a stomach and a duodenum — cankers of a mucous membrane of a stomach, are more rare than a duodenum, developing for the second time at pathology of other internals and systems of an organism.
Gastroduodenal ulcerations as complications at extensive burns are described in 1842 by Kurlin-g (Th. Century of Curling). In 1937 H. Eppinger paid attention to a frequent combination of cirrhosis to pathological changes of gastroduodenal area. In the next years many clinical physicians noted that at patients with ulcerations of a mucous membrane of a stomach and duodenum in some cases usual antiulcerous therapy does not give effect. At detailed inspection of such patients it was revealed that ulcer defects at them are secondary, accompany other diseases, have no hereditary character, and also characterized by a peculiar clinical current. It formed the basis for allocation of this pathology in special group. In domestic literature accurate differentiation of symptomatic ulcers and a peptic ulcer (see) V. of X is carried out. Vasilenko (1970) and other scientists. In the International statistical classification of diseases, injuries and causes of death of the IX review one of types of symptomatic ulcers — medicamentous ulcers are included in the headings «Stomach Ulcer» and «Ulcer of a Duodenum».
Etiology and pathogeny. Depending on the reason and origins allocate stressful, endocrine, medicamentous, neuroreflex, trophic, vascular, specific ulcers. Stressful ulcers develop at the extraordinary (stressful) influences which are followed by adrenergic crises and also at patients with injuries or diseases of a brain, after neurosurgical operations, at massive burns, sepsis, a myocardial infarction, shock. Endocrine ulcers arise at patients with Itsenko's syndromes — Cushing (see Itsenko — Cushing a syndrome) and Zollingera — Ellisona (see Zollinger — Ellisona a syndrome). In the first case their education is connected with excess products of cortisol bark of adrenal glands, in the second — with the increased release of gastrin. Carry to endocrine also the ulcers arising at a thyrotoxicosis, a diabetes mellitus, a hyperparathyreosis at women in the period of a climax. Emergence of medicamentous ulcers is caused by reception of a number of medicines (glucocorticoids, acetilsalicylic to - you and other salicylates, Brufenum, quarrystone of a dion, indometacin, Reserpinum, gistdmin. quinophan, acetphenetidiene, etc.). Nervnoreflektorny ulcers can develop at patients cholelithic and a nephrolithiasis, acute and an appendicism, cholecystitis, pancreatitis, an adnexitis, at acute intestinal impassability. Trophic ulcers form at persons with hron. intoxication at such diseases as chronic hepatitis and cirrhosis, chronic bronchitis, chronic pneumonia, a chronic renal failure. Vascular (hypoxemic) ulcers are formed at hron. circulatory disturbances, compression occlusion (stenosis) of a celiac trunk, fibrinferment and embolism of arteries of a stomach, at patients with the expressed atherosclerosis, at general diseases of connecting fabric. Specific ulcers arise at patients with syphilis, tuberculosis, at a disease Krone, and also at the persons which were affected by ionizing radiation.
The mechanism of formation of symptomatic ulcers is various, however, as a rule, the disease develops against the background of a mucosal atrophy of a stomach. The possibility of transition of symptomatic ulcers to a peptic ulcer is doubtful.
Pathological anatomy. Symptomatic ulcers, as a rule, acute, the morphological picture is stereotypic and depends on an etiology a little. In most cases they are localized in a stomach, at
Zollinger's syndrome — Ellisona are located in a duodenum and even in initial department of a jejunum more often. Symptomatic ulcers affect various departments of a stomach, preferential being located on its small curvature, however unlike a peptic ulcer meet also on big curvature. I. pages usually happen multiple, oval, is more rare than a slit-like form; at merge of several ulcers defect gains irregular shape. Deep ulcer defects usually have an appearance of a funnel, the basis a cut is turned to a gleam of a stomach, and top — to a serous layer. Around ulcers erosion and hemorrhages are often visible.
At a histologic research the bottom of ulcers is covered with the necrotic masses impregnated with fibrin, slime, infiltrirovanny neutrophylic more rare eosinophilic granulocytes. The necrosis can extend in the parties from defect under the remained mucous membrane of a stomach. The fibrinoid necrosis and granulyatsionny fabric meet seldom. Absence expressed inflammatory and fibroplastic reactions is characteristic of steroid ulcers.
During the formation of ulcer defect and progressing of process there can be an arrosion of blood vessels (see the Arrosion) that brings to heavy, sometimes to fatal, gastric bleeding (see. Gastrointestinal bleeding). The ulcers located in 3 — 4 cm from small and big curvature of a stomach since in these zones there pass large branches of gastric arteries are especially dangerous in this respect.
The clinical picture of symptomatic ulcers is usually characterized smaller, than at a peptic ulcer (see), by expressiveness of dispeptic frustration and a pain syndrome. Complaints to an eructation air or the eaten food, nausea, feeling of weight in an anticardium prevail; the aching pain in an upper half of a stomach without accurate localization develops at once or 20 — 30 min. later after food and not always ceases after reception antiacid and antispasmodics. At a palpation of a stomach diffuse morbidity preferential in an anticardium is defined. At a number of patients considerable weight loss is noted. Lack of seasonality of aggravations is characteristic. Except the listed above symptoms nek-ry forms Ya. pages have the features. So, at stressful and medicamentous ulcers heartburn, vomiting by acid gastric contents and slime, a constant
pain syndrome, frequent bleedings develop. The ulcers arising at patients with Itsenko's syndromes — Cushing and Zollinger — Ellisona, are characterized by persistent heartburn, vomiting acid gastric contents, a constant colicy pain in an anticardium with irradiation in a back, are followed by frequent bleedings or perforation. The asymptomatic course of process is quite often observed, in this case the ulcer comes to light accidentally at inspection of the patient or at once is shown went. - kish. bleeding, perforation.
The diagnosis is based on detection of ulcer defect at endoscopic or rentgenol. research. At an endoscopic research symptomatic ulcers differ in the big amount, depth and plurality of defeat. At rentgenol. a research the ulcer niche of a rounded or oval shape surrounded with the big inflammatory shaft sometimes blocking an entrance to an ulcer crater and forming
defect of filling in a zone of defeat comes to light (acute steroid ulcers have no inflammatory shaft). Convergence of folds to a niche at symptomatic ulcers is expressed slightly, it is caused by preferential spastic reduction of muscles what disappearance of convergence at purpose of antispasmodics testifies to. The relief of a mucous membrane is usually changed slightly, signs of functional frustration clearly are expressed. At a research of a gastric juice at persons with symptomatic ulcers are noted normal contents salt to - you or a hypochlorhydria at quite sufficient or increased volume of secretion, decrease in proteolytic activity, increase in amount of slime, level sialine to - t, activities of a lactate dehydrogenase. At stressful, medicamentous and endocrine ulcers the hyperacidity which is especially expressed and persistent at patients with Itsenko's syndromes — Cushing and Zollinger — Ellisona can come to light.
In diagnosis I. page detection of diseases is of great importance, to-rye can lead to developing of an ulcer. At the same time careful studying of anamnestic data is necessary that can give essential help in differential diagnosis with a peptic ulcer and in specification of the cause and effect relations during the developing of symptomatic ulcers. So, special attention should be paid on the previous stressful influences, the postponed cherepnomozgovy injuries, operative measures, a myocardial infarction, diseases of endocrine system, atherosclerotic defeat of vessels, communication between reception of medicines and emergence of dispeptic frustration, etc. At diagnosis the wedge, pictures (character and frequency of pains, seasonality of aggravations, a condition
of century of N of page, etc.), data a lab consider also features. researches of a gastric juice, localization of an ulcer, efficiency of treatment, etc. Differentsia lno-diagnostich e with to and I am the characteristic I. to page and a peptic ulcer it is presented in the table.
Treatment. In spite of the fact that in treatment of symptomatic ulcers and a peptic ulcer (see) much in common, an indispensable condition of therapy of symptomatic ulcers — elimination of the factors causing their development, napr, treatment of a basic disease, cancellation of the corresponding medicine. Along with it in therapy of symptomatic ulcers the means applied at treatment of a peptic ulcer, promoting elimination of dispeptic frustration are used; pain syndrome, normalization of a tone of a stomach, to increase in regenerator properties of a mucous membrane of a stomach and duodenum. At a hyperacidity apply inhibitors of a kislotoobrazovaniye and antiacid means. At a hypochlorhydria and an achlorhydria of means, stimulating secretion of a stomach, it is not necessary to appoint. Due to the danger of a malignancy, especially at the ulcers which are localized in a stomach, nek-ry researchers do not recommend to appoint the drugs increasing metabolism of fabrics and mitotic activity of an epithelium of a mucous membrane of a stomach (B12 vitamin, metronidazole, inosine, anabolic hormones, etc.). As a rule, to lay down. actions can be effective only if the diagnosis of the disease which caused development I is correctly made. the page is also appointed adequate etiopatogene-tichesky treatment. At a complication of a symptomatic ulcer profuse bleeding or perforation by the only method of treatment is operation. At patients with high operational risk the complication shall be whenever possible liquidated by less traumatic intervention, napr, underrunning or excision of the bleeding ulcer in combination with vagisection, apply also endoscopic methods of a stop of bleeding — electrothermic coagulation and laser photocoagulation.
The forecast at I. the page is defined by a current and an outcome of a basic disease, development of such complications as bleedings or perforation.
Prevention consists in careful purpose of the drugs having ulcerogenic effect (at impossibility of their replacement with other drugs) and in co-administration of antiacid means (see). At emergence in patients with diseases of internals and systems of dispeptic frustration or pains in epigastric area it appoint a diet No. 1 (see clinical nutrition), antiacid and cholinolytic means (see. Cholinolytic substances).
DIFFERENTIAL and DIAGNOSTIC CHARACTERISTIC of SYMPTOMATIC ULCERS AND PEPTIC ULCER
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