Page 15 of 73 PEPTIC ULCER
True frequency of a peptic ulcer is unknown. According to the researchers who carried out detailed studying of this question to Erie Kaunti (the district of New York) at children till 15 flyings annual incidence makes 3,5 on 100 000, and to 15-year age it increases to 3,7 on 100 000 at boys and 3,9 on 100 000 at girls. At children this disease occurs less than at adults; in many large children's clinics only 2 — 4 fresh cases a year are registered. Though biological characteristics, diagnostic methods and treatments of round and stressful ulcers are in many respects similar, it is more convenient to consider these diseases separately.
Round ulcers arise mainly in a duodenum less often in a stomach. Children of the first or second year have lives of stomach ulcer and a duodenum meet identical frequency, but at children 7 years are more senior duodenal ulcers prevail.
Patomorfologiya and Pathogeny. The etiology of round ulcers is not found out, however it is possible to point to a number of the factors playing an important role in development of this disease. Emergence of cankers at members of one family (at parents and sibs of a proband) indicates the importance of genetic factors. It is shown that at adults the frequency of a peptic ulcer depends on blood group and the secretory status.
Hyperoxemia of a gastric juice — a major factor in a pathogeny of a peptic ulcer. At adults and children with a round ulcer of a duodenum acid secretion in general is increased though in many cases it same, as at healthy faces. Researches showed that products of acid do not correlate neither with ulcer sizes, nor with a symptomatology duration. At localization of an ulcer in a stomach production of hydrochloric acid meets standard or is even reduced. An important role in a pathogeny, apparently, is played by the pepsinogen participating in self-digestion of a mucous membrane. Its ability to resist to a yazvoobrazovaniye depends on resistance of fabrics. The last falls at insufficient intake of oxygen, bad blood supply, and also under the effect of drugs. It is known that salicylates and other drugs break integrity of a mucous membrane, creating conditions for the return diffusion of acid; therefore they promote ulceration even at the normal or lowered acidity of a gastric juice. Believe that: important factors are also activity of regenerative processes, quality and amount of the cosecreted slime. In general at duodenal ulcers the leading place is taken by an acid and peptic factor, and at stomach ulcers — fabric resistance.
The ulcer can be superficial or getting deeply into a mucous membrane and a submucosal layer, can penetrate a vessel, causing bleeding, even to perforate a wall of a stomach or a gut. Usually the ulcer is surrounded with the inflammatory shaft containing inflammatory cells. The most superficial ulcers regard as an erosion. If the inflammation and hypostasis are expressed sharply, then it can lead to an acute or chronic delay of evacuation of contents from a stomach. In some cases at endoscopic research the red granular mucous membrane of a duodenum is visible; this state is regarded as the duodenitis preceding ulceration. However communication of this defeat with clinical manifestations or the valid yazvoobrazovaniye is not established yet. Duodenal ulcers are localized mainly on a back wall of a bulb, and gastric — on small curvature or in antral department. Malignant stomach ulcers at children are extremely rare.
Clinical manifestations. Signs of a peptic ulcer are changeable and not really specific, but pains, vomiting, a loss of blood through a digestive tract and the expressed family character of a disease are most often observed. At adult patients with the complaints of dispepsichesky character allowing to assume a peptic ulcer at inspection the diagnosis is confirmed only in 15% of cases; the similar situation, apparently, is observed also in pediatric practice. It is easy to confuse symptoms of a peptic ulcer with signs of damage of a gall bladder, with displays of colitis, an esophagitis, pancreatitis or illness of kidneys. Pancreatitis can arise as complication of the penetrating duodenum ulcer.
Despite variety of symptoms, it is possible to note some signs which meet mainly in this or that age group. So, on the first month of life as the leading displays of an illness it is necessary to consider bleeding and perforation. Ulcers during this period usually stressful (see below), they accompany sepsis, heart troubles or respiratory a distress syndrome. It is very probable that many cases of a peptic ulcer at which the symptomatology is not really demonstrative remain not distinguished. At children aged from 1 month till 2 flyings in a clinical picture repeated vomitings, a growth inhibition and gastrointestinal bleedings prevail. At children of preschool age the atypical pains around a navel which are often amplifying after meal are noted. Persistent vomitings and intestinal bleedings are characteristic.
At children 6 years a clinical picture same, as at adults are more senior. More often boys are ill; dyspepsia, an acute or chronic loss of blood are noted, family character of a disease clearly is expressed. Unlike adults at whom pains have acute or burning character children complain of the stupid or aching pains. They can last of several minutes till several o'clock, the frequent periods of an aggravation are replaced by remissions lasting several weeks or months. Antacids kill pain not at all patients. The peptic ulcer cannot be distinguished from functional frustration, being guided only by clinical manifestations. At patients with acute or chronic blood loss, and also with an ulcer penetration shock, anemia, pancreatitis or peritonitis can develop in adjacent bodies.
Diagnosis. A X-ray analysis of an upper part of a digestive tract — the most available diagnostic method. Approximately in 25% of cases the ulcer which is localized in a duodenum at the first research does not manage to be revealed, At newborns it is difficult to investigate a bulb as it is sharply turned kzad. The ulcer crater has to be recorded on a series of roentgenograms not to confuse it with zateky a baric suspension pleated of a mucous membrane at the healthy child. Deformation of a bulb — a reliable symptom of the ulcer postponed in the past, but it tells nothing about existence or. absence of an ulcer at the time of research. The bulb spasm after which there comes its relaxation is often observed at healthy faces therefore such conclusions of radiologists as "duodenitis", "irritation of a bulb" or "pylorospasm", it is not necessary to interpret as manifestations of a peptic ulcer.
It is necessary to resort to a gastroduodenoskopiya when, on the basis of radiological data it is impossible to draw a certain conclusion and also when severe pains or signs of chronic blood loss demand urgent establishment of the diagnosis. At acute bleeding from an upper part of a digestive tract endoscopy is a choice method (on condition of removal from a stomach of clots). The visual estimate of a condition of an upper part of a digestive tract significantly increased the accuracy of diagnosis of bleedings, however it is impossible to tell that it reduced mortality from this Complication.
It is impossible to recognize determination of acidity of a gastric juice as an informative diagnostic method as this indicator differs at healthy and sick a little. At the heavy course of often recurrent ulcer or at multiple ulcer defects it is necessary to measure concentration of serumal gastrin to exclude Zollinger's syndrome — Ellisona.
By the patient with heavy bleeding from an upper part of a digestive tract in certain cases when urgent assessment of the situation is necessary, carry out the selection abdominal angiography. Release of contrast medium in a gastric cavity or intestines through an ulcer indicates a bleeding point, and infusion of vasopressin in a vessel proksimalny zones of bleeding can promote its stop, and also helps to establish correctly a catheter for therapeutic embolization of the bleeding vessel.
Treatment. The treatment purpose — to accelerate healing of an ulcer, to kill pain and to prevent complications. As gastric acid plays the leading role in emergence and development of an ulcer, apply measures to control of secretory function — observance of a diet, use of antacids for acid neutralization, restriction of action of stimulators of secretory function and use of the drugs suppressing secretion. It is necessary to exclude administration of drugs which promote ulceration or developing of bleeding. As it was shown, observance of a rigid diet does not influence secretory function therefore the patient has to eat usual food, except for those products which cause discomfort. It is proved that neither the sparing diet, nor refusal of Pepsi Cola, Coca-Cola, coffee and spices brake products of gastric acid. It is not necessary to take aspirin as it suppresses resistance of a mucous membrane. Smoking slows down healing of an ulcer. In works of the last time it is shown that developing of an ulcer against treatment by corticosteroids is connected not with drugs, and with a basic disease concerning which they are appointed.
Atatsida are the main means of regulation of acidity of a gastric juice. At adults high doses of antacids accelerate healing of an ulcer of a duodenum. Buffer properties of various antacids widely vary and depend on a dosage form: in the liquid state antacids are much more active, than in tablets which should be chewed carefully to increase medical effect. The antacid dose capable to neutralize 100 mmol of hydrochloric acid, needs to be accepted in 1 — 3 h after each food and before going to bed. It is not necessary to eat food before going to bed as it stimulates gastric secretion at night. The intensive course of treatment antacids usually proceeds 4 — 6 weeks.
The majority of antacids represent the mix consisting of magnesium hydroxide, trisilicate of magnesium and aluminum hydroxide. Salts of magnesium are especially effective, but they cause diarrhea; aluminum hydroxide provokes locks. If diarrhea becomes persistent, it is reasonable to pass to reception of antacids which contain aluminum hydroxide in the basic. The antacids containing aluminum connect food phosphates and break that their absorption. At patients who it is long accept aluminum hydroxide, without receiving in addition phosphorus salt, development of signs of a hypophosphatemia — anorexia, osteomalacy and osteoporosis is possible (especially against pathology of kidneys). Antacids, calcigerous, can provoke increase of products of acid after their neutralized action comes to an end. Sodium bicarbonate — very effective converter of acid, but long reception it conducts to an alkalosis and a delay of sodium in an organism.
Cimetidinum, the strong antagonist Ng-retseptorov of a histamine, blocks secretion of hydrochloric acid. The dose for children usually makes 300 mg/sq.m; drug is accepted to food and before going to bed. Side effects arise infrequently, but can be shown by a gynecomastia and, in rare instances, a coma. It is not proved that this drug reduces acidity of a gastric juice more effectively, than usual antacids, but it can accelerate healing process.
Drugs with anticholinergic action can slow down production of gastric acid, but they are effective only in such doses which cause side reactions, for example dryness in a mouth and accommodation disturbance. At children it is difficult to define such changes therefore it is not recommended to use these drugs as a main type of treatment.
Surgical intervention is necessary at perforation, not stopped pains, chronic or acute bleeding if for 48 h the patient loses about a third of volume of the circulating blood. At heavy incessant bleeding its source can be established by means of the selection abdominal angiography (if it is not possible to conduct endoscopic research). Having defined where there is a bleeding ulcer, it is possible to resort to a bleeding stop by means of local infusion of vasopressin or embolization of a vessel gelfoamy or other drug. These methods allow to win time necessary to improve hemodynamic indicators, and to avoid operation. Surgical treatment is shown in need of peloric department of a stomach owing to hypostasis and development of fibrosis around a chronic ulcer if the drainage of contents, a stomach through a nasal catheter during 72 h does not yield results. In pediatric practice most often apply vagisection in combination with a pyloroplasty or an antrektomiya.
Stressful erosion or ulcers usually arise against a physical injury, burns, sepsis, hemorrhagic shock or other critical states. Such ulcers, as a rule, acute, i.e. in them are absent signs of a chronic inflammation and necrotic masses at the bottom of a crater; multiple ulcerations are characteristic. The ulcers and erosion arising against a craniocereberal injury are localized usually in distal part of a stomach and a duodenum; ulcers of proximal department of a stomach, apparently, are connected with other morbid conditions. The stressful ulcers accompanying burns tend to a penetration; they affect a duodenum and proximal part of a stomach.
The massive, acute, not followed by pains bleeding can be the first and sometimes only clinical display of such ulcer. Mortality or bleeding is high even if he manages to be stopped as it arises against a serious basic disease. At the adults making "risk group", reception of antacids or Cimetidinum allows to reduce the frequency of developing of stressful ulcers. The similar measures directed to regulation of acidity of a gastric juice are recommended to be applied also at treatment of acute stressful states at children, especially in case of burns and brain injuries. Believe that the majority of the ulcers arising in the neonatal period and within the first 5 years of life treat stressful.
Treatment of stressful ulcers is similar to treatment of a chronic round ulcer; especially it concerns reception of antacids. Often bleeding manages to be stopped, applying a gastric lavage ice saline solution. Refusal of aspirin, hemotransfusion, correction of defects of a blood coagulation — important components of treatment. As it was stated above, the selection intra arterial administration of vasopressin or embolization of the bleeding vessel allow to stop bleeding or at least to delay surgical intervention at very weakened patients. Surgical treatment consists in sewing up of the bleeding ulcer with simultaneous vagisection and a pyloroplasty.
Zollinger's syndrome — Ellisona
This rare syndrome is characterized by multiple recurrent ulcers in duodenal and to a jejunum, is frequent in combination with diarrhea. Acidity and volume of a gastric juice are considerably increased; radiological the hypertrophy of folds of a mucous membrane of a stomach is defined. Diseases are the cornerstone a hypertrophy or a tumor of islands of Langergans and sharp increase of level of the serumal gastrin stimulating secretion of hydrochloric acid; it is possible that the tumor also cosecretes other hormones possessing diarrheal action. Prolonged treatment by Cimetidinum can suppress gastric secretion thanks to what it is possible to reduce indications to a total gastrectomy. Therapeutic measures allow to control displays of a disease for a long time even if these slowly growing tumors do not manage to be removed completely.