Peptic ulcer is a chronic recurrent disease in which an ulcer is formed in the stomach as a result of a violation of the nervous and humoral mechanisms that regulate trophic, motor and secretory processes in the gastroduodenal zone.
Etiology, pathogenesis of gastric ulcer
With localization of an ulcer in the stomach, the main etiopathogenetic mechanisms are caused by a violation of local factors, manifested in a decrease in the resistance of the gastric mucosa, weakening of its resistance to the damaging effects of gastric juice, against the background of existing ultrastructural changes in the mucous membrane and disturbances in tissue metabolism.
P azlichayut ( Johnson , 1965), three types of stomach ulcers: I – ulcers small curvature (60%), II – combination of gastric and duodenal ulcers (20%), III – prepiloricheskie ulcers (20%). The basis of the formation of ulcers of lesser curvature of the stomach is duodenogastric reflux, resulting from a violation of the neurohumoral regulation of the motility of the pyloroduodenal segment of the digestive canal. Prolonged exposure of the contents of the duodenum (especially lysolecithin and bile acids) to the gastric mucosa violates the protective mucous barrier. The resulting enhanced reverse diffusion of H + leads to the development of chronic atrophic gastritis. The latter usually affects the antrum of the stomach and spreads along the lesser curvature to its acid-producing α-zone. Regenerative disturbances arising from gastritis, local ischemia and immunological changes, insufficient mucus formation lead to necrosis of the stomach wall with the formation of an ulcer. With an ulcer of lesser curvature of the stomach, the production of hydrochloric acid decreases, which is associated with reverse diffusion of H +, a decrease in the mass of parietal cells due to atrophic gastritis. The higher the ulcer is located along the lesser curvature, the more pronounced is the manifestation of gastritis and the lower the production of hydrochloric acid. The formation of a combined gastric and duodenal ulcer is explained on the basis of the theory of antral stasis ( Dragstedt , 1942, 1970). The starting point in such patients is considered to be a duodenal ulcer, which alone or due to stenosis leads to impaired evacuation from the stomach, stretching of the antrum , and increased gastrin excretion . Hypersecretion of the latter leads to the formation of gastric ulcers. The pathogenesis of prepiloric ulcers is the same as duodenal ulcers.
Clinic of gastric ulcer
The clinic of gastric ulcer has its own characteristics and depends on the location of the ulcer, the age of the patient and the presence of complications. Common to gastric localization ulcers is a lower intensity of the pain syndrome than with localization of the ulcer in the duodenum. The pain is noted in 0.5-1.5 hours after eating, while in case of duodenal ulcer – after 2.5-3 hours. In case of gastric ulcer, the pain syndrome is traced to the composition of the food taken. Pain intensifies after eating spicy and poorly processed foods. Radiation of pain usually depends on the location of the ulcer and the presence of complications. With localization of the ulcer in the cardial part of the stomach, the pain is localized in the xiphoid process, radiating to the heart, left shoulder, back, left shoulder blade. The pain occurs with food or shortly after it. The intensity of the pain increases when penetrating ulcers pancreas zhelezu.Yazvy pylorus and prepiloricheskie ulcers are characterized by pain, irradii – ruyuschey back, early dyspeptic disorders such as nausea, heartburn, regurgitation, rvoty.V middle and old age, when there are already atherosclerotic vascular changes ulcers in the stomach often have significant sizes, quickly become callous, accompanied by various complications.
Diagnosis of gastric ulcer
Diagnosis of gastric ulcers, as well as duodenal ulcers, is based on gastroduodenoscopy data , during which sampling of material for a biopsy from 4-5 points at the edge of the ulcer is mandatory, followed by cytological examination. Subsequently, during drug treatment, dynamic endoscopic monitoring of the treatment results is performed, and after its completion, a control gastroduodenoscopy and biopsy are performed. X-ray diagnosis of gastric ulcer is based on the identification of characteristic symptoms, which are divided into direct and indirect. At the same time, attention is drawn to the anatomical changes caused by the ulcerative process (ulcer size, its localization), as well as the accompanying functional disorders of the lower esophageal sphincter, motor-evacuation function of the stomach and duodenum.
In gastric ulcer, disorders of gastric secretion, as a rule, are the opposite of those observed with duodenal ulcer. Usually, with gastric ulcer, the secretion of hydrochloric acid and pepsin is normal or reduced, which should be considered when choosing treatment tactics. The course of gastric ulcer is torpid in nature with exacerbations in the spring-autumn period.
Complications of gastric ulcer
Like duodenal ulcer, gastric ulcer is accompanied by a number of complications. The penetration of gastric ulcers is due to the localization of the ulcer defect and its size. Most often, a stomach ulcer penetrates into the small omentum, pancreas, left lobe of the liver, less often into the transverse colon, its mesentery.
Large ulcers localized in the antrum or prepiloric section of the stomach lead to stenosis of the outlet section of the stomach and impaired evacuation function. Abundant vascularization of the stomach and torpid course of peptic ulcer with unexpressed pain syndrome are often accompanied by bleeding of various intensities. One of the severe complications of stomach ulcers is malignancy of ulcers, the frequency of which, according to the literature, ranges from 5.5 to 18.5%. It is this complication that forces surgeons at an earlier stage to switch from conservative treatment to surgical treatment. Absolute indications for surgery are: stenosis of the output section of the stomach with impaired evacuation, suspicion of mapignization or malignancy of a stomach ulcer, unstoppable bleeding from an ulcer; relative – ulcers of great curvature and the cardiac section of the stomach, as the most frequently malignant , callous ulcers with a diameter of more than 2 cm, recurrent and re-bleeding ulcers. The operation of choice in gastric ulcer is pyloropreserving resection of the stomach, which is feasible with localization of the ulcer on the lesser curvature of the stomach and the absence of inflammatory changes in the wall of the stomach within 3-4 cm from the pylorus. With double localization of the ulcer or the spread of ulcerative infiltrate to the prepyloric stomach, a resection of the stomach is indicated. by Billroth-1. In patients with gastric ulcer complicated by perforation or bleeding, when it is necessary to quickly complete the operation, vagotomy with wedge-shaped excision of the ulcer and pyloroplasty is acceptable . Gastric resection by Billroth- N in various modifications can be used only with the technical complexity of the formation of gastroduodenal anastomosis, after extensive excision of the stomach and in the presence of duodenostasis . The choice of the method of operation for gastric ulcer complicated by malignancy is carried out taking into account oncological requirements.