LectureLecture: :

ULCERAL DISEASE

  

Gastric antral and body mucous Gastric antral and body mucous helikobakterial contamination helikobakterial contamination degree determinationdegree determination

a) smears stained by the method of Romanovsky - a) smears stained by the method of Romanovsky - Giemsa and study of spiral or S - like bacteria in the Giemsa and study of spiral or S - like bacteria in the microscope field of view with increasing 360. microscope field of view with increasing 360.

They diagnose with three degrees of contamination.They diagnose with three degrees of contamination. - Up to 20 germs in sight - a faint degree (+)- Up to 20 germs in sight - a faint degree (+) - 20 to 50 - the average degree (+ +)- 20 to 50 - the average degree (+ +) - 50> - high (+ + +)- 50> - high (+ + +)

Diagnosis of HPDiagnosis of HP

a) diagnosis contamination of HP can be a) diagnosis contamination of HP can be performed with SLO - test (firm Delta), which is performed with SLO - test (firm Delta), which is a special plate with the reagent in the center, a special plate with the reagent in the center, one of which fits biopsy and to change the one of which fits biopsy and to change the color of the central ring of biopsies judged on color of the central ring of biopsies judged on the availability of HP.the availability of HP.b) for the same purpose the de-nol-tests (by b) for the same purpose the de-nol-tests (by "Yamanouchi")."Yamanouchi").c) urea breath test, based on the reception in c) urea breath test, based on the reception in the middle of urea labeled carbon (C13, C14).the middle of urea labeled carbon (C13, C14).

Diagnosis of HPDiagnosis of HP

Histological examinationHistological examination

They are:They are:-severity of inflammation,-severity of inflammation,- activeness of the - activeness of the processprocess- atrophy (decrease in - atrophy (decrease in the number of glands)the number of glands) - intestinal metaplasia - intestinal metaplasia - degree of mucous HP  - degree of mucous HP insemination.insemination.

Histological examinationHistological examination

determine the type of determine the type of intestinal intestinal metaplasia.metaplasia.

There are 3 types of There are 3 types of intestinal metaplasia.intestinal metaplasia.Type I - entericType I - entericType II - incomplete colonType II - incomplete colonType III - colon with Type III - colon with secretion sulfomutsyniv.secretion sulfomutsyniv.

Intragastric pH - metry allows you to Intragastric pH - metry allows you to set the concentration of free set the concentration of free hydrogen ions on the surface of the hydrogen ions on the surface of the body and pyloric stomachbody and pyloric stomach

pH in the range 0.1 -1.3 indicates hiperpH in the range 0.1 -1.3 indicates hiperacidityacidity,, 1,3-2,0 of normo-,1,3-2,0 of normo-, 1,7-3,0 - hipoa1,7-3,0 - hipoacidicidittyy,,

and pH 3.0 and more about anand pH 3.0 and more about anacidityacidity..

Chronic gastritis

Atrophic gastritis

Intestinal metaplasia

Dysplasia

Gastric adenocarcinoma

Normal stomach shell mucose†

~ 30 л

ет

Peptic ulcer.Peptic ulcer.

Definitions. Definitions. Peptic ulcer - a common chronic relapsing Peptic ulcer - a common chronic relapsing

disease with a tendency to progression disease with a tendency to progression of polycyclic course, theme of which is of polycyclic course, theme of which is seasonal exacerbation, accompanied seasonal exacerbation, accompanied by the appearance of the ulcer in the by the appearance of the ulcer in the lining of the stomach or duodenum, and lining of the stomach or duodenum, and the development of complications that the development of complications that threaten the life of the patient. (Ithreaten the life of the patient. (I..II.. Degtyarev, NDegtyarev, N..VV.. Kharchenko, 1996). Kharchenko, 1996).

Epidemiology.Epidemiology. Being a fairly Being a fairly

common disease, common disease, peptic ulcer disease peptic ulcer disease leads to 20% of all leads to 20% of all cases of organic cases of organic naturenature dyspepsia. In dyspepsia. In the European the European population incidence population incidence of peptic ulcer is of peptic ulcer is 10% among men 10% among men and 5% among the and 5% among the female population. female population.

In Ukraine ulcer disease In Ukraine ulcer disease affected about 5 million affected about 5 million people. A characteristic people. A characteristic feature of our time is feature of our time is sexual dyzmorfizmsexual dyzmorfizm.. In In recent years there has recent years there has been increasing incidence been increasing incidence among women 2-3. The among women 2-3. The male / female is 1 to 2.3 male / female is 1 to 2.3 for duodenal ulcer and 1 for duodenal ulcer and 1 to 4.8 for gastric ulcer. to 4.8 for gastric ulcer. The incidence of stomach The incidence of stomach ulcers are almost identical ulcers are almost identical among the elderly.among the elderly.

Etiology:Etiology: Pylori contamination of the gastric mucosa;Pylori contamination of the gastric mucosa; Features gastric Features gastric acid productionacid production (decrease the pH of (decrease the pH of

gastric contents, decreased activity of alpha 1-gastric contents, decreased activity of alpha 1-antitrypsin) deficiency antitrypsin) deficiency mmukohlikoproteukohlikoproteiininis s gastric gastric mucus, excessive postprandial release hastrin;mucus, excessive postprandial release hastrin;

Hereditary factor (the presence of blood group I (0), Hereditary factor (the presence of blood group I (0), HLA B5 antigen);HLA B5 antigen);

Stressful factors;Stressful factors; Dyzbalans hormones (sex, thyroid, parathyroid Dyzbalans hormones (sex, thyroid, parathyroid

glands);glands); Tobacco;Tobacco; Reception "ulcerogenic" of drugs (especially NSAIDsReception "ulcerogenic" of drugs (especially NSAIDs

pathogenesispathogenesis

The predominance of "aggression The predominance of "aggression factors" (hfactors" (hyyperatsperatsidityidity, increase pepsyc , increase pepsyc component of gastric contents, dysmoty, component of gastric contents, dysmoty, microcirculation disturbances) over microcirculation disturbances) over "protection factor" (the formation of "protection factor" (the formation of mucus and bicarbonate, mucus and bicarbonate, pprostrostaaglandin, glandin, regenerative processes in the stomach regenerative processes in the stomach mucosa) ("weight Sheya").mucosa) ("weight Sheya").

classificationclassification Localization of the ulcer:Localization of the ulcer:

Gastric ulcers:Gastric ulcers:-cardia-cardia--body-stomach, small and body-stomach, small and large curvature large curvature (mediogastral)(mediogastral)

-antral-antral-pyloric channel-pyloric channel

Duodenal ulcer (DU):Duodenal ulcer (DU): -bulbar-bulbar -postbulbarni-postbulbarniMultiple ulcers (stomach or Multiple ulcers (stomach or

duodenum)duodenum)Combined ulcersCombined ulcers

course:course:first detectedfirst detected        recurrent course        recurrent course

Phase:Phase:        -active phase         -active phase (exacerbation)(exacerbation)        n        nonaonaktyv-phase ktyv-phase (remission: clinical, (remission: clinical, endoscopic, eradication of endoscopic, eradication of Hp)Hp)

Gravity flow:Gravity flow: --LightLight-sharpening every 1-2 -sharpening every 1-2

years;years;--MildMild-2 times a year;-2 times a year;--SevereSevere-more than 3 times -more than 3 times or difficult.or difficult.

classificationclassification

The presence of H. pylori contamination of the gastric mucosa:The presence of H. pylori contamination of the gastric mucosa:- H- HPP - associated - associated- Hp- HpPP- not associated- not associatedCondition atsydnosti gastric contents:Condition atsydnosti gastric contents:- Status normaciditas- Status normaciditas- Status h- Status hyyperaciditasperaciditas- Status h- Status hyypoaciditaspoaciditas- Status anaciditas- Status anaciditas

Presence of complications:Presence of complications:-bleeding (in terms of the source of bleeding and severity of clinical -bleeding (in terms of the source of bleeding and severity of clinical and endoscopic (by Jand endoscopic (by J. . Forest) features)Forest) features)-perforation-perforation- Penetration (in terms of the object / body penetration)- Penetration (in terms of the object / body penetration)-pyloric stenosis (in terms of the degree for radiographic features)-pyloric stenosis (in terms of the degree for radiographic features)-malignancy (for stomach ulcers)-malignancy (for stomach ulcers)Peptic ulcer is always accompanied by gastritis, duodenitisPeptic ulcer is always accompanied by gastritis, duodenitis

• Diagnosis of peptic ulcer provides next volume clinical examination:•Anamnestic examination (identification of etiologic factors, comorbidities, genetic predisposition to debutants, determine the number and rate of relapse, the effectiveness of antiulcer therapy and metafilaktyky).•Physical examination (local palpation pain in the area of the projection of the ulcer, positive symptom of Mendel at peryviscerytis), presence of pylori-bulbar shaft.•Endoscopic examination, diagnostic accuracy which reaches 95%, has advantages over X-ray only when localising duodenal ulcer. The optimal method of monitoring the effectiveness of antiulcer therapy (duodenal ulcer uncomplicated, if full clinical remission endoscopic control is optional).

HP and duodenal ulcerHP and duodenal ulcer

X-ray examinationX-ray examination is superior to endoscopic is superior to endoscopic

where gastric ulcer where gastric ulcer localization, because it localization, because it allows to assess the state of allows to assess the state of gastric motility, gastric motility, convergence of folds of convergence of folds of mucous membrane, which mucous membrane, which is valuable in the is valuable in the differentiation of ulcer-differentiation of ulcer-cancer. In addition, X-ray cancer. In addition, X-ray method is leading in the method is leading in the assessment of cardiac and assessment of cardiac and pyloric sphincter and to pyloric sphincter and to establish the extent of their establish the extent of their dysfunctiondysfunction

Interpretation of pH data (V.M.Chernobrovyy, 1998):

pH Acidic condition

7,0 – 7,53,6 – 6,92,3 – 3,51,6 – 2,21,3 – 1,50,9 – 1,2

anacidityexpressed hypoaciditymoderate hypoaciditynormaciditymoderate hyperacidityexpressed hyperacidity

Treatment. At the present stage ulcer requires the use of combinations of the means that can affect the basic pathogenetic links ulceration. Featured Maastricht 2-2000 consensus, 2003-2005. modern concept of treatment of infections associated with H. Pylory, provide mandatory Helicobacter therapy in cases of duodenal ulcer and gastric ulcer (active or inactive, complicated or uncomplicated).Two component circuits are inefficient (low percentage of eradication). Optimum is currently schema triple and quadro therapy based on proton pump inhibitor

at Maastricht at Maastricht 2002003-2005 expanded 3-2005 expanded indications for eradication of H. indications for eradication of H. pylori by ekstrapylori by ekstraggastrastricic diseases diseases

Now recommends eradication of Now recommends eradication of H.H. P Pyloriylori with coronary artery disease with coronary artery disease

(level of scientific evidence B)(level of scientific evidence B) immune thrombocytopenia immune thrombocytopenia

(level B)(level B) unexplained iron deficiency unexplained iron deficiency

anemia (level B).anemia (level B). In addition, the Maastricht In addition, the Maastricht 2002003-3-

2005 necessarily recommended 2005 necessarily recommended (level A) to eradicate H. (level A) to eradicate H. PPylori in ylori in dyspepsia, and in all cases dyspepsia, and in all cases apply the strategy «Test and apply the strategy «Test and treattreat

Treatment

III line-for patients with newly diagnosed ulcer-the absence of anamnestic instructions on receiving macrolides, including erythromycin

II line- If first-line therapy did not lead to eradication H.pylory- In relapse- In the long history of ulcerative

Proton pump blockers (only the means with proven high antisecretory activity: Loseke, Ultop, Pariet, Oprazol, Kontralok, Esomeprazole) - Omeprazole 20 mg twice a day to 3 weeks- Clarithromycin (klatsyd) 500 mg twice a day- Amoxicillin (Flemoksyn, Osmamoks) 1000 mg twice a day The duration of treatment 7 days

                    Proton pump blockers (only the means with proven high antisecretory activity: Loseke, Ultop, Pariet, Oprazol, Kontralok, Esomeprazole) - Omeprazole 20 mg twice a day to 3 weeks- Bismuth subcitrate * (de-nol) or subsalitsylat- Metronidazole 500 mg three times a day- Tetracycline 500 mg 4 times a day The duration of treatment 7 days

*minimum inhubuyucha bismuth subcitrate concentration is 4 times higher than in subsalitsилату

THANKS FOR ATTENTION!!!