How is chronic gastritis and gastroduodenitis treated?

Indications for hospitalization

To treat chronic gastritis in the acute stage can be outpatient or in a day hospital. Indications for hospitalization are severe pain syndrome, a clinical picture of gastric bleeding with erosive gastroduodenitis, a psychotraumatic situation or socially unfavorable conditions at home.

Purpose of treatment of chronic gastritis and gastroduodenitis in children

The main goal of the treatment is the normalization of the functional and morphological state of the cells of the mucous membrane of the stomach and duodenum to achieve long-lasting and stable remission of the disease.

The first stage: therapeutic measures are aimed at reducing the effect of aggression factors (suppression of the acid-peptic factor, eradication of H. Pylori, suppression of hypermotorism and dysfunction of the central and autonomic nervous systems).

The second stage: treatment is focused on restoration of resistance of the mucous membrane of the stomach and duodenum.

The third stage: restorative treatment (preferably non-drug) for the normalization of the functional and morphological state of cells in the mucous membrane of the stomach and duodenum.

General principles of treatment of chronic gastritis and gastroduodenitis

An obligatory component of the treatment of children suffering from chronic gastritis and chronic gastroduodenitis is adherence to the curative and protective regimen and diet, the choice of which depends on the concomitant pathology, the stage of the disease, the nature of the prescribed medicines. Thus, when the disease worsens, the diet should be gentle (table number 1 according to Pevzner), and if the child receives colloidal bismuth tricalium dicitrate (de-nol), then a dairy-free diet (table No. 4) is shown, as in the case of intestinal pathology.

Medication for chronic gastritis and gastroduodenitis in children

The choice of medicines depends on the severity of the clinical symptoms of the disease, involvement in the pathological process of other organs and systems, especially the gastrointestinal tract, the presence of H. Pylori infection, analysis of the results of previous treatment, functional state of the stomach and vegetative status.

Of the drugs currently used for the treatment of chronic gastritis and chronic gastroduodenitis, the most known antacids, reducing the acidity of gastric contents by chemical interaction with hydrochloric acid in the stomach cavity. The effectiveness of antacids is assessed by the acid-neutralizing ability, in modern means fluctuating within 20-105 mEq / 15 ml of suspension. The daily acid neutralizing ability of antacids depends on the type of drug, the dosage form and the frequency of administration.

It has been reported that antacid agents not only reduce the acidity of gastric contents, but also contribute to enhancing the protective properties of the mucosa by stimulating the synthesis of prostaglandins and epidermal growth factor. Preference is given to nonabsorbable antacids, acting by the mechanism of buffer capacity. These drugs are slower to neutralize and adsorb hydrochloric acid, but do not have systemic side effects.

Antacids are safe, are referred to non-prescription drugs, but have side effects and drug interactions.

The greatest curative effect among antacids is provided by aluminum-containing medicines (aluminum hydroxide, magnesium hydroxide, simethicone and aluminum phosphate), which have a rapid symptomatic effect, have a convenient release form (gels, chewable tablets) and good organoleptic characteristics, but contribute to the development of constipation, in a number of cases violate the absorption of enzymes, provoke hypophosphatemia. Antacids containing aluminum and magnesium hydroxide are in great demand, most known aluminum phosphate (maalox). This antacid, due to the optimal ratio of aluminum and magnesium, has a beneficial effect on the motor function of the intestine.

Aluminum hydroxide, magnesium hydroxide is prescribed by one dosage spoon 3 times a day for 2-3 weeks, simethicone - one dosage spoon 3 times a day for 2-3 weeks, aluminum phosphate - inside 1 packet 3 times a day ( for children under 5 years - 0.5 package 3 times a day) for 2-3 weeks.

Antacids are prescribed 1 hour after meals, timed to stop the buffering action of food during the period of maximum gastric secretion, 3 hours after eating to replenish the antacid equivalent, reduced due to evacuation of gastric contents, at night and immediately after sleep before breakfast.

In various clinical situations, an individual selection of an adequate antacid preparation is necessary, taking into account the characteristics of the rhythm of production of hydrochloric acid according to pH-metry.

Antisecretory drugs occupy an important place in the treatment of gastroduodenal pathology. These include peripheral M-cholinolytics, H ₂ -receptor blockers , proton pump inhibitors.

In pediatric practice, selective M-cholinolytics are often used, the antisecretory effect of which is small, short-lived and often accompanied by side reactions (dry mouth, tachycardia, constipation, etc.). More powerful antisecretory action has blockers of H ₂ -receptors of histamine, preparations of II and III generations (ranitidine, famotidine) are preferable.

Children ranitidin prescribe inside 300 mg per day in 2 doses for 1.5-2 months. Famotidine for children over 12 years of age is prescribed for ingestion of 20 mg 2 times a day.

Treatment with H ₂ -receptor blockers of histamine should be continuous (> 3-4 weeks) with a gradual decrease in the dose of the drug (for the same period) to exclude withdrawal syndrome, characterized by a sharp increase in acid release and early relapse of the disease. New research has shown that histamine H ₂ -receptor blockers maintain a pH level above 4.0 of no more than 65% of the time of observation, and addiction rapidly develops, which limits their effectiveness.

Proton pump inhibitors, such as omeprazole, lansoprazole, pantoprazole, rabeprazole and esomeprazole. Have a highly selective inhibitory effect on the acid-forming function of the stomach. Proton pump inhibitors do not act on the receptor apparatus of the parietal cell, but on the intracellular enzyme H + \ K + -ATPase, blocking the work of the proton pump and the production of hydrochloric acid.

All inhibitors of the proton pump are inactive pro-drugs of selective action. After ingestion, they are absorbed in the small intestine, enter the bloodstream and transported to the site of action - the parietal cell of the gastric mucosa. By diffusion, inhibitors of the proton pump accumulate in the lumen of the secretory tubules. Here they pass into the active form - sulfenamide, which binds SH-groups of H +, K + -ATPase, forming a covalent bond. The molecules of the enzyme are irreversibly inhibited, as a result of which the secretion of hydrogen ions is possible only because of the synthesis of new molecules of H +, K + -ATPase.

For the treatment of chronic gastritis a and chronic gastroduodenitis, proton pump inhibitors are prescribed 1 mg / kg body weight. At the age of up to 5 years, soluble forms (MAPS tablets) of omeprazole or esomeprazole are used. Older children use all dosage forms.

In Ukraine, the most widely used drugs are omeprazole, prescribed 20 mg twice a day or 40 mg in the evening hours. In clinical practice, children older than 12 years are prescribed new inhibitors of the proton pump, such as rabeprazole (pariet) and esomeprazole.

Rabeprazole is faster than other proton pump inhibitors, it is concentrated in the active (sulfanamide) form, having an inhibitory effect even after 5 minutes after administration. Esomeprazole (Nexium) is the S-isomer of omeprazole.

The main indication for the appointment of H ₂ -receptor blockers and proton pump inhibitors is a high acid-forming function of the stomach.

Preparations of local protective action - cytoprotectors, including sucralfate and preparations of colloidal bismuth.

Sucralfate (sulfatized disaccharide combined with aluminum hydroxide) interacts with a defect in the mucous membrane, forming a film that protects against the action of the acid-peptic factor for 6 hours. The drug binds isoleucitin, pepsin and bile acids, increases the content of prostaglandins in the wall of the stomach and increases the production of gastric mucus. Assign sucralfate in a dose of 0.5-1 g 4 times a day for 30 minutes before meals and at night.

Preparations of colloidal bismuth (de-nol) by the mechanism of action are close to sucralfate. In addition to the above, preparations of colloidal bismuth inhibit the life of H. Pylori, so these drugs are widely used in anti-Helicobacter pylori treatment.

Prokinetics - regulators of motor-evacuator function. With gastroduodenal pathology, spasm, gastro- and duodenostasis, duodenogastric and gastroesophageal reflux, irritable bowel syndrome often occur; these symptoms require appropriate medication correction.

The most effective antireflux medications currently used in pediatrics are dopamine receptor blockers, which include metoclopramide (cerucal) and domperidone (motilium). The pharmacological action of these drugs is to enhance the anthropyloric motility, which leads to an acceleration of the evacuation of the contents of the stomach and an increase in the tone of the lower esophageal sphincter. When metoclopramide is administered at a dose of 0.1 mg per 1 kg of the child's body weight 3-4 times a day, extrapyramidal reactions often occur, which limits the use of the drug.

Domperidone has a pronounced antireflux effect, practically does not cause extrapyramidal disorders. Motilium is prescribed in a dose of 0.25 mg / kg as a suspension or tablets 15-20 minutes before meals and at bedtime (3-4 times a day). The drug can not be combined with antacids, since an acidic medium is necessary for its absorption.

Drugs used to treat H. Pylori infection in children

• Bismuth tricalcium dicitrate (de-nol) - 4 mg / kg.
• Amoxicillin (Flemoxin solutab) - 25-30 mg / kg (<1 g / day).
• Clarithromycin (klatsid, fromilid) - 7.5 mg / kg (<500 mg / day).
• Roxithromycin (rulid) - 5-8 mg / kg (S300 mg / day).
• Azithromycin (sumamed) - 10 mg / kg (S1 g / day).
• Nifuratel (makmiror) - 15 mg / kg.
• Furazolidone - 20 mg / kg.
• Metronidazole - 40 mg / kg.
• Omeprazole (losek, losek-MAPS) - 0.5 mg / kg.
• Ranitidine (zantac) - 300 mg / day.

[1], [2], [3]

Modern treatment regimens for H. Pylori infection in children

One-week triple treatment regimen with bismuth tricalium dicitrate

Scheme # 1:

• bismuth tricalcium dicitrate;
• amoxicillin (flemoxin soluteba) / roxithromycin / clarithromycin / azithromycin;
• nifuratel (makmiror) / furazolidon / metronidazole.

Scheme 2:

• bismuth tricalcium dicitrate;
• roxithromycin / clarithromycin / azithromycin;
• amoxicillin (flemoxin solute).

One-week triple treatment regimen with H + / K + -ATPase blockers

Scheme No. 1:

• omeprazole (Celol);
• roxithromycin / clarithromycin / azithromycin;
• nifuratel (makmiror) / furazolidon / metronidazole.

Scheme 2:

• omeprazole (Celol);
• roxithromycin / clarithromycin / azithromycin;
• amoxicillin (flemoxin solute).

One-week quadrotherapy

• bismuth tricalcium dicitrate.
• amoxicillin (flemoxin soluteba) / roxithromycin / clarithromycin / azithromycin.
• nifuratel (makmiror) / furazolidone.
• omeprazole.

Quadrotherapy is recommended for the treatment of a disease caused by strains resistant to antibiotics, as well as in case of unsuccessful previous treatment and in the case when the determination of the sensitivity of the strain is difficult.

Causes of ineffective treatment

Unmodifiable factors:

• primary resistance of H. Pylori;
• intolerance of the drugs used.

Modifiable factors:

• inadequate treatment:
  • elimination of antibiotics;
  • non-compliance with the duration of antibiotic use;
  • low doses of antibiotics;
  • wrong choice of antibiotics.
• use of ineffective treatment regimens;
• irrational administration of antibiotics for the treatment of other diseases;
• intrafamily circulation of H. Pylori.

The most common reasons for the ineffectiveness of treatment are the marked resistance of H. Pylori strains to the drugs used and failure to adhere to the prescribed treatment regimen because of drug intolerance and low compliance of treatment.

The effectiveness of the chronic treatment of chronic gastritis and chronic gastroduodenitis associated with H. Pylori infection largely depends on a competent choice of the eradication scheme that takes into account both the pharmacokinetic effects of the drugs and the socioeconomic aspects of the treatment.

Given the ecological niche that H. Pylori occupies, the antibiotic treatment that is carried out must meet the following requirements:

• the effectiveness of the drugs used against H. Pylori;
• use of acid-fast antibiotics;
• the ability of drugs to penetrate the layer of gastric mucus;
• local action of drugs (in the mucosa);
• rapid removal of drugs from the body, lack of cumulation.

Amoxicillin 125, 250, 500 mg (Flemoxin soluteba) is an antibiotic, highly effective in the treatment of Helicobacter pylori infection in children due to a unique dosage form (tablet, suitable for whole adoption, chewing, dissolving in liquid to form a suspension). In addition to convenience and safety of use, this antibiotic forms the largest area of contact with the mucous membrane of the stomach, providing eradication.

H. Pylori does not develop resistance to bismuth preparations, practically does not form resistance to amoxicillin, but the number of strains resistant to metronidazole and clarithromycin is constantly increasing. At present, metronidazole is excluded from existing treatment regimens for helicobacteriosis, replacing nifuratel (makmirorom) and furazolidone.

Chronic inflammatory diseases of the upper gastrointestinal tract associated with H. Pylori, in 85% of cases lead to a change in the qualitative and quantitative composition of the colon microflora, aggravated with prescribed drugs. In this regard, in the complex treatment of children with diseases of the upper gastrointestinal tract associated with H. Pylori infection, it is advisable to include probiotics from the first day of treatment: bifidumbacterin forte 10 doses 2 times a day, bifiform 1 capsule 2 times a day or linex 1 capsule 2 times a day for 20-30 minutes before meals for 7-10 days.

The duration of treatment of chronic gastritis and chronic gastroduodenitis depends on a number of causes (the severity of the disease, the severity of certain clinical symptoms of the stomach and duodenum, other organs of the gastrointestinal tract, association with H. Pylori infection) and an average of 3-4 weeks.

After a 7-day course in a triple scheme using de-nol, a double tactic is possible: prolonging the course of de-nol to 3-4 weeks or replacing the drug with antacids at age dosages for the same period.

The use of proton pump inhibitors or H ₂ -receptor blockers in anti-Helicobacter therapy requires prolongation of the course of treatment with these drugs up to 3-4 weeks. The cancellation of proton pump inhibitors can be single-step, unlike H ₂ -receptor blockers _{of the} bicarbonate syndrome does not occur. H ₂ -receptor blockers of histamine require a gradual withdrawal, which lengthens the course of treatment.

[4], [5], [6], [7], [8]

Dispensary supervision

Patients are on dispensary with a gastroenterologist for at least 3 years. In the period of remission, it is necessary:

• observance of a sparing diet;
• herbal medicine - decoctions of St. John's wort, yarrow, celandine, chamomile - for 2-3 weeks (in autumn and spring);
• physiotherapy - electrophoresis of calcium, bromine, diadynamic currents hydrotherapy, mud therapy;
• mineral waters (Essentuki No. 4, Slavyanovskaya, Smirnovskaya, Borzhomi) with repeated courses for 2-3 weeks after 3-4 months;
• vitamins (A, group B, C) repeated courses.

Sanatorium treatment is indicated in the remission period not earlier than 3 months after exacerbation.

Once a year, EGDS and HP eradication control are performed. From dispensary registration of patients are removed after a full clinical remission, lasting for 3 years.

[9]