Erosive bulbitis: acute, chronic, superficial, focal

In gastroenterology, erosive bulbitis is distinguished - inflammation of the proximal part of the duodenum - the bulb that adjoins the sphincter of the pyloric part of the stomach.

In essence, erosive bulbitis is a limited duodenitis with a clearly localized superficial epithelial defect (erosion) in the bulb area.

[ 1 ], [ 2 ], [ 3 ], [ 4 ]

Epidemiology

The epidemiology of erosive bulbitis is not separately traced, but, according to clinical studies, in 95% of cases of duodenal ulcers, it is localized in its bulbar part (bulb).

According to experts from the World Gastroenterology Organisation, the number of adult patients with duodenal ulcers (which begin with erosion of the mucous membrane) is almost two thirds of all patients with peptic ulcers of the gastrointestinal tract.

[ 5 ]

Causes erosive bulbitis

The most common causes of erosive bulbitis are the same as those of most diseases of the digestive tract:

• infection of the stomach with campylobacter Helicobacter pylori, which produces cytotoxins (detected in the vast majority of cases);
• intestinal giardiasis (Giardia intestinalis) or hookworm disease (Ancylostoma duodenale);
• poor nutrition (irregular meals, excess of fatty and spicy foods in the diet);
• prolonged stress and psycho-emotional disorders (due to which the synthesis of neurohormones increases, indirectly activating acid formation in the stomach);
• duodenogastric reflux (when bile flows from the duodenum into the stomach, passing through the bulb);
• long-term use of drugs that affect the mucous membrane or disrupt the synthesis of protective factors (non-steroidal anti-inflammatory drugs, glucocorticoids);
• radiation and chemotherapy for oncology.

Risk factors

Additional risk factors include: alcohol, nicotine and substance abuse; immune deficiency; hereditary predisposition;

The presence of other diseases of the digestive system (Crohn's disease, liver cirrhosis), diabetes mellitus or autoimmune diseases (in which the body produces antibodies that attack the cells of the mucous tissue).

[ 6 ], [ 7 ], [ 8 ]

Pathogenesis

The listed reasons and factors lead to disruptions in the functioning of the protective barrier of the duodenum. And their pathogenesis may be associated with an increase in the aggressive effect of hydrochloric acid and pepsin (impregnating the contents of the stomach, entering the duodenum directly through the bulb). Or the pathogenic effect lies in a significant decrease in the components of the mucous layer of the walls of the bulbar section and a reduction in the normal reproduction of cellular elements of the mucous membrane, which disrupts the natural process of its regeneration.

In the mucous membrane of the duodenum and its bulb there are duodenal glands (Brunner's glands), which produce an alkalizing mucous secretion to neutralize gastric acid, and damage to them due to one of the above reasons can play a role in the development of erosive bulbitis.

In addition, the mucous tissue of the gastrointestinal tract is distinguished by the presence in the crypts of special epithelial cells Paneth cells, which are of primary importance for protecting other cells from microbial and fungal damage, as they secrete such antibacterial enzymes as α-defensin, lysozyme and phospholipase A2, as well as TNF-α - tumor necrosis factor-alpha, stimulating phagocytosis. So when these protective cells are damaged, the resistance of the mucous membrane to any pathogenic effects decreases.

[ 9 ]

Symptoms erosive bulbitis

The main symptoms of erosive bulbitis are nonspecific and similar to the manifestations of inflammation of the gastric mucosa.

In some patients, the first signs of the disease, especially at the initial stage, are dyspepsia and loss of appetite, while in others, heartburn, belching and bloating (flatulence). And how intensely these symptoms manifest themselves and in what order depends on the individual characteristics of the body.

Acute erosive bulbitis manifests itself as pain in the upper abdomen (in the middle), which can be either dull and aching or burning, radiating to the back and chest, as well as in the form of spasms. Pain usually occurs at night or on an empty stomach. In the chronic form of the pathology, there may be no pain during the day, but palpation of the initial section of the small intestine is quite painful, and after eating, discomfort occurs in the epigastric region (as if the stomach is full to the limit).

Nausea and vomiting are also clinical symptoms of inflammation and erosion of the mucous membrane of the duodenal bulb.

When gastric chyme stagnates in the bulbar part of the duodenal section of the small intestine, gastroesophageal reflux is often observed, causing sour belching and heartburn. And bitterness in the mouth is evidence of duodenogastric reflux.

If blood is noticed in the stool, this most often occurs with erosive-ulcerative or erosive-hemorrhagic bulbitis.

[ 10 ], [ 11 ]

Forms

Depending on the course of the disease, a distinction is made between acute erosive bulbitis (damage and inflammation of the mucous membrane occurs quickly, with an acute clinical picture) and chronic erosive bulbitis (the disease develops slowly - sometimes worsening, sometimes subsiding).

If the patient exhibits most of the symptoms and the examination confirms their connection with inflammation and the presence of erosion of the mucous membrane of the duodenal bulb, severe erosive bulbitis can be diagnosed.

Based on the results of an endoscopic examination, gastroenterologists can also determine the following morphological types of disease:

• erosive-ulcerative bulbitis, in which the erosion is deep and affects not only the superficial layer of the epithelium and its proper plate, but also spreads to the muscular plate of the mucous membrane of the bulbar part of the duodenum;
• catarrhal-erosive bulbitis - acute superficial erosive bulbitis affecting the goblet enterocytes of the upper layer of the intestinal epithelium and its cytoplasmic outgrowths (microvilli);
• erosive focal bulbitis - characterized by limited foci (spots) of destroyed mucous membrane;
• erosive-hemorrhagic bulbitis - spreads to the submucosa with blood vessels, when they expand and are damaged, blood may be present in the feces;
• confluent erosive bulbitis – is diagnosed in cases of fusion of individual foci and formation of a fibrin film on the affected surface.

[ 12 ]

Complications and consequences

The main consequences and complications of erosive bulbitis, especially erosive-ulcerative and erosive-hemorrhagic, are associated with the formation of a duodenal ulcer.

In the case of a duodenal ulcer localized in the bulb, there is a risk of perforation and bleeding.

At the same time, duodenal ulcers are not prone to malignancy, which is possible in almost 5% of cases of gastric ulcers. For more information, see – Gastric and duodenal ulcers

Diagnostics erosive bulbitis

The key method that provides the basis for an accurate diagnosis of "erosive bulbitis" is instrumental diagnostics by fibrogastroduodenoendoscopy. During this endoscopic examination, the mucous membrane of the duodenum and its bulbar section is clearly visualized; in addition, a tissue sample is taken for histopathological examination.

Diagnosis of erosive bulbitis includes determination of the acidity level (pH) of the stomach, as well as tests:

• general and biochemical blood analysis,
• blood test for antibodies to H. Pylori,
• stool analysis.

Differential diagnosis

Differential diagnosis should exclude Crohn's disease, Whipple's disease, Zollinger-Ellison syndrome, malignant lymphoma, duodenal carcinomas, infections (Salmonella, Shigella).

[ 13 ], [ 14 ]

Treatment erosive bulbitis

If Helicobacter pylori is detected, treatment of erosive bulbitis begins with its eradication with antibacterial drugs: Azithromycin or Amoxicillin (1 g once a day for three days) and Clarithromycin (0.5 g twice a day for 14 days).

In drug therapy of this disease, drugs of the pharmacological group of histamine H2-receptor antagonists are also used, which reduce the production of hydrochloric acid in the stomach: Ranitidine (Aciloc), Famotidine (Famosan, Gasterogen), Cimetidine (Tagamet), etc. - 0.2-0.4 g two or three times a day (during meals). Drugs of this group can cause side effects: headache, fatigue, dizziness, decreased heart rate, tinnitus, etc.

With normal liver function, gastroenterologists also prescribe drugs to suppress acid formation - proton pump inhibitors Omeprazole (Omez, Omipiks, Peptikum, Helicid), Rabeprazole, Pantoprazole (Nolpaza), etc. The dosage and duration of treatment will depend on the individual manifestation of erosive bulbitis. The side effects of these drugs are quite numerous: from headaches and urticaria to sleep disorders, nephritis and increased blood lipid levels.

The antisecretory drug Misoprostol (Cytotec) can be used - one tablet (0.2 mg) three times a day; there may be side effects in the form of dyspepsia, edema, decreased or increased blood pressure, as well as pain in the stomach.

Antacid and enveloping agent Relzer (with aluminum hydroxide, simethicone and licorice root extract) is recommended for patients over 12 years old - one or two tablets twice a day (crushed, with glasses of water); duration of use - two weeks. There may be side effects: taste changes, nausea, diarrhea.

It is possible to use Adjiflux tablets or suspension.

Antispasmodics, best of all No-shpa (Drotaverin, Spazmol), will help with severe pain: one tablet (40 mg) three times a day. No-shpa should not be taken in case of atherosclerosis, enlarged prostate, glaucoma and pregnancy.

And for better healing of erosion of the duodenal bulb, vitamins C, E, B6, B12, PP are recommended.

Homeopathy offers sublingual tablets Gastricumel - three times a day, one tablet (reduces belching, heartburn and increased gas formation in the intestines). And also Duodenohel tablets (taken in the same way and in the same dosage) - against inflammation, pain and spasms and as an antacid. However, it should be borne in mind that homeopathic remedies often cause allergic reactions.

In the remission stage, physiotherapeutic treatment of erosive bulbitis is possible, which consists of drinking natural mineral water - sodium bicarbonate.

Folk treatment of erosive bulbitis

In addition to drug treatment, folk treatment is possible using decoctions and infusions of medicinal plants taken internally after consultation with the attending physician.

Most often, herbal treatment is carried out using a decoction of St. John's wort, which is prepared from a tablespoon of dry herb per one and a half glasses of water; take 80 ml half an hour before meals (no more than four times during the day).

It helps to drink a mixture of decoctions of stinging nettle (a tablespoon per glass of boiling water) and oats (in a similar proportion). Prepare the decoctions separately, mix (1:1) and drink half a glass 30-40 minutes before each meal.

Herbalists recommend taking fresh plantain juice (a tablespoon three times a day) or a decoction of dried leaves - half a glass (with the addition of 15 g of honey). Also used is a decoction of oak bark and infusions of fireweed, calendula, speedwell, orchis, goose, and meadowsweet.

Diet and Lifestyle

Successful treatment of erosive bulbitis, as well as all diseases of the digestive system, is largely ensured by a healthy lifestyle - with regular meals (without harmful products), with abstinence from alcohol and smoking, etc. By the way, prevention also lies in a healthy diet and the absence of bad habits.

For both chronic and acute forms of the disease, a diet for erosive bulbitis is recommended - detailed information in the materials Diet for duodenitis, as well as Diet for erosive gastritis

During an exacerbation of the disease, it is recommended to only drink (for two 24-48 hours), then food is consumed in a highly crushed or mashed form - in small portions up to six times a day. It is important to drink liquid (not hot and not cold).

It is clear that spicy and fatty dishes, sauces and confectionery, canned goods and semi-finished products have no place in the menu for erosive bulbitis. Vegetable soups and purees, steamed cutlets and meatballs from lean meat and fish, boiled porridge with a small amount of oil, baked fruits, and jelly are preferable.

Forecast

Erosive bulbitis is a complex disease, but it does not pose a threat to life. However, a favorable prognosis for this pathology depends on its treatment, as well as on the treatment of background gastrointestinal diseases - gastritis, cholecystitis, pancreatitis, etc., which are often included in the "bouquet" of problems of the digestive system.

[ 15 ]