strictly proved. At the same time character and intensity of a pain syndrome, frequency of a recurrence and duration of remissions, and also existence in the anamnesis of complications of a disease is important. According to different researchers, an operative measure in connection with inefficiency of conservative therapy is made in 30 — 50% of cases.

At a duodenal or piloro-duodenal ulcer operation is shown to patients with the long term of a disease and a frequent recurrence which are characterized by the expressed symptomatology and clear endoscopic or radiological symptoms of an ulcer in the absence of effect of conservative treatment and loss by the patient of working capacity. Operational treatment is shown also at the ulcers of the peloric channel and duodenal ulcers which were complicated earlier by a perforation or bleeding at the persistent course of a disease, and also at ulcers of the big sizes at lindens is younger 20 and 65 years are more senior.

Features of a course of stomach ulcer (unlike an ulcer of a duodenum) cause features to lay down. tactics. S. S. Yudin considered that at stomach ulcers «terms of therapeutic treatment can be reduced the more surely, than more ulcer, than is deeper a niche, than the patient is more senior and than acidity is lower». According to many clinical physicians, majority hron. recurrent stomach ulcers it is necessary to treat quickly. Such medical tactics is the most justified in connection with a possibility of permanent treatment, the smallest lethality and lower interest of complications, and also in connection with an opportunity to reveal timely a carcinoma of the stomach.

At uncomplicated I. preference is given to planned operations, to-rye allow to avoid development of heavy complications I., increasing risk of operation and worsening its long-term results.

At complications I. indications to operation depend on character of a complication (a perforation, a penetration, bleeding, a pyloric stenosis or a combination of these complications). At a perforation of the ulcer, irrespective of its look (the «free» or «covered» perforation) the only reliable method of treatment is the immediate surgery. In rare instances when operation cannot be executed because of weight of a condition of the patient (the fresh extensive myocardial infarction, heavy is gray - dechno - pulmonary insufficiency), or at flat refusal of the patient of operation use the conservative method of treatment for the first time applied by Taylor and Warren (N. of Taylor, Warren, 1956) — continuous aspiration of contents of a stomach via the nazogastralny probe against the background of introduction of antibiotics in high doses and intravenous injection of liquids. According to indications carry out a laparoscopy (see Pe-ritoneoskopiya) with introduction of drainages to an abdominal cavity for the purpose of evacuation of the streamed gastric contents. The indication to operation is also the penetration of a duodenal ulcer in adjacent bodies — a pancreas, a cross colon, the general bilious channel. However in this case it can be executed also in a planned order.

The helcomenia of a stomach and duodenum is stopped in most cases by conservative methods and only approximately in 25% of cases are required urgent (emergency or urgent) operation.

Conservative treatment of massive gastroduodenal bleedings is based on the principle of an intensive care (see). Ensuring adequate infusional therapy by catheterization of the central vein, constant control behind the main functions of an organism, including behind the central venous pressure, a diuresis is very important. By means of the nazogastralny probe make aspiration of contents of a stomach and exercise control of the proceeding bleeding. Among conservative methods of a stop of bleeding can be used a gastric lavage by cold (ice) water, the constant decompression of a stomach which is carried out via the nazogastralny probe, local administration of thrombin, inhibitors of proteases, aminocaproic to - you, the managed hypotonia, endovascular embolization (see. X-ray endovascular surgery), etc. The majority of these methods can provide only a temporary stop of bleeding. Recently apply endoscopic electrothermic coagulation and laser photocoagulation of a bleeding point to a stop of bleeding, and also use a method of drawing on the bleeding surface through an endoscopic catheter of filmogens.

The immediate surgery at ulcer bleeding is for the patient with serious intervention. Extremely high risk of operation is quite often caused by such factors as massiveness of bleeding, serious associated diseases at patients are more senior than 60 years, localization of an ulcer, «unprofitable» concerning danger of bleeding. The lethality after urgent operations for massive helcomenias is nearly 5 times higher than a lethality after the planned operations made after a stop kro

a votecheniya and elimination of anemia, however in some cases conservative treatment is inefficient, and the delay becomes even more dangerous. Absolute indications to an immediate surgery at bleeding are: the massive bleeding

and a limit anemization which are followed expressed a wedge, signs of hemorrhagic shock — falling of the ABP, pallor of skin, increase of breath and pulse, reduction of a hemoglobin content is lower than 70 g! l when delay with operation and attempts to stop bleeding conservative means constitute big danger to the patient, and also a recurrence of the bleeding which is earlier stopped in the conservative ways.

The indication to urgent operation is the proceeding bleeding, especially at patients 60 years when conservative ways of its stop during 24 — 48 hours are inefficient, or in the absence of confidence in reliability of a stop of bleeding by conservative methods, including and endoscopic are more senior (electrothermic coagulation, laser photocoagulation, etc.). The most informative criteria of the proceeding bleeding are continuous plentiful intake of blood via the nazogastralny probe, steady the wedge, manifestations of hemorrhagic shock and the expressed changes of hemodynamic indicators, despite massive infusional therapy and transfusion more than 1500 ml of blood throughout the 24th hour.

Planned operation, especially in the presence is shown to the patients who transferred the helcomenia stopped by conservative methods in connection with tendency of massive bleedings to recuring in the anamnesis of numerous bleedings, a persistent current I. and development of the combined complications (e.g., bleeding and pyloric stenosis or penetration of an ulcer). It concerns preferential to patients with stomach ulcer, and also to persons 60 years which it is necessary to operate in earlier terms are more senior. As criterion of threat of a recurrence of bleeding serve the data obtained at a gastroduodenoskopiya (the sizes, depth of an ulcer, existence of the thrombosed vessels of a large diameter).

The pyloric stenosis (pylorostenosis) is the reason of an operative measure at I. almost in 10% of cases. Before operation the particularly important becomes differential diagnosis between the true stenosis caused by cicatricial changes of output department of a stomach, and the so-called functional stenosis with ulcer defect in this area which is also followed in some cases by the expressed disturbances motor evakuatornoy functions of a stomach. The last, however, does not demand an operative measure and disappears after a short course of antiulcerous therapy. Because in clinic there are no exact methods of definition of extent of anatomic narrowing of output department of a stomach before operation and a wedge, the picture often does not correspond to extent of its narrowing and also in view of the fact that the begun process of a steno-zirovaniye at a recurrence of a disease inevitably progresses, indications to operation do not depend on degree of manifestation of a stenosis. Considering also that heavy system disturbances at a dekompensirovanny pyloric stenosis considerably complicate treatment, significantly increasing risk of operation, most of surgeons consider that at a pyloric stenosis operation is shown always when there are proofs of its cicatricial and ulcer nature, irrespective of weight a wedge, manifestations, expansion ratio of a stomach and the delay of evacuation revealed at rentgenol. research. A question of operation at a combination of a stenosis of output department of a stomach and hron. stomach ulcers, and also at a combination of a stenosis with other complications of a peptic ulcer (a perforation, bleeding, a penetration) decides depending on the clinical situation which is quite often demanding urgent intervention.

Persons of advanced and senile age have indications to operation at uncomplicated I. are defined by the persistent course of a disease and threat of development of heavy complications, especially at hron. the recurrent or long not healing ulcers of gastric localization inclined to a malignancy. At complications of a peptic ulcer, such as perforation and bleeding, operative measures carry out according to absolute indications.

Preoperative preparation and anesthesia. Important conditions for performance of operative measures on a stomach are the satisfactory general condition, lack of the expressed inflammatory changes in the operated body which can be observed at activity of ulcer process. However these conditions can be met only at planned operations. It is also necessary to carry out thorough training went. - kish. a path (release of a large intestine from contents, especially if was the day before made rentgenol. research, and gastric emptying). At uncomplicated I. before operation carry out also usual preoperative inspection (blood tests, urine, definition of biochemical indicators of blood, rentgenol. research of bodies of a thorax) and treatment taking into account specific features of the patients connected with age changes of an organism and associated diseases (see. Preoperative period). Preoperative training of patients with complications I. has the features. So, at the expressed pyloric stenosis with heavy disturbances of water and electrolytic exchange and metabolic shifts carry out intensive infusional care under control of data a lab. researches. However the specified disturbances which were a consequence it is long the existing stenosis, quite often corrections therefore an operative measure shall be made for elimination of the reason of these disturbances after 5 — 7-day vigorous infusional therapy hardly give in. Preoperative preparation at massive bleeding or at a perforation of the ulcer with development of peritonitis (see) is under construction on the principles of an intensive care.

Anesthesia at stomach, duodenum operations and vagus nerves shall provide a good relaxation of muscles of a stomach, suppression of the reflex influences connected with a surgical injury and positive control of functions of breath and blood circulation. To all these requirements, especially at an immediate surgery, the multicomponent endotracheal anesthesia (see) with use of a neyroleptanalge-ziya (see), muscular relaxants (see Muscle relaxants) and the managed breath answers (see. Artificial respiration).

Methods of an operative measure. Until recently only by a justified method of operation at I. considered a resection of a stomach. In 50 — the 60th there are 20 century after development of new operations including vagisections, there was a tendency to search of so-called ideal operation at the peptic ulcer excluding use of all known operations. In the subsequent there was obvious an illegality of such approach to treatment I., and this point of view was succeeded by more rational concept about the individualized approach to the choice of a method of operation in each case. On the basis of the careful analysis of results of various operations it is revealed that a classical resection 2/3 — 3/4 stomachs, rather reliably curing from I., gives, however, rather high percent of a lethality and in 10 — 15% of cases leads to development of the expressed postrezek-tsionny disturbances (see Postgast-rorezektsionny complications). Use of a subtotal resection of a stomach is limited first of all at patients with high degree of operational risk, especially at urgent interventions. The aspiration of surgeons to more economical resection of a stomach promoted development of operations of vagisection (see) in combination with antrectomy or with a hemigastrectomy (fig. 6), to-rye


Fig. 6. The diagrammatic representation of the resected site of a stomach: and — at

antrectomy; and and — at a hemigastrectomy.

are technically simpler, and pathophysiologically, apparently, more reasonable. Despite the lethality close to a lethality at a resection of a stomach, number of post-resection disturbances and cases of emergence of round ulcers (see) at these operations much less. The vagisection in combination with the draining operations relating to so-called organ-preserving operations was widely adopted; it irrespective of type of vagisection (trunk, the selection) and a type of the draining operation (different types of a pyloroplasty, gastroduode-no-or gastroyeyunoanastomoz) is rather small on volume and low-traumatic intervention; diarrhea is followed rather low (to 1%) by a lethality and rather small number and small expressiveness of postoperative disturbances, such as a dumping syndrome (see Postgastro-rezektsionnye of a complication). Despite rather high percent (6 — 7%) of postoperative emergence of round ulcers, this operation is shown to patients with high degree of operational risk, especially in need of an immediate surgery. Recently the operation of the selection proximal vagisection (see) based on limited denervation of a kislotoprodutsiruyushchy zone of a stomach found application. As a result of this operation secretion salt to - you considerably decreases and normal motive function of a stomach remains that leads to healing of a duodenal ulcer. Operation is most effective at persistent ulcers of a duodenum, especially at persons of young age. It differs minimum (0 — 0,5%) in a lethality and small frequency of the post-operational disturbances characteristic of trunk or selection vagisection known under the name post-vagotomicheskogo a syndrome (see Vagisection, late complications). Frequency of a recurrence of an ulcer after the selection proximal vagisection, according to many researchers, makes 5 — 7%.

Unity of the pathogenetic moments I. does not exclude essential a wedge, the distinctions of stomach ulcer and ulcer of a duodenum which are shown in expressiveness of vegetative frustration, features of gastric secretion and motility, frequency and character of separate complications, tendency to a malignancy, etc. And the wedge, a picture at localization of an ulcer in prepyloric area, and also its combined form on features of clinic differs from a clinical picture at the «true» stomach ulcers located in the field of small curvature and reminds symptomatology of a duodenal ulcer more. Therefore operational treatment of a peptic ulcer at ulcers of various localization shall be differentiated. Question about you -

first of all depending on localization of an ulcer (an ulcer of a duodenum or stomach ulcer), character of complications, and also a wedge, situations (features of a course of a disease, degree of operational risk, etc.).

At an ulcer of the duodenum which is not giving in to conservative therapy use of the operative measures creating conditions for its healing (or providing removal of the ulcer) and reliable decrease in gastric secretion is proved at the most careful attitude to a stomach. Here vagisection is justified. The selection proximal vagisection is shown to a considerable part of patients. At patients with high gastric secretion, complications I. in the anamnesis (bleeding, a perforation) in the absence of serious associated diseases and high degree of operational risk Billroth of I or Billroth of II apply vagisection in combination with antrectomy (see the Stomach, operations) or a hemigastrectomy on a way (see Billroth operation). The subtotal resection of a stomach applied by some surgeons has no advantages here.

At difficult Uda limy ulcers of a duodenum the so-called resection of a stomach on switching off offered in 1918 by H. Finsterer can be in exceptional cases applied, at a cut leave a duodenal ulcer together with peloric department of a stomach (see Billroth operation, a way Billroth of II). In these cases a number of surgeons recommends careful removal of all mucous membrane of the left antral department of a stomach, as provides prevention of a recurrence of an ulcer of a duodenum.

At localization of an ulcer in a stomach the choice of operation depends on the nature of gastric secretion, atrophic changes of a mucous membrane, a possibility of a malignancy of process. Operation of the choice is the distal resection of a stomach (hemigastrectomy) with excision of all antral department. In the absence of cicatricial and inflammatory changes in a duodenum carry out a gastroduodenal anastomosis on a way Billroth of I, and also a resection of a stomach with preservation of the gatekeeper. At highly located periesophagal stomach ulcers apply, e.g., a resection of a stomach on Shemakera with high excision of a stomach on small curvature (see Billroth operation, a way Billroth of I). At patients with high degree of operational risk p apply — a resection — d an ist lno go department of a stomach with leaving of highly located ulcer or vagisection with a pyloroplasty. These operations promote bystry healing of stomach ulcer. Operational treatment of ulcers with localization in the field of the gatekeeper (so-called piloroduodenalny ulcers), and also ulcers at the combined forms of a peptic ulcer (an ulcer of a duodenum and stomach) is carried out by the principles of treatment of ulcers of a duodenum (see above).

At complications I. (a perforation, massive bleeding, a pyloric stenosis or a combination of several complications) the issue of the choice of a method of operation is resolved taking into account character of a complication, weight of a condition of the patient and degree of operational risk.

At a perforation of the ulcer of a stomach or duodenum and development of peritonitis or in patients with high degree of operational risk in connection with serious associated diseases the main method of treatment is sewing up of ulcer defect. However after such operation in 50 — 75% of cases in the next 3 — 5 years a repeated operative measure in connection with again developing complications is required. Therefore after sewing up of perforated stomach ulcer it is necessary to confirm its high-quality nature (the clinical and endoscopic signs of healing of an ulcer given to a biopsy) and to resolve an issue of a radical operative measure.

In case of a perforation of the ulcer of a duodenum at the patients of young and middle age brought in a hospital in several hours after a perforation in the absence of symptoms of widespread peritonitis and serious associated diseases sometimes apply trunk vagisection with a pyloroplasty. Patients with a persistent current of a peptic ulcer who in the anamnesis have instructions on bleedings a perforation, and at persons with the combined form have diseases at identification morfol. changes characteristic of a «old» ulcer of a duodenum, in case of lack of symptoms of peritonitis and at small degree of operational risk sometimes apply vagisection with antrectomy. At difficulties in definition of degree of operational risk (serious condition of the patient, possible technical difficulties of antrectomy at an ulcer of a duodenum) a question of the choice of a method of operation should be solved in favor of less traumatic intervention.

At bleeding operation shall provide first of all a stop of bleeding, and also in the subsequent to prevent a recurrence of a disease. The issue of the choice of a method of urgent operation is resolved taking into account age of the patient, associated diseases, degree of blood loss that finally and defines degree of operational risk, and also taking into account intraoperative technical specifications and personal experience of the surgeon. At the bleeding ulcer of a duodenum at elderly people and at patients with high degree of operational risk make trunk vagisection with a pyloroplasty and underrunning of the bleeding ulcer or its excision. Rather small injury of this operation, lack of the complications connected with insufficiency of seams of a duodenal stump or a gastroenterostomy reduce probability of a recurrence of bleeding from the taken-in ulcer in the early postoperative period. The last complication meets quite seldom, as a rule, at ulcers of the big sizes penetrating in a pancreas. This operation differs considerably in a smaller lethality in comparison with a lethality after a resection 2/3 — 3/4 stomachs. Especially at the persistent course of a disease, at the same localization of the bleeding ulcer vagisection with antrectomy is shown to patients with rather small risk degree (young age, small or average degree of blood loss). This operation differs in bigger technical complexity, however provides more reliable stop of bleeding and is a radical method of treatment of a peptic ulcer. Operation is usually carried out in modification Billroth of II.

During the performance of antrectomy in modification Billroth of II owing to the expressed cicatricial and inflammatory process in a zone of low located ulcer and at a penetration of an ulcer in a pancreas can arise need of atypical closing of a stump of a duodenum. In this case use various special techniques facilitating reliability of closing of a «difficult» duodenal stump. The number of these receptions is huge, they differ in various technical complexity. Yudin's way and a method of Yakobovichi which are of historical interest concern to them. One of extended in a crust, time is R. Nissen's way, to-ry consists in a podshivaniye of a mucous membrane of free edge of a duodenum after its crossing to bottom edge of an ulcer; at the same time there is packing of ulcer defect.

At the bleeding stomach ulcer at patients with small degree of operational risk the resection of distal department of a stomach with removal of the bleeding ulcer is shown. At patients with high degree of operational risk the helcomenia of a stomach can be stopped by means of less difficult surgeries which are not connected with excision of body and imposing of an anastomosis. At the discretion of the surgeon in these cases it is possible to apply local excision • ulcers with a pyloroplasty and vagisection or underrunning of highly located bleeding ulcer of small curvature through gastrotomichesky access and bandaging of the left gastric artery in combination with vagisection and the draining operation.

At a combination of the bleeding stomach ulcer to an ulcer of a duodenum the choice of a method of operation is based on the same principles, as at treatment of the bleeding ulcer of a duodenum.

At a pyloric stenosis the method of operation is defined by the heavy disturbances of water and electrolytic balance characteristic of late stages of a stenosis, disturbances mo - even evakuatornoy functions of a stomach, and also the possible technical difficulties depending on expressiveness cicatricial inflame - telnogo process and a penetration of a duodenal ulcer in a pancreas (see the Pyloroplasty). The opinion on unfitness existing earlier in this case of vagisection is rejected since it is established that vagisection in itself does not lead to the expressed and irreversible disturbances of motor and evakuatorny function of a stomach if they did not arise before operation owing to the expressed pyloric stenosis any more. At persons of young age with rather low degree of operational risk at dekompen-sirovanny motor function of a stomach (a stenosis of the III—IV stage), and also at the combined form of a peptic ulcer (a cicatricial and ulcer pi-loroduodenalny stenosis and chronic stomach ulcer) apply a distal resection of a stomach (antrectomy) with vagisection (the selection or trunk). This operation promotes elimination of the expressed disturbances of evacuation from a stomach and I am a radical method of treatment. Usually prefer a resection of a stomach on a way Billroth of II. At massive cicatricial and inflammatory process in a duodenum and adjacent bodies there can be a need of use of atypical closing of a stump of a duodenum and a resection of a stomach «on switching off» (see above). At a high risk it is necessary to make less traumatic operation. And also at emergence of insuperable technical difficulties on the course of operation vagisection in combination with the draining operations (a pyloroplasty, a gastroduodenostomy or a gastroyeyunostomiya) is shown to patients of advanced age with high degree of operational risk in the absence of gross violations of motility of a stomach (the compensated stenosis). This type of an operative measure is less traumatic, it liquidates difficulty of gastric emptying, gradually normalizes its motive function and provides adequate decrease in gastric secretion and consequently, the recurrence of a disease warns. At the correct definition of indications to operation the expressed evakuatorny disturbances in the postoperative period meet quite seldom. In the presence of associated diseases at patients with extremely high degree of operational risk in connection with deep disturbances of motor function of a stomach it is necessary to hold in addition a number of special events, such as long aspiration of gastric contents in the postoperative period, administration of drugs of group of Metoclopramidum or imposing in the course of operation of a temporary gastrostomy (see the Gastrostomy).

The frequent combination pi sometimes results the ENT specialist of a duodenal stenosis with a functional incompetence of cardia in need of performance on the course of operation of surgical correction of esophageal and gastric transition, especially at organ-preserving operations. Use at a pyloric stenosis of a gastroyeyu-nostomiya — technically the simplest and low-traumatic operative measure — is proved only at patients with extremely high degree of operational risk or at patients of advanced age with a cicatricial stenosis without active ulcer and at low gastric secretion (the so-called ceased ulcer).

Features of the postoperative period depend on weight of a condition of the patient (advanced age and associated diseases, existence of complications I.), and also from the nature of the made surgery. Carry out by all patient operated concerning a peptic ulcer in the postoperative period infusional therapy. Intravenous injection of liquids and electrolytes is made under control of these laboratory researches and a diuresis. In day of operation and the first two days of the postoperative period of the patient usually receives intravenously kapelno

1,5 — 2 l of liquid (5% solution of glucose, isotonic solution of sodium chloride). It is necessary to appoint infusional therapy taking into account both renal, and extrarenal losses. Adequacy of its carrying out has special value for the patients operated concerning a piloroduo-denalny stenosis and also at the disturbances of evacuation which developed after operation from a stomach.

In the first days of the postoperative period the patient twice a day make control sounding of a stomach. Continuous aspiration of contents of a stomach through a gastric tube is shown to persons with disturbances of evacuation from a stomach.

Food is of great importance. Reception of liquid in limited quantity (to 500 ml) is allowed, as a rule, in the first day after operation (apart from day of operation). With 2 — the 3rd day of the patient can drink practically without restriction. Food is given with 2 — the 3rd day (diet No. 0) each 2 — 3 hours in the small portions. Gradually the diet is expanded, and on 6 — the 7th day patients receive a diet No. 1A with an exception of the dishes prepared on whole milk; food fractional — 6 times a day.

A physical activity is shown to the operated patients. The movement by legs (both passive, and active) is allowed at once during the awakening after an anesthesia. Since first day of the postoperative period the respiratory gymnastics is appointed. It is allowed to get up in the absence of contraindications (weight of the general state, threat of a recurrence of bleeding from the taken-in ulcer, drainage of an abdominal cavity) on 2 — the 3rd days of the postoperative period. At a favorable current of the postoperative period seams remove on 7 — the 8th days, write out patients from a hospital after organ-preserving operations with vagisection for the 10th days, after a resection of a stomach (antrectomy) — on 12 — the 14th days.

Among complications of the early postoperative period distinguish the complications which are found at any other abdominal organs operations and the complications which are directly connected with the nature of surgery. Carry the peritonitis connected with insufficiency of seams of an anastomosis or arising without discrepancy of seams, infiltrates and abscesses of an abdominal cavity, bleeding to the last (intraperitoneal or in a gleam of a digestive tract), postoperative pancreatitis, intestinal impassability, disturbance of evacuation from a stomach or its stump. Complications develop after a resection of a stomach, including and antrectomy more often. At the organ-preserving operations which are characterized by smaller injury, the specified complications develop less often. For prevention a reflux - ezofagi - that at vagisection is recommended to carry out fundoplication of cardial department of a stomach.

At timely diagnosis and treatment (as a rule, operational) the forecast at these oslozh

neniye usually favorable (see P ostgastrorezektsionny oslozh

a neniya).

Rehabilitation

Rehabilitation of patients with I. includes the actions directed to recovery of their health and working capacity. The complex of rehabilitation actions includes the course and prolonged treatment in a hospital or policlinic, antirecurrent treatment, a dignity. - hens. treatment. During the carrying out prolonged and an antirecurrence-nogo of treatment widely use sanatoria dispensaries of the enterprises, in to-rykh along with a diet and prescription of medicines apply physiotherapeutic treatment and psychotherapy. Great value for rehabilitation of patients I. medical examination has. Dispensary observation for the patient I. it is carried out it is long (within 5 years after another recurrence or an aggravation). It includes carrying out preventive courses of treatment especially in the spring and in the fall (in some cases all the year round), sanitation of the centers hron. infections, treatment of associated diseases, rentgenol. and lab. researches, appointment to lay down. physical cultures. During the carrying out medical examination it is necessary to watch working conditions and life, correctness of food of the patient, to define indications to a dignity. - hens. to treatment and also to resolve issues of working capacity and employment of the patient. The patient is considered recovered and is struck off the dispensary register in the absence of a recurrence of a disease for 5 years.

The forecast

the Forecast at I. the wedge, currents, localizations of ulcer defect, complications, associated diseases, and also working conditions and life depends on age, sex, features.

At early recognition of a disease and timely effective treatment there can come the absolute recovery, a cut is observed approximately in V3 of cases. The forecast at uncomplicated forms Ya., as a rule, favorable; at timely treatment, holding preventive anti-recurrent actions working ability of patients remains. The forecast worsens at is long the current and often recurrent processes; at I., arising at children's and youthful age, in connection with tendency to a recurrence, resistance of a disease to treatment and development of serious complications, such as bleeding, a perforation; at persons of advanced and senile age in view of frequent development of life-threatening complications; at persons with associated diseases (cholecystitis, a hypertension, atherosclerosis, etc.), and also at disturbances in food, alcohol intake, smoking, a psychoemotional overstrain. At emergence of complications the forecast serious; it depends on timeliness and efficiency of medical actions.

Examination of working capacity. The issue of working ability of the patient is resolved strictly individually depending on weight a wedge, manifestations I., efficiency to lay down. actions, existence of complications and the burdening associated diseases, conditions of professional activity, at the operated patients — from a look and results of an operative measure. For the term of course treatment patients admit temporarily disabled a hospital or out-patient conditions, at to-rykh at clinical, radiological or endoscopic researches the ulcer comes to light for the first time, and also in case of an exacerbation of a disease. During the carrying out prolonged and protivoretsidivno-go treatments, especially in the conditions of sanatorium dispensary, patients are not exempted from work, except for the days necessary for the next inspection (once a year). At identification of negative influence of a profession or working conditions on the course of a disease raise a question of employment. Negatively the work connected with a considerable physical and mental overstrain, with forced position of a body with action of vibration, work during a night shift, etc. influences ulcer process. The profession of the driver of the car is most adverse, for a cut the combination of several above the listed negatively operating factors is characteristic. In most cases to persons of high qualification it is employed within their professional competence; a part of patients (preferential young age) trains for a new profession.

At a severe disease, especially at elderly people, and also at the operated patients it is necessary to resolve an issue of their transfer into disability. Persons with it is long proceeding, often recurrent (3 — 4 times a year) I., complicated by repeated bleedings, gastritis, gastroduodenity, periprotsessy, followed by the expressed disturbance of functions of a stomach, dvenadtsatiperst-

ache guts, the liver, biliary tract, a pancreas and intestines expressed by weight loss transfer III and II groups to disability. II and III groups temporarily transfer to disability also «the operated patients, professional activity to-rykh is connected with hard physical work, «with long and frequent business trips, work during a night shift. Patients, at to-rykh a wedge, displays of a disease reach extreme degree of manifestation and are combined with the inoperable ulcer penetrating in nearby bodies (especially in a pancreas), or • with other irreversible changes of internals and disturbance of the general metabolism, are subject to transfer into disability of the I group.

Prevention

Distinguish primary and secondary prevention I. Primary prevention is directed to the prevention of a disease. Great preventive value the correct organization of work and rest, good and regular nutrition, fight against smoking and abuse of alcohol, creation • a favorable situation in working collective and a family has, exercises and a hardening of an organism. It includes also early identification and treatment of predjyazvenny states: a functional gastric disturbance of hypersthenic type, antral gastritis, a duodenitis and a gastroduodenit, and also identification and elimination of other factors of the increased risk of a disease.

Secondary prevention provides preduprezhdeniye of exacerbations of a disease. It is carried out at medical examination.

Features of a peptic ulcer at children

I. at children is quite widespread disease. More often it is observed at children of the advanced school age though at a half of them the first symptoms of a disease are noted at preschool and younger school age. So, according to V. B. Shifrin (1981), prevalence I. at children of younger school age makes 1,8 on 1000 people, and at children of the advanced school age — 6,2 for 1000 persons. Among children with diseases of the alimentary system I. made, by data A. V. Mazurin (1984), in 1973 —

3,6%, in 1974 - 6,5%, in 1975 -

6%, in 1977 - 7,6%, in 1978,-6,9%, in 1979 - 7,6%, in 1980 —

6,2%. Aged up to 12 years I. equally often occurs at boys and girls; after the period of puberty — is more often at boys. At children of an ulcer are localized preferential in a duodenum, and approximately the multiple ulcers located both on a lobby, and on a back wall of a bulb are found in a half of patients. In 15% of cases the post-bulbar ulcers differing in special weight of a current and giving the greatest number of complications are observed. I. at children is a mul-tifaktorialny disease (see. Hereditary diseases); the coefficient of heritability at children makes 0,74. Along with genetic predisposition in emergence I. disturbances of food (especially long breaks in meal), stressful situations in a family, school and other factors matter.

Depending on a wedge, pictures and expressivenesses of symptoms allocate four stages of a disease. At a fresh ulcer (a kliniko-endoscopic picture I of a stage) the leading symptom are late (in 1 — 2 hour after food), hungry or night abdominal pains. The accurate rhythm of developing of pains (hunger — pain — meal is noted — simplification), however after food they completely do not disappear. Pains have the pristupoobrazny, pricking, cutting character, arise suddenly, quite often irradiate in a back, the right shoulder. At a superficial palpation zones of a skin hyperesthesia, a positive symptom of Mendel (pain come to light at effleurage of an abdominal wall in piloroduo-denalny area). The deep palpation of a stomach is impossible because of a pain syndrome and an active muscle tension of a prelum abdominale. Pain is followed by dispeptic symptoms — nausea, an eructation, vomiting, is more rare heartburn that is caused by disturbance of motility went. - kish. path. At an endoscopic research of a duodenum against the background of the expressed duodenitis defect of a mucous membrane more often than the rounded or oval shape surrounded with the high hyperemic shaft creating a picture of a deep ulceration comes to light. Edges of an ulcer are edematous, the bottom is covered with imposings of gray, yellow or green color.

The beginning of epithelization of defect (a kliniko-endoscopic

picture II of a stage) is characterized by late abdominal pains, to-rye preferential arise in the afternoon and is more rare at night. Pains gain the pressing, aching character, develop gradually, irradiate less often, after meal at most of children almost completely disappear. Dispeptic frustration are expressed to a lesser extent. The superficial palpation of a stomach is painless, at a deep palpation the muscle tension of a prelum abdominale remains. At an endoscopic research the hyperemia and an inflammatory shaft are expressed less, than at

1 stage of a disease, edges of defect are flattened, uneven, move to the center of an ulcer, the bottom begins to be cleared, there is a convergence of folds directed to an ulcer.

At full epithelization of ulcer defect (a kliniko-endoscopic picture III of a stage) late abdominal pains are observed only in the afternoon; the pains of the aching or pulling character arising after food completely disappear. Dispeptic symptoms are poorly expressed or are absent. The stomach is available to a deep palpation, morbidity remains only in a piloroduodenalny zone. At an endoscopic research find signs of a duodenitis, sometimes traces of defect in the form of the hems of a linear form or spots representing sites of granulyatsionny fabric.

The Kliniko-endoskopichesky picture IV of a stage is characterized by lack of clinical symptomatology. At an endoscopic research the mucous membrane of a duodenum without changes, is sometimes noted disturbance of a relief of folds or deformation of a bulb. At treatment in the conditions of a hospital transition from I to the II stage usually comes during 2 weeks, from II in the III stage — in 2 — 3 weeks and from III in IV — on average within

2 years.

I. at boys proceeds heavier, than at girls. At multiple ulcers the disease accepts a recurrent current. A recurrence of ulcers at multiple defeats usually arises in 6, 12 and

24 months, at single defeats — in 4 — 5 and 9 months. The most frequent complication is went. - kish. bleeding, meets a functional stenosis and a penetration of an ulcer in surrounding bodies less often (is more often in a pancreas).

Diagnosis I. at children put on the basis a wedge, pictures and data of an endoscopic research; rentgenol. a research at children not always informatively. Differential diagnosis is carried out with hron. gastritis (see), hron. a duodenitis (see), gastroduodenity, is more rare — with pancreatitis (see) and cholecystitis (see). Wedge, manifestations hron. gastritis and a duodenitis, especially in the presence of hypersecretion, have strong likeness with I., however the pain syndrome at these diseases is less expressed, night pains are absent, smaller morbidity of a stomach at a palpation is noted, bleedings are not observed. At pancreatitis of pain have the surrounding character, concentrate in the field of a projection of a pancreas; increase in level of enzymes of a pancreas in blood, urine, duodenal contents is noted; at ultrasonic investigation increase and consolidation of a pancreas comes to light. Localization of pains in right hypochondrium is characteristic of cholecystitis. Their emergence is usually connected with the use of greasy food. Increase in a liver, positive symptoms of Ortner, Murphy, etc. can be observed (see. Gall bladder, symptomatology). At diagnosis * also results of a research of bile, a X-ray and tool inspection of a gall bladder are considered.

480 ULCER nonspecific colitis


In all cases are the main differential diagnostic character detection of an ulcer in a stomach or a duodenum.

Treatment I. at children stage, essentially does not differ from treatment of adults. Operational treatment at children's age is applied much less often, is preferential at the complicated disease (bleeding, cicatricial pi the ENT specialist a duodenal stenosis, a perforation); preference is given to organ-preserving operations with vagisection.

The forecast is defined by the nature of defeat: in the presence of a single ulcer the forecast favorable, at the multiple ulcers inclined to recuring, the forecast worsens, the disease leads to an invalidism of the child. Girls have a forecast more favorable, recovery is more often observed.

Prevention I. it is directed to the organization of healthy nutrition, the mode, elimination of stressful situations, especially at children with the burdened heredity and having gastritis in the anamnesis and gastroduodenit. The prevention of a recurrence of a disease consists in performing stage treatment, in long observance of a diet, in systematic antirecurrent treatment.

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