Round ulcer of a gullet — the acute or chronic disease which is characterized by an ulceration of a mucous membrane of a distal piece of a gullet owing to impact on it of an active gastric juice.
Epidemiology The disease meets by 50 — 60 times less than round ulcers of a stomach and duodenum. Almost in 25% of cases the round ulcer of a gullet is combined with a peptic ulcer of a stomach and duodenum.
Etiology and pathogeny Major importance in development of a round ulcer of a gullet has systematic flowing or a pelting in a gullet from a stomach of an active gastric juice owing to an incompetence of cardia and its proteolytic impact on a mucous membrane of a distal piece of a gullet. It is observed at the axial (sliding) hernia of an esophageal opening of a diaphragm, after operative measures in an ezofagokardialny zone with damage of the lower esophageal (cardial) sphincter, at a system scleroderma (owing to an atrophy of smooth muscle fibers of a distal third of a gullet and an ezofagokardialny sphincter), disturbances of a vermicular movement and tone of a stomach at the peptic ulcer of a stomach and duodenum, cholelithiasis, diseases which are followed by frequent vomiting, etc. High acidity of a gastric juice promotes development of a round ulcer.
Classification Distinguish the acute round ulcers of a gullet arising in the postoperative period at the diseases which are followed by frequent vomiting acid gastric contents, and also the chronic ulcers arising in cases when the incompetence of cardia and a gastroesophagal reflux are caused it is long the existing reason (hernia of an esophageal opening of a diaphragm, a system scleroderma, etc.). There is no standard classification of ulcers of a gullet.
Approximate formulation of the diagnosis: 1. A chronic ulcer of a gullet in an aggravation stage, axial hernia of an esophageal opening of a diaphragm.
Clinical picture, preliminary diagnosis Are characteristic the persistent heartburn amplifying after food at a trunk inclination, in a prone position, vomiting, pain at a proglatyvaniye and a dysphagy (usually at the long anamnesis — owing to forming of a cicatricial and ulcer stricture of a gullet). The hematemesis, a melena are possible (owing to a helcomenia). X-ray inspection allows to reveal an ulcer niche not always, however hernia of an esophageal opening of a diaphragm, a gastroesophagal reflux and complication of an ulcer — a stricture of a gullet are found with bigger degree of reliability. Systematic (in 2 — 3 days) research the calla on the occult blood allows to reveal occult ulcer bleeding and is an indirect method of an assessment of dynamics of scarring of an ulcer during treatment. Perforation of an ulcer in a mediastinum (with development of a mediastinitis), pleural (with development of pleurisy) and an abdominal cavity (with clinic of "acute abdomen") is rather rare complication of a round ulcer of a gullet.
Differential diagnosis, verification of the diagnosis Ezofagoskopiya — the main method of verification of the diagnosis. However at purpose of this research elderly people should consider contraindications to it: An ischemic heart disease, high arterial hypertension, the expressed spondylosis of chest department of a backbone, etc. The differential diagnosis is carried out first of all with a malignant ulcer of a gullet. The gastric akhiliya testifies against peptic character of an ulcer, but in differential diagnosis the ezofagoskopiya with an aim biopsy from edges and a bottom of an ulcer has major importance. Seldom tubercular and syphilitic ulcers of a gullet meet, they usually arise at patients against a clinical picture of a basic disease; in differential diagnosis the corresponding serological tests and an ezofagoskopiya with a biopsy matter.
Treatment, prevention Treatment is carried usually out in a hospital, it is preferable in departments of a gastroenterological profile. The provision of a bed with the raised upper half of a trunk — for prevention of a gastroesophagal reflux is recommended. Appoint a diet No. 1 and 1b, frequent fractional food (5 — 6 times a day), high doses of antiacid drugs after each meal and to night: Almagel (at severe pain — almagel-A), Vicalinum or Vicairum (on 1 — 2 tablets on reception, having crushed them and having stirred in 1/4 glasses of warm water, to accept lying, small drinks), the antiacid knitting mix (a kaolin of 2 g, calcium a carbonate, basic bismuth nitrate and magnesium an oxide — on 0,5 g; to accept powder, having stirred in the form of a suspension in 1/4 glasses of warm water), etc. In need of long reception of antacids (1 1/2 — 2 months and more) further it is more preferable to use fosfalugel. In addition to the main treatment it is possible to recommend 0,06% silver nitrate solution on 30 ml of 4 — 6 times a day in 30 min. prior to food (better to enter through a thin rubber probe into the area of an ulceration kapelno 60 ml 2 times a day); sea-buckthorn oil (on 1 teaspoon 3 times a day in 30 min. prior to food), vinylene on 1 dessertspoon before going to bed. Cholinolytics and myotropic spasmolysants are usually not appointed as they reduce a tone of a cardial sphincter and quite often strengthen a gastroesophagal reflux. At the accompanying esophagism some effect gives cerucal. Treatment of a round ulcer of a gullet long (1 1/2 — 2 1/2 months and more). Surgical treatment is carried out in the absence of effect from long (not less than 6 months) conservative therapy, and also at ulcer bleeding which does not manage to be stopped therapeutic means. When forming a cicatricial and ulcer stricture of a gullet carry usually out bougieurage it.
Considering tendency to recuring of chronic round ulcers of a gullet, patients have to be on dispensary accounting with periodic (at least 1 — 2 time in a year) radiological, and at recurrence of symptoms and endoscopic research, carrying out preventive antirecurrent courses of treatment the antiacid and knitting drugs (2 — 4 times in a year depending on weight of a course of a disease and frequency of recuring in the past). Patients have to adhere constantly to a moderate sparing diet (with an exception of the hot, fried dishes and other products stimulating gastric secretion), it is recommended frequent (4 — 5 times a day) fractional food, a careful prozhevyvaniye of food, is forbidden smoking, reception of alcoholic beverages.