The variety of manifestations of the clinical picture of stomach cancer is associated with the location of the tumor, the form of growth, the prevalence of the process, and complications. Due to the predominance of certain symptoms, dyspeptic, pain, feverish, anemic, edematous, cachectic (terminal) forms of gastric cancer are distinguished. However, most often the clinical picture does not fit into this scheme; it is more complex nature. Analysis pain syndrome in case of stomach cancer, it shows that pain occurs in the epigastrium soon after eating, is associated with the nature of the food, often turns out to be long-lasting, and when the lesion is localized in the lower parts of the stomach, it can resemble ulcerative pain in nature. So, the infiltrative-ulcerative form of stomach cancer in the early stages can occur under the guise of a benign ulcer, responding well conservative treatment and simulating ulcer healing.
According to most researchers, the largest share of all forms of gastric cancer still falls on ulcerative forms. Among the ulcerative forms of gastric cancer, primary ulcerative and infiltrative-ulcerative forms are distinguished.
The development of stomach cancer has been linked with persistent Hp infection (Helicobacter pilori). Erosive and ulcerative lesions of the gastroduodenal zone are accompanied by high contamination of the gastric mucosa with human herpes viruses (HHV), which with destructive inflammation of the mucous membrane reaches 60%, including HHV-4 ( Epstein-Barr virus), HVV-5 (cytomegalovirus), HVV-6, 7, 8 (lymphoproliferative viruses). Moreover, the more pronounced the destruction, the higher the frequency of detection of viruses in the samples. Being lymphoproliferative, these viruses, especially HHV-4, 6, 7, 8, affect the T- and B-cell immunity, leading to the development of immunodeficiency states and generalized forms of infection, similar in their final manifestations to the action of the human immunodeficiency virus. HHF, along with HP, probably play a significant role in maintaining chronic inflammation in the wall of the stomach, are markers of a severe immunodeficiency state and mediated carcinogens. The most significant phenomena of immunodeficiency with a decrease in functional activity cellular immunity, in particular the mechanisms of antitumor immunity, were found in elderly and senile patients.
Primary ulcerative gastric cancer little studied. It is rarely discovered. This form includes exophytic cancer with ulceration at the very beginning of its development (plaque-like cancer), with the formation of an acute and then chronic cancer ulcer, which is difficult to distinguish from an ulcer-cancer. At microscopic examination Undifferentiated cancer is more often detected.
Saucer-shaped cancer (cancer-ulcer)- one of the most common forms of stomach cancer. Occurs when ulceration of an exophytically growing tumor (polyposis or fungos cancer) and is a round formation, sometimes reaching large sizes, with roller-like whitish edges and ulceration in the center. The bottom of the ulcer may be neighboring organs into which the tumor grows. Histologically, it is more often represented by adenocarcinoma, less often by undifferentiated cancer.
Ulcer-cancer develops from a chronic gastric ulcer, so it occurs where a chronic ulcer is usually localized, i.e. on the lesser curvature. The signs of a chronic ulcer distinguish ulcer-cancer from saucer-shaped cancer: extensive proliferation of scar tissue, sclerosis and thrombosis of blood vessels, destruction of the muscle layer in the scar base of the ulcer and, finally, thickening of the mucous membrane around the ulcer. These signs remain with the malignancy of a chronic ulcer. Particular importance is attached to the fact that in saucer-shaped cancer the muscle layer is preserved, although it is infiltrated by tumor cells, and in ulcer cancer it is destroyed by scar tissue. The tumor grows predominantly exophytically in one of the edges of the ulcer or along its entire circumference. More often has histological structure adenocarcinoma, less often - undifferentiated cancer.
The fact of malignancy of gastric ulcers has been known for a long time. Malignancy of a gastric ulcer can only be said when morphological study against the background of a chronic ulcer, a focus of malignant growth is revealed in one of its edges. When identifying the source of malignancy at the bottom of the ulceration, one should first think about the primary ulcerative form of cancer. It must be emphasized that the correct diagnosis can be established by careful histological examination of the resected stomach. Less accurate information about the incidence of malignancy of gastric ulcers can be obtained from endoscopic gastrobiopsy. According to modern ideas, the frequency of malignancy of gastric ulcers averages 7 - 10% (one can find data on a significantly lower frequency of 1 - 2%). It should be borne in mind that many patients with mediogastric ulcers have concomitant atrophic gastritis, which is also a precancerous disease. Therefore, the origin of gastric cancer in some patients with gastric ulcers is not associated with genuine malignancy, but with the development of a tumor against the background of epithelial dysplasia away from the ulcer. Some authors believe that there is no convincing evidence of the transformation of high-grade gastric ulcers into cancer.
Malignization of a chronic ulcer can occur at different times of the ulcer history, at any age of the patient, but more often in middle-aged and older patients with a long-term history peptic ulcer. Clinical manifestations of malignancy of a gastric ulcer practically indicate advanced cancer, and not early stage its development.
Signs of malignancy of a stomach ulcer include:
change in the course of gastric ulcer (disappearance of periodicity, cyclicity, reduction of periods of remission);
change in the nature of pain (less sharp, but constant, independent of food intake);
loss of appetite;
progressive weight loss;
unmotivated weakness;
reduction of pain on palpation of the abdomen;
hypochromic anemia, decreased acidity of gastric juice, constant presence of occult blood in the stool.
!!! Something to keep in mind that the condition of a patient suffering from cancer that developed from an ulcer can improve after dietary and drug treatment. Disappearance of the niche noted during the control x-ray examination, may be due to tumor growth rather than ulcer healing.
X-ray signs of ulcer malignancy: large niche (more than 2 cm), deep with wide infiltration around (symptom of a submerged niche), irregularity of the relief of the mucous membrane around the niche, weakening of muscle wall contractions. IN initial stage development of cancer in the edge of the ulcer, X-ray diagnosis of malignancy of the ulcer is very difficult. Ulcers with a diameter of more than 2.5 cm, especially those located in the prepyloric part, make one suspect its malignancy.
Infiltrative-ulcerative cancer found in the stomach quite often. This form is characterized by pronounced cancrosis infiltration of the wall and ulceration of the tumor, which in time sequence can compete: in some cases it is late ulceration of massive endophytic carcinomas, in others it is endophytic tumor growth from the edges of a malignant ulcer. Therefore, the morphology of infiltrative-ulcerative cancer is unusually diverse - these are small ulcers of varying depths with extensive infiltration of the wall or huge ulcerations with a tuberous bottom and flat edges. Histological examination reveals both adenocarcinoma and undifferentiated cancer.
When an ulcerative defect in the stomach is detected in elderly and senile people, it is important to confirm the benign nature of the ulcer. It should be borne in mind that malignancy (malignancy) of a long-existing gastric ulcer is much less common than is commonly assumed (the risk of malignancy of a gastric ulcer in general is not higher than the risk of gastric cancer in a patient who does not have an ulcer). As our own experience and literature data show, the vast majority of malignant gastric ulcers are not represented by malignant benign ulcers, but by the primary ulcerative form of gastric cancer.
The primary ulcerative form of gastric cancer is supported by such signs as short (usually less than 1 year):
medical history,
localization of the ulcerative defect on the greater curvature of the stomach,
very large size of the ulcer,
pronounced weight loss and lack of appetite,
anemia and accelerated ESR,
histamine-resistant achlorhydria,
characteristic radiological data (detection of an irregularly shaped “niche” with uneven contours, breakage of folds of the mucous membrane, rigidity of the stomach wall at the site of the lesion, etc.),
endoscopic signs ( irregular shape ulcers, uneven edges, tuberous bottom, stepped breakage of the walls of the ulcer crater, infiltration of the mucous membrane adjacent to the ulcer, rigidity and bleeding of the edges of the ulcer, etc.).
At the same time, the infiltrative-ulcerative form of gastric cancer can give an x-ray and endoscopic picture of a benign ulcer. Therefore, a final conclusion about the nature of the ulceration can be made only after repeated histological examination of biopsies taken from the edges and bottom of the ulcer.
Clinical criteria differential diagnosis ulcerations of malignant and benign nature, unfortunately, cannot be considered sufficiently reliable, even stating the benign nature of a stomach ulcer does not exhaust all diagnostic problems.
Differential diagnosis between the primary ulcerative form of gastric cancer and gastric ulcer must be carried out in stages (the specificity of the algorithm is 98.4%):
Stage I - a comprehensive x-ray endoscopic examination of the stomach, and it is rational to use x-ray as the primary research method; taking into account radiological signs, it is necessary to perform gastroscopy with a biopsy of suspicious areas, and the biopsy must be performed not only on the basis of visual endoscopic signs, but also taking into account the signs identified during X-ray, ultrasound and CT examination, even if there are no visual signs during endoscopy.
Stage II - transabdominal ultrasound examination, the purpose of which is to search for additional intramural signs of the nature of the identified ulceration, as well as to search for extra-organ manifestations of gastric ulceration in abdominal cavity(metastases).
Stage III - conducting X-ray computed tomography if differential diagnostic difficulties are intractable and in the absence of morphological confirmation of tumor lesions, it is advisable to use the possibilities.
Stage IV - endoscopic (with biopsy) and ultrasound examination for the purpose of dynamic monitoring of the nature of intramural changes in the process of conservative treatment and scarring of gastric ulcers.
Cancer treatment. Treatment is surgical (radical or palliative surgery). In case of inoperability - drug treatment(chemotherapy), is of lesser importance (due to the low radiosensitivity of the tumor) radiation therapy. For patients with gastric ulcer against the background of high-grade dysplasia, surgical treatment is indicated, since continued dynamic observation actually increases the risk of malignancy and untimely detection of the primary ulcerative form of gastric cancer, which significantly worsens treatment results and prognosis. Malignancy of an ulcer is an absolute indication for surgery, which is performed according to all the principles of oncological radicalism.
In accordance with the WHO International Statistical Classification of Diseases, Injuries and Causes of Death, 10th revision, gastric ulcer, ulcer duodenum, gastrojejunal ulcer:
By 25 - stomach ulcer,
By 26 - duodenal ulcer,
K 27 - peptic ulcer of unspecified localization,
By 28 - gastrojejunal ulcer.
Depending on the severity and characteristics of the process, ulcers are divided into: acute with bleeding, acute with perforation, acute with bleeding and perforation, acute without bleeding or perforation, chronic or specified with perforation, chronic or unspecified with bleeding, chronic or unspecified with bleeding and perforation, chronic without bleeding or perforation.
IN International classification As complications of peptic ulcer disease, only emergency conditions (bleeding, perforation) are included, while disorders of the evacuation-motor function of the stomach and duodenum, penetration, malignancy, and peri-processes are not reflected in the international classification.
Formulation diagnosis of peptic ulcer based on clinical and endoscopic data, includes: name and phase of the disease (exacerbation, fading exacerbation, remission), its morphological substrate (ulcer, post-ulcer scar, deformation, gastritis, duodenitis, esophagitis, indicating localization, distribution), complications - bleeding, penetration , stenosis, perforation and malignancy.
Reactive pancreatitis and hepatitis, as well as dyskinesia of the biliary tract and colon, are not complications, but variants clinical course peptic ulcer, since peptic ulcer is general illness, one of the leading etiological factors of which is a violation of neurotrophic processes in the mucous membrane of the gastroduodenal zone. The latter occurs as a result of increased tone of the parasympathetic division of the autonomic nervous system, which is usually caused by a violation of higher (central) regulation at the level of the hypothalamic centers.
Despite the greatest vulnerability to neurogenic dystrophies of the mucous membrane of the stomach and duodenum, since there are aggressive factors - HCL and gastric proteases, their reduced ratio with protective factors, as well as disruption of anabolic processes against the background of hypercatabolic phenomena, they still play an important role in evacuation -motor disorders resulting from hypertonicity vagus nerve. Increased parasympathetic impulse causes evacuation disorders: chaotic peristalsis and antiperistalsis, stasis and spasms not only in the stomach, pylorus and duodenum, but also in the biliary and pancreatic system, small and large intestines. The latter cause biliary dyskinesia, cholecystitis and angiocholitis associated with peptic ulcer disease, caused by impaired outflow of bile as a result of stagnation in the biliary tract, gallbladder and spasm of the sphincter of Oddi. Spasm of the sphincter of Oddi, inflammatory processes in the duodenum, duodenostasis and delayed emptying of the ductular pancreatic system cause functional and organic lesions of the pancreas in the form of pancreatitis.
The so-called reactive hepatitis in peptic ulcer disease should apparently be considered as the functional basis of damage to the hepatocyte, a decrease in its protein composition, amino acid-forming function, slight vulnerability of the cell membrane as a result of liver damage along with the mucous membrane of the gastroduodenal zone, neurogenic dystrophy, since it is known that all organs with high level protein synthesis are vulnerable in the presence of neurogenic dystrophies in the body. Often the diagnosis of chronic nonspecific reactive hepatitis in patients with peptic ulcers is not justified. These patients mainly have fatty degeneration liver.
The presence of irritable bowel syndrome of the hypomotor-hyperkinetic type in peptic ulcer disease is also the result of increased tone of the vagus nerve. Pyloric and duodenal helicobacteriosis can also often cause disruption of the motor-evacuation function of the gastroduodenal zone, which can result in diseases of the bilioduodenopancreatic zone accompanying peptic ulcers. Thus, lesions of nearby digestive organs and sphincter diseases observed during peptic ulcers should be considered as variants of the clinical course of the disease, and not as complications. Complications of peptic ulcer disease should be divided into complications in the ulcer area (penetration, perforation, bleeding, malignancy) and in the organ area (stenosis of the outlet of the stomach and duodenum, peri-processes: perigastritis, periduodenitis, perivisceritis).
Classification of peptic ulcer disease (I.I. Degtyareva, 1999)
/. Stages of peptic ulcer
Stage I - pre-ulcerative condition (antral gastritis type B seu chronic primary gastroduodenitis) and mild course of peptic ulcer disease (with “light” intervals between relapses from 2 to 7 years);
Stage II - peptic ulcer moderate severity and severe course;
Stage III - complications;
Stage IV - relapse of peptic ulcer after surgical treatment(gastric resection, various types vagotomy).
//. Expressiveness of the process
A. Ulcer-like (seu non-ulcer) dyspepsia.
B. Pre-ulcerative condition (chronic primary gastroduodenitis, antral gastritis type B).
B. ulcus pepticum - peptic ulcer disease with the presence of an ulcerative defect.
III. Forms of ulcerative lesions of the esophagogastroduodenal area:
peptic ulcer disease;
symptomatic ulcers (senile gastric ulcer, allergic ulcers, ulcerogenic adenoma; stress ulcer - nervous shock, postoperative, burn, traumatic brain or other severe injury, uremia, condition after kidney transplant, hypoxia due to blood loss, blood diseases, chronic pulmonary and cardiac insufficiency, pneumonia, atherosclerosis of the aorta and mesenteric vessels, narrowing of the trunk of the celiac artery, myocardial infarction, cirrhosis of the liver, hyperparathyroidism, hyperplasia of gastrin-producing cells; after the use of ulcerogenic drugs - non-steroidal anti-inflammatory drugs (acetylsalicylic acid, butadione, reserpine, indomethacin, ortofen, olfen, diclof enaka sodium), non-coated antibiotics, synthetic glucocorticoid hormones, etc.). Often against the background of ulcerogenic drugs in case of genetic predisposition true peptic ulcer disease develops.
IV. According to the location of the ulcer:
gastric (cardiac part, lesser and greater curvature, anterior and posterior walls, antrum, pylorus);
duodenum (bulbous, extra-bulbous, as their variety - postbulbar);
combined ulcers of the stomach and duodenum;
peptic ulcers of the esophagus; peptic ulcers small intestine, gastroenteroanastomosis (after gastrectomy). Most surgeons classify them as symptomatic manifestations and explain them by the entry of HCI and pepsin into an atypical location for them - the small intestine.
V. By severity: light, medium and heavy.
VI. According to the complaints: the presence of pain, dyspeptic syndrome, latent course.
VII. Clinical course options:
without concomitant pathology;
with the involvement of nearby organs (reactive pancreatitis, dyskinesia of the gallbladder and biliary tract, chronic cholecystitis, irritable bowel syndrome with constipation, chronic nonspecific reactive hepatitis, fatty liver).
VIII. Uncomplicated and complicated peptic ulcer.
Complications in the ulcer and organ area:
in the area of the ulcer - perforation, penetration, bleeding and malignancy;
in the organ region (periprocesses) - perigastritis, periduodenitis, perivisceritis, violation of the evacuation-motor function of the stomach and duodenum: stenosis of the pylorus or duodenum (compensated, sub- and decompensated).
IX. Phases of the disease:
active (period of exacerbation, period of incomplete remission after healing of ulcers - corresponds to the endoscopic stage of the “pink scar”).
inactive (stage of complete remission after healing of erosive and ulcerative lesions - corresponds to the endoscopic stage of the “white scar”).
X. Consequences of the operations undergone: resected stomach, condition after vagotomy, suturing of a perforated ulcer, post-vagotomy syndrome.
XI. Violations functional state stomach and duodenum(functions - secretory, acid-forming, pepsin-forming, motor-evacuation, acid-neutralizing).
XI. Variants of the severity of peptic ulcer disease are characterized by the following features:
Mild course: periods of exacerbation no more than once every 1-2 years, clinical manifestations are not pronounced, are easy to treat, ability to work during remission is completely preserved;
Course of moderate severity: exacerbation 1-2 times a year, pronounced clinical manifestations requiring longer hospital treatment, in pathological process In addition to the stomach and duodenum, other digestive organs are involved, remission for a long time is incomplete - certain manifestations of the disease remain, work capacity is often limited;
Severe course: functional disorders and corresponding clinical manifestations are pronounced, which are severe, do not respond well to long-term conservative treatment, various complications are often observed, there is no stable remission, work ability is significantly reduced, often due to ineffectiveness therapeutic treatment shown surgical intervention. Exacerbation occurs several times a year.
In medical practice, along with the classic clinical picture of peptic ulcer, sometimes there are special variants of the disease, distinguished by the atypical location of the mucosal defect, some pathogenetic features, as well as the originality of symptoms, which causes certain diagnostic difficulties. This group includes pyloric ulcers, giant and postbulbar ulcers.
Pyloric Ulcers. Pyloric ulcers are very difficult for X-ray recognition, but, according to most domestic researchers, they are not so rare and account for 12-14% of all gastric ulcers and 2.1 - 6.6% total number patients suffering from peptic ulcer (G. A. Gusterin, 1954; V. A. Fanarjyan, 1954; S. A. Reinberg and M. M. Salman, 1963). The clinical picture is dominated by pain in combination with dyspeptic disorders. The pain, as a rule, is rhythmic in nature, more often there are late, sometimes hungry and night pains radiating to the back or upper lumbar region. In some cases, the pain becomes two-wave in nature. The pain may be accompanied by nausea and vomiting. The latter in some patients is caused by mechanical obstacles caused by swelling around the ulcer or cicatricial changes in the pyloric canal, but in most cases, vomiting is of a reflex nature.
Indicators of gastric secretion most often approach those in patients with duodenal ulcers. When pyloric ulcers are combined with antral gastritis the curve of gastric secretion acquires a staircase ascending character. In such patients, bleeding is common, but perforation is rare. Ulcers are most often located on the lesser curvature and back wall pyloric canal.
Detection of a niche is crucial in recognizing pyloric ulcers, while indirect x-ray signs do not play a significant diagnostic role (S. A. Reinberg and M. M. Salman, 1963). Pyloric ulcers are not prone to malignancy.
Postbulbar ulcers. Postbulbar extrabulb ulcers can be located in the upper part, in the area of the superior flexure or in the initial segment of the descending part of the duodenum. The first reports of such ulcers based on autopsy data date back to the 60s of the last century (Klings, 1860; Heckford, 1866; Robison, 1868). The first review of clinical observations was published by Perry and Schaw (1894). According to most researchers, the frequency of postbulbar ulcers ranges from 5 to 20% (S. A. Reinberg and M. M. Salman, 1964; Bergner and Gold, 1964; V. M. Mayorov, 1968). Postbulbar ulcers predominate in men. Average age of patients is 10 years higher than that with the ulcer located in the bulb.
In the clinical picture, some originality in the nature of pain should be noted. The latter can be localized in the right upper quadrant of the abdomen or in the back. They occur more often at the end of the day, do not always remain periodic, and lose connection with food intake. The pain can be very persistent and not relieved by conventional medications and heat.
The main features of postbulbar ulcers are: 1) a tendency to frequent bleeding; 2) combination with duodenal stenosis or functional pylorospasm, with excruciating pain and repeated vomiting; 3) a tendency to penetrate into the pancreas and common bile duct.
Postbulbar ulcers are more common than they are diagnosed. Accurate diagnosis is only possible with the help of a radiologist, subject to a thorough examination of all parts of the duodenum (see chapter “X-ray examination”).
Giant ulcer. A giant or large ulcer of the stomach or duodenum is defined as ulcers that have a niche diameter of at least 3 cm on x-ray examination.
Giant ulcers of the lesser curvature of the stomach are rarely malignant, but may be accompanied by atypical clinical manifestations in the form of depression, severe cachexia, pain that is more reminiscent in nature renal colic or pancreatitis. V. S. Afanasyeva (1966) includes normal or reduced acidity levels and a small palpable area of pain that does not correspond to the true size of the ulcer as features of the clinical picture of such ulcers. Giant ulcers are most often observed in the elderly. The clinician has to differentiate giant ulcers from stomach or pancreatic cancer.
Greater curvature ulcers can be gigantic or simply large (diameter less than 3 cm). Many authors believe that both malignant tumors with ulceration and benign ulcers can be located on the greater curvature (Comfort, 1957; Findley, 1961).
Benign ulcers of normal size in the same location should be distinguished from giant ulcers of the greater curvature. According to Findley (1961), who analyzed huge material - 7 California hospitals over 10 years (1951-1960), out of 1600 cases of gastric ulcers, ulcers of the greater curvature occurred in 2.75% of patients. Lentinen (1970) believes that ulcers of the greater curvature, as a rule, are a consequence of long-term use medicines(aspirin, rheopirin, steroid hormones).
Giant duodenal ulcers have some clinical features. In most patients, the disease is accompanied by acute pain caused by frequent involvement of the pancreas and gall bladder in the pathological process. The intensity of pain does not decrease under the influence of antispasmodics and antacids. The pain may be accompanied by vomiting, often not associated with food intake. There is marked weight loss and hypoproteinemia, the cause of which remains unclear. Giant ulcers can occur latently and manifest only as one or another complication. The diagnosis is made after x-ray examination. These forms can have an unfavorable course, do not respond well to conservative treatment and require surgical intervention.
A stomach ulcer is chronic illness, characterized by the formation of defective formations on the gastric mucosa. Most often, this disease is diagnosed in men aged 20-50 years, but women are also susceptible to this pathology. The frequency of diagnosis of gastric ulcer depends on several factors:
- under what conditions does a person work?
- Is the diet being followed?
- how often alcoholic beverages are consumed.
According to statistics, 14% of the world's population has a diagnosed gastric ulcer.
We recommend reading:Reasons for development
If earlier reasons While the development of stomach ulcers was believed to be caused by poor diet and alcohol abuse, modern research has proven that the main cause of the disease in question is the bacterium Helicobacter pylori. This is a spiral-shaped microorganism that survives well in the aggressive environment of the stomach, neutralizes acid in gastric juice. But as the bacteria lives and develops, small fragments begin to separate from the mucous membrane - this is what leads to the formation of ulcers. Moreover, it is very easy to become infected with Helicobacter pylori - bacteria of this type are transmitted through kissing, dirty hands, when using shared utensils, through dirty medical instruments, from mother to fetus.
There are a number of factors that are not definitely the causes of the development of the disease in question, but in 84% of cases they provoke it. These include:
- Long-term use of medications - most often the formation of gastric ulcers is promoted by aspirin, diclofenac and other non-steroidal anti-inflammatory drugs. The risk is greater in patients over 65 years of age or when taking these drugs and coagulants, glucocorticoids simultaneously.
- The presence of major diseases in the body - tuberculosis, syphilis, diabetes mellitus, lung cancer, liver cirrhosis, pancreatitis and others.
- Any abdominal injuries - blows/bruises, internal and external burns, frostbite.
Some doctors believe that a major role in the occurrence of peptic ulcers is played by hereditary factor. In fact, only 40% of parents diagnosed with gastric ulcers have children with the same disease in the future.
Separately, it is worth listing the factors that, under certain circumstances, increase the likelihood of the occurrence of the disease in question to the maximum possible:
- smoking – we are talking not only about cigarettes/cigarettes, but also about cigars and hookahs;
- alcohol abuse;
- too much a large number of consumed carbonated drinks and coffee;
- constant consumption of very hot, or vice versa, ice-cold food and drinks;
- frequent depression, neuroses;
- regular use of non-steroidal anti-inflammatory drugs for medical reasons;
- violation of the diet.
Possible causes of stomach ulcers are described in the video review:
Symptoms of a stomach ulcer
Gastric ulcers have fairly clear symptoms – this allows you to promptly consult a doctor for diagnosis and treatment. Signs of a stomach ulcer include:
- Pain syndrome. Most often it occurs in the upper abdomen - it is recorded in 75% of patients. Moreover, in half of the cases the pain is of low intensity, and the second half of the patients complain of acute sensations. The pain syndrome increases significantly after consuming alcoholic beverages, spicy/smoked foods, and physical activity.
- Heartburn. It is observed in 80% of patients and is characterized by a strong burning sensation in the epigastric region. Heartburn is the entry of acidic stomach contents into the lumen of the esophagus. The feeling is very unpleasant and occurs approximately 2 hours after eating food.
- Decreased appetite. This symptom is psychological in nature. The fact is that pain and heartburn occur in patients with stomach ulcers always after eating - this fear makes them refuse to eat.
- Nausea. Sometimes the symptom is accompanied by vomiting, which is facilitated by impaired gastric motility. If there is a stomach ulcer, vomiting may appear 2 hours after eating, accompanied by pain. It is noteworthy that as the stomach is emptied of its contents, the patient feels better.
- Feeling of heaviness. It occurs in the stomach immediately after eating and is absolutely independent of how much food was consumed.
- Increased gas formation.
- Belching. There is a surge of gastric contents into oral cavity, after which it remains bitter or sour.
In addition, patients complain of intestinal dysfunction - most often this manifests itself as constipation. There are also several atypical symptoms - plaque on the tongue (it indicates pathologies in gastrointestinal tract at all), increased sweating palms, pain when pressing on the stomach.
The most pronounced pain syndrome is often the basis for making a preliminary diagnosis of a stomach ulcer. The pain can be completely different; by its nature you can determine in which part of the stomach the defective formation is located.
Characteristics of pain due to ulcers:
- If the ulcer is located in the cardinal or subcardinal part of the stomach, then the pain syndrome appears 20 minutes after eating food, its localization is very high - almost in the solar plexus area. Very often the pain radiates to the heart, so a heart attack may be misdiagnosed (this happens during self-diagnosis). With this location of the defective formation, there is never pain after physical exertion, and after drinking even a small amount of milk, the patient’s condition stabilizes.
- If the peptic ulcer is localized in the lesser curvature of the stomach, the pain will be especially intense in the left iliac region. The syndrome occurs 1 hour after eating, the condition stabilizes after the stomach digests the contents. Most often, patients complain of pain in evening time, sometimes they are accompanied by vomiting.
- An ulcer located in the upper curvature of the stomach has a very hidden course and can be quickly diagnosed very rarely, but it is the ulcers of the upper curvature of the stomach that are malignant.
- Ulcer damage antrum hollow organs are characterized by pain in the evening and at night, and may be completely unrelated to food intake. The pain is constant, aching, accompanied by belching and heartburn.
- If the ulcer is located in the pyloric part of the stomach, then the pain will be acute, paroxysmal, and prolonged (in some cases, one attack lasts more than 40 minutes).
In very rare cases, gastric ulcer is characterized by atypical pain syndrome - for example, occurring in the lower back or . Doctors cannot quickly diagnose the disease in question with such symptoms, which leads to various complications.
Diagnosis of gastric ulcer
A doctor, seeing a patient with the symptoms described above, cannot immediately make an accurate diagnosis - it is necessary to take some measures. Diagnostic procedures for suspected gastric ulcers include:
- laboratory examination of urine, blood and feces;
- FEGDS - examination with a special tube with a camera at the end of the gastric mucosa;
- ultrasound examination of the abdominal organs - pancreas, liver, gall bladder;
- X-ray with contrast agent;
- tests for the detection of Helicobacter pylori.
When performing FEGDS, the doctor can take a small fragment of biomaterial (gastric mucosa) for a biopsy - histological examination, allowing you to determine the nature of the disease (malignant/benign).
If the doctor, after the specified set of diagnostic measures, still has doubts about the classification of the pathology, then he may be prescribed CT scan, consultation with more specialized specialists.
Possible complications of a stomach ulcer
Stomach ulcer – dangerous disease, which can lead to serious consequences ending fatal. The most frequently recorded complications of the disease in question are:
Gastric ulcer is a very complex and dangerous disease that is only chronic and difficult to treat. Nevertheless, if you follow a diet and undergo courses of therapy, you can achieve long-term remission. The symptoms, causes and methods of diagnosing gastric ulcers are described in detail in the video review:
Tsygankova Yana Aleksandrovna, medical observer, therapist of the highest qualification category.
A gastric ulcer is a chronic pathology, often recurrent, the main symptom of which is the formation of an ulcerative defect in the wall of the stomach, penetrating into the submucosal layer. This pathology occurs with alternating periods of exacerbation and remission.
In developed countries, the incidence of the disease is approximately 10-15% of the population, and these are very large numbers. There is also a trend towards an increase in pathology among women, although previously it was believed that stomach ulcers were predominantly a male disease. Mostly people between 30 and 50 years old suffer from this pathology.
Why and how does an ulcer develop?
| Helicobacter pylori infection | The main reason for the development of the disease. This spiral-shaped bacterium causes 45-75% of all cases of stomach ulcers. The source of infection is a sick person or a bacteria carrier. The microbe can be transmitted through:
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| Due to taking medications | The second most common cause of pathology. These medications include:
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| As a complication of various chronic diseases |
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| As a result acute diseases and conditions (so-called “stress ulcers”) |
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| Social reasons |
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What are the types of stomach ulcers?
Symptoms of a stomach ulcer
Signs of pathology can be quite varied; they depend on the size and location of the defect, individual sensitivity to pain, the phase of the disease (exacerbation or remission), the presence of complications, the age of the patient and concomitant pathology.
Pain is the main symptom of a stomach ulcer. The pain syndrome has some features:
- pain can be early (in the first couple of hours after eating, if the defect is located in the body or cardia of the stomach), late (more than two hours, usually when localized in the pylorus), fasting or hungry (disturbed before meals) and night (usually appear during second half of the night);
- pain may appear and disappear, depending on the activity of the inflammatory process;
- pain tends to worsen in spring and autumn;
- by nature it can be sharp, cutting, pulling, stabbing, blunt, and so on;
- the pain goes away after taking antisecretory medications and antacids;
- its intensity varies, from mild discomfort to unbearable sensations;
- usually experiences pain in the epigastrium, left side chest, behind the sternum, left arm or in the back. Atypical localization of pain is the right hypochondrium, lumbar region, pelvis.
It should be remembered that about 20% of patients do not have pain. This usually happens in old age, when diabetes mellitus, taking NSAIDs.
Other signs of peptic ulcer:
- heartburn is a burning sensation in the epigastric region. The reason for its appearance is the entry of aggressive acidic gastric contents into the lumen of the esophagus;
- nausea and vomiting are caused by impaired gastric motility. Vomiting occurs a couple of hours after eating and causes relief;
- belching is a sudden involuntary reflux of a small amount of gastric juice into the oral cavity. It is characterized by a sour or bitter sensation in the mouth. Belching occurs due to disruption of the cardiac sphincter.
- loss of appetite– appears due to a violation of the motor function of the gastrointestinal tract, or a person consciously refuses to eat for fear of pain;
- constipation – delay in bowel movements for more than 2 days. Occurs due to increased secretion of hydrochloric acid and retention of food in the stomach;
- feeling of heaviness in the stomach, occurring after eating;
- fast saturation;
- feeling of bloating.
Complications
Like many other diseases, stomach ulcers can have complications, sometimes quite dangerous. These include:
Penetration
Penetration is the destruction of the stomach wall, with the bottom of the ulcer becoming a nearby organ. This is usually the pancreas. Hydrochloric acid and pepsin destroy its structure, causing acute destructive pancreatitis. The first symptoms of penetration are sharp girdling pain in the abdomen, fever and an increase in alpha-amylase in the blood.
Perforation
Perforation is the destruction of the wall of an organ and the entry of its contents into the abdominal cavity or retroperitoneal space. Occurs in 7-8% of cases. Violation of the integrity of the wall can be caused by lifting weights, heavy physical labor, eating fatty and spicy foods, and drinking. Clinical picture characterized by all the signs of diffuse peritonitis (general weakness, abdominal pain throughout, intoxication and others).
Plain radiography of the abdominal cavity helps to diagnose gastric perforation. vertical position! On it you can see a disc-shaped clearing (gas) under the dome of the diaphragm.
Malignancy
Malignancy is the degeneration of an ulcer into stomach cancer. This complication occurs infrequently, in approximately 2-3% of patients. It is noteworthy that duodenal ulcers never transform into malignant tumor. As cancer develops, patients begin to lose weight, they develop an aversion to meat foods, and their appetite is reduced. Over time, symptoms of cancer intoxication appear (fever, nausea, vomiting), pallor skin. A person can lose weight up to cachexia (complete exhaustion of the body).
Pyloric stenosis
Pyloric stenosis occurs if the ulcerative defect is localized in the pyloric region. The pylorus is the narrowest part of the stomach. Frequent relapses lead to scarring of the mucosa and narrowing of the pylorus. This leads to disruption of the passage of food into the intestines and its stagnation in the stomach.
There are 3 stages of pyloric stenosis:
- compensated– the patient has a feeling of heaviness and fullness in the epigastric region, frequent sour belching, but the general condition remains satisfactory;
- subcompensated– patients complain that even a small meal causes a feeling of fullness and heaviness in the abdomen. Vomiting occurs frequently and provides temporary relief. Patients lose weight and are afraid to eat;
- decompensated– general condition is severe or extremely serious. The food eaten no longer passes into the intestines due to complete narrowing of the pylorus. Vomiting is profuse, repeated, and occurs immediately after eating foods. Patients are dehydrated, they experience weight loss, electrolyte and pH imbalance, and muscle cramps.
Bleeding
Gastrointestinal bleeding occurs due to destruction of the vessel wall at the bottom of the ulcer (see). This complication is quite common (about 15% of patients). Clinically it manifests itself as vomiting " coffee grounds", melena and common features blood loss.
“Coffee grounds” vomiting gets its name from the fact that blood entering the lumen of the stomach enters chemical reaction with hydrochloric acid. And in appearance it becomes brown-black with small grains.
Melena is tarry or black stool (see). The color of stool is also due to the interaction of blood with gastric juice. However, it should be remembered that some medications (, Activated carbon) and berries (blackberries, blueberries, black currants) can turn the stool black.
Common signs of blood loss include general pallor, decreased blood pressure, . The skin becomes covered with sticky sweat. If the bleeding is not controlled, the person may lose too much blood and die.
How to identify the disease?
The patient's complaints and medical history help the doctor suspect a peptic ulcer. However, in order to accurately diagnose the disease, therapists prescribe a number of special procedures.
Methods for detecting stomach ulcers:
- General blood analysis— Decrease in the number of red blood cells and hemoglobin (anemia), increased ESR
- Fibroesophagogastroduodenoscopy (FEGDS)— Using a special rubber tube with a camera (fibrogastroscope), the doctor can see with his own eyes the condition of the mucous membrane digestive tract. This method also allows you to perform a biopsy of the organ wall, that is, pinch off a small piece from it.
- X-ray of the stomach with contrast— The technique is currently somewhat outdated. Its essence is as follows: the patient drinks a barium contrast mixture. The radiologist then takes a series of pictures that show how the contrast moves through the mucosa. The presentation of a peptic ulcer is usually described as a “niche symptom.”
- pH-metry and daily monitoring of gastric juice pH“This is an invasive and painful technique that allows you to assess how aggressive gastric juice is in relation to the mucous membrane.
Methods for identifying Helicobacter:
- Serological - Detection of antibodies in the blood to H. pylori
- Radionuclide urease breath test— Based on the release of urea by the microbe, which comes out with the air. The technique is safe; to detect Helicobacter, you only need to breathe into a special container.
- Stool test - Detection of Helicobacter antigen in stool, used to determine the effectiveness of treatment
- Rapid urease test— Performed after fibrogastroscopy. The resulting piece of mucous membrane is tested with a special indicator that detects H. pylori
Treatment of stomach ulcers
Therapy for this disease is multicomponent. It is mandatory to eradicate (destruct) Helicobacter pylori, reduce the acidity of gastric juice, eliminate unpleasant symptoms (heartburn, nausea) and prevent complications.
Antibiotic therapy
When the connection with Helicobacter pyloris peptic ulcer has been proven, treatment cannot be accomplished without the use of antibiotics. Previously, it was believed that treatment should last until the microbe completely disappeared, which was confirmed by:
- blood test for antibodies
- sowing
- urease test for FGDS
Then it turned out that not all types of Helicobacter cause the disease, and their complete destruction cannot be achieved, since when they die in the duodenum and stomach, it moves lower into the intestines, leading to inflammation and severe dysbiosis. Re-infection is also possible when using shared utensils and during the FGDS procedure, which should be performed only according to strict indications.
Today, it is advisable to carry out 1 or 2 courses of antibiotic therapy, if after the first course the bacteria are not killed, a different treatment regimen is selected, the following drugs are used:
- Macrolides (Clarithromycin)
- Semi-synthetic penicillins (Amoxicillin)
- Tetracycline
- Nitroimidazole derivatives (Metronidazole) for proven Helicobacter infection
Antisecretory drugs
- Antacids - Almagel, Maalox, sucralfate, queal. They envelop the mucous membrane, also neutralize hydrochloric acid and have an anti-inflammatory effect.
- H2-histamine receptor blockers— Ranitidine, rhinitis, famotidine, quamatel. Histamine receptor blockers interfere with the action of histamine, interact with parietal cells of the mucosa and increase the secretion of gastric juice. But they have practically ceased to be used because they cause withdrawal syndrome (when symptoms return after stopping therapy).
- Proton pump blockers- , omez, pantoprazole, rabeprazole, esomeprazole, lansoprazole, controloc, rabeloc, nexium (see more full list). They block the H + /K + -ATPase or proton pump, thereby preventing the formation of hydrochloric acid.
- Synthetic analogs of prostaglandin E 1 Misoprostol, Cytotec. Inhibits the secretion of hydrochloric acid, increases the formation of mucus and bicarbonates.
- Selective blockers of M-cholinergic receptors(pirencipin, gastrocepin) reduce the production of hydrochloric acid and pepsin. Used as an auxiliary therapy for severe pain, among side effects and heartbeat.
Agents that increase mucosal protection
- Sucralfate (Venter)- creates a protective coating at the bottom of the ulcer
- Sodium carbenoxolone (biogastron, ventroxol, kaved-s) helps speed up the recovery of the mucous membrane.
- Colloidal bismuth subcinate— . Forms a peptide bismuth film that lines the stomach wall. In addition, bismuth ion has a bactericidal effect against Helicobacter.
- Synthetic prostaglandins (enprostil) stimulate cell restoration and mucus formation.
Other drugs
- list of probiotics). Prescribed for antibiotic therapy.
The course of treatment for stomach ulcers is 2-6 weeks, depending on general condition and size of the defect.
Treatment regimens
The destruction of H. pylori promotes better scarring of the ulcer. This is the first step in treating peptic ulcers. There are two main schemes antibacterial therapy. They are prescribed step by step, that is, the first-line medications did not work, then they try the second regimen.
1st line of eradication (within a week):
- Semi-synthetic penicillins (Amoxicillin) 1000 mg twice a day or nitroimidazole derivatives (Metronidazole) 500 mg also twice a day.
- Macrodids (Clarithromycin) 500 mg twice a day.
In case of failure, a 2nd line of eradication is proposed (1 week):
- Proton pump inhibitors 20 mg twice a day.
- Nitroimidazole derivatives (Metronidazole) 500 mg also three times a day.
- Bismuth subcitrate (De-nol) 120 mg 4 times a day.
- Tetracyclines (Tetracycline) 0.5 g 4 times a day.
Currently, doctors are developing new methods for treating pathology. A vaccine against Helicobacter is already being tested. For better healing mucosal defects, cytokine drugs, trefoil peptides and growth factors are used.
Nutrition of the sick
Treatment with folk remedies
Fresh milk, soda, decoction of calamus root, all types of nuts, pea powder and carrot juice will help relieve heartburn (see). To neutralize the hydrochloric acid contained in gastric juice, use fresh potato juice. To do this, you need to grate the root vegetable and strain the resulting mass through cheesecloth. Take half a glass of potato juice an hour before breakfast for a week.
Herbal treatment also promotes recovery. Doctors recommend infusions of fireweed, yarrow, marsh cudweed, strawberry and apple leaves, flax seeds, aspen buds, and birch chaga mushroom.
It also has healing properties herbal tea, which includes elecampane rhizome, chamomile flowers, yarrow, marsh cudweed, flax seed, licorice root,. All herbs need to be washed well, dried and poured with boiling water. It is advisable to take a tablespoon 10 minutes before meals. Positive result will not keep you waiting.
