How is chronic gastritis and gastroduodenitis treated?

Indications for hospitalization

Chronic gastritis in the acute stage can be treated on an outpatient basis or in a day hospital. Indications for hospitalization are severe pain syndrome, clinical picture of gastric bleeding in erosive gastroduodenitis, a traumatic situation or socially unfavorable conditions at home.

The goal of treatment of chronic gastritis and gastroduodenitis in children

The main goal of treatment is to normalize the functional and morphological state of the cells of the gastric and duodenal mucosa to achieve long-term and stable remission of the disease.

First stage: treatment measures are aimed at reducing the effects of aggressive factors (suppression of the acid-peptic factor, eradication of H. pylori, relief of hypermotility and dysfunction of the central and autonomic nervous systems).

The second stage: treatment is aimed at restoring the resistance of the gastric and duodenal mucosa.

The third stage: restorative treatment (preferably non-drug) to normalize the functional and morphological state of the cells of 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 compliance with the therapeutic and protective regimen and diet, the choice of which depends on the concomitant pathology, the stage of the disease, the nature of the prescribed drugs. Thus, during an exacerbation of the disease, the diet should be gentle (table No. 1 according to Pevzner), and if the child receives colloidal bismuth tripotassium dicitrate (de-nol), then a dairy-free diet is indicated (table No. 4), as in the case of intestinal pathology.

Drug treatment of chronic gastritis and gastroduodenitis in children

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

Of the drugs currently used to treat chronic gastritis and chronic gastroduodenitis, the most well-known are antacids, which reduce the acidity of gastric contents by chemically interacting with hydrochloric acid in the stomach cavity. The effectiveness of antacids is assessed by their acid-neutralizing capacity, which for modern drugs ranges from 20-105 mEq/15 ml of suspension. The daily acid-neutralizing capacity of antacids depends on the type of drug, dosage form, and frequency of administration.

Data have been published showing that antacids not only reduce the acidity of gastric contents, but also help to increase the protective properties of the mucous membrane by stimulating the synthesis of prostaglandins and epidermal growth factor. Preference is given to non-absorbable antacids that act by the mechanism of buffer capacity. These drugs neutralize and adsorb hydrochloric acid more slowly, but do not have systemic side effects.

Antacids are safe and are considered over-the-counter medications, but they do have side effects and drug interactions.

The greatest therapeutic effect among antacids is possessed by aluminum-containing drugs (aluminum hydroxide, magnesium hydroxide, simethicone and aluminum phosphate), which have a quick symptomatic effect, have a convenient form of release (gels, chewable tablets) and good organoleptic characteristics, but contribute to the development of constipation, in some cases disrupt the absorption of enzymes, provoke hypophosphatemia. Antacids containing aluminum and magnesium hydroxide are in great demand, the most famous is 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 are prescribed 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 - orally 1 packet 3 times a day (for children under 5 years old - 0.5 packet 3 times a day) for 2-3 weeks.

Antacids are prescribed 1 hour after a meal, timing it to coincide with the cessation of the buffering effect of food during the period of maximum gastric secretion, 3 hours after a meal to replenish the antacid equivalent, reduced due to the evacuation of gastric contents, at night and immediately after sleep before breakfast.

In various clinical situations, it is necessary to individually select an adequate antacid drug, taking into account the characteristics of the rhythm of hydrochloric acid production according to pH-metry data.

Antisecretory drugs play an important role in the treatment of gastroduodenal pathology. They include peripheral M-anticholinergics, H2-receptor blockers _, and proton pump inhibitors.

In pediatric practice, selective M-anticholinergics are more often used, the antisecretory effect of which is small, short-lived and often accompanied by side effects (dry mouth, tachycardia, constipation, etc.). A more powerful antisecretory effect is provided by histamine H2-receptor blockers _, drugs of the second and third generations are preferable (ranitidine, famotidine).

Ranitidine is prescribed to children orally at 300 mg per day in 2 doses for 1.5-2 months. Famotidine is prescribed to children over 12 years of age for oral administration at 20 mg 2 times per day.

Treatment with histamine H2-receptor blockers _should be prolonged (>3-4 weeks) with gradual reduction of the drug dose (over the same period) to exclude withdrawal syndrome, characterized by a sharp increase in acid secretion and early relapse of the disease. New studies have shown that histamine H2-receptor blockers _maintain the pH level above 4.0 for no more than 65% of the observation time, addiction to them develops quickly, 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 act not 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 proton pump inhibitors are inactive prodrugs of selective action. After oral administration, they are absorbed in the small intestine, enter the bloodstream and are transported to the site of action - the parietal cell of the gastric mucosa. By diffusion, proton pump inhibitors accumulate in the lumen of the secretory canals. Here they are converted to an active form - sulfenamide, which binds to the SH-groups of H+, K+-ATPase, forming a covalent bond. The enzyme molecules are irreversibly inhibited, as a result of which the secretion of hydrogen ions is possible only due to the synthesis of new H+, K+-ATPase molecules.

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

In Ukraine, the most widely used drugs are omeprazole, prescribed at 20 mg 2 times a day or 40 mg in the evening. In clinical practice, children over 12 years of age are prescribed new proton pump inhibitors, such as rabeprazole (Pariet) and esomeprazole.

Rabeprazole is concentrated into the active (sulfonamide) form faster than other proton pump inhibitors, exerting an inhibitory effect within 5 minutes after administration. Esomeprazole (Nexium) is the S-isomer of omeprazole.

The main indication for the use of H2-histamine receptor blockers _and proton pump inhibitors is high acid-forming function of the stomach.

Local protective drugs - cytoprotectors, including sucralfate and colloidal bismuth preparations.

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

Colloidal bismuth preparations (de-nol) are similar in mechanism of action to sucralfate. In addition to the above, colloidal bismuth preparations inhibit the activity of H. pylori, due to which these agents are widely used in anti-Helicobacter treatment.

Prokinetics are regulators of the motor-evacuation function. Spasm, gastro- and duodenostasis, duodenogastric and gastroesophageal reflux, irritable bowel syndrome often occur in gastroduodenal pathology; these symptoms require appropriate drug correction.

The most effective antireflux drugs currently used in pediatrics are dopamine receptor blockers, which include metoclopramide (Cerucal) and domperidone (Motilium). The pharmacological action of these drugs is to enhance antropyloric motility, which leads to accelerated evacuation of stomach contents and increased tone of the lower esophageal sphincter. When prescribing metoclopramide 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 and 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 before bedtime (3-4 times a day). The drug cannot be combined with antacids, since an acidic environment is necessary for its absorption.

Drugs for the treatment of H. pylori infection in children

• Bismuth tripotassium dicitrate (de-nol) - 4 mg/kg.
• Amoxicillin (flemoxin solutab) - 25-30 mg/kg (<1 g/day).
• Clarithromycin (clacid, 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 (macmiror) - 15 mg/kg.
• Furazolidone - 20 mg/kg.
• Metronidazole - 40 mg/kg.
• Omeprazole (Losec, Losec-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 tripotassium dicitrate

Scheme #1:

• bismuth tripotassium dicitrate;
• amoxicillin (flemoxin solutab) / roxithromycin / clarithromycin / azithromycin;
• nifuratel (macmiror) / furazolidone / metronidazole.

Scheme No. 2:

• bismuth tripotassium dicitrate;
• roxithromycin / clarithromycin / azithromycin;
• amoxicillin (flemoxin solutab).

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

Scheme No. 1:

• omeprazole (helol);
• roxithromycin / clarithromycin / azithromycin;
• nifuratel (macmiror) / furazolidone / metronidazole.

Scheme No. 2:

• omeprazole (helol);
• roxithromycin / clarithromycin / azithromycin;
• amoxicillin (flemoxin solutab).

One week quadruple therapy

• bismuth tripotassium dicitrate.
• amoxicillin (flemoxin solutab) / roxithromycin / clarithromycin / azithromycin.
• nifuratel (macmiror) / furazolidone.
• omeprazole.

Quadruple therapy is recommended for the treatment of diseases caused by strains resistant to antibiotics, as well as in cases where previous treatment has been unsuccessful and in cases where determining the sensitivity of the strain is difficult.

Reasons for the ineffectiveness of radiation treatment

Non-modifiable factors:

• primary resistance of H. pylori;
• intolerance to the drugs used.

Modifiable factors:

• inadequate treatment:
  • exclusion of antibiotics;
  • failure to comply with the duration of antibiotic treatment;
  • low doses of antibiotics;
  • incorrect choice of antibiotics.
• use of ineffective treatment regimens;
• irrational use of antibiotics for the treatment of other diseases;
• intrafamilial circulation of H. pylori.

The most common reasons for the ineffectiveness of prescription treatment are severe resistance of H. pylori strains to the drugs used and failure of patients to comply with the prescribed treatment regimen due to drug intolerance and low treatment compliance.

The effectiveness of eradication treatment of chronic gastritis and chronic gastroduodenitis associated with H. pylori infection largely depends on the competent choice of eradication regimen, taking into account both the pharmacokinetic action of drugs and the socio-economic aspects of the treatment.

Considering the ecological niche occupied by H. pylori, the antibacterial treatment carried out must meet the following requirements:

• the effectiveness of the drugs used against H. pylori;
• use of acid-resistant antibiotics;
• the ability of drugs to penetrate under the layer of gastric mucus;
• local action of drugs (in the area of the mucous membrane);
• rapid elimination of drugs from the body, no accumulation.

Amoxicillin 125, 250, 500 mg (Flemoxin Solutab) is an antibiotic that is highly effective in the treatment of Helicobacter pylori infection in children due to its unique dosage form (a tablet suitable for taking whole, chewing, dissolving in liquid to form a suspension). In addition to the convenience and safety of use, this antibiotic forms the largest contact area with the gastric mucosa, ensuring 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. Currently, metronidazole is excluded from existing treatment regimens for helicobacteriosis, replacing it with nifuratel (macmiror) and furazolidone.

Chronic inflammatory diseases of the upper gastrointestinal tract associated with H. pylori in 85% of cases lead to changes in the qualitative and quantitative composition of the colon microflora, aggravated by the prescribed drugs. In this regard, it is advisable to include probiotics in the treatment complex for children with diseases of the upper gastrointestinal tract associated with H. pylori infection 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 20-30 minutes before meals for 7-10 days.

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

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

The use of proton pump inhibitors or histamine _H2 -receptor blockers in anti-Helicobacter therapy requires an extension of the course of treatment with these drugs to 3-4 weeks. The withdrawal of proton pump inhibitors can be immediate; unlike histamine H2-receptor blockers, _rebound syndrome does not occur. Histamine H2-receptor blockers _require gradual withdrawal, which extends the course of treatment.

[ 4 ], [ 5 ], [ 6 ]

Outpatient observation

Patients are registered with a gastroenterologist for at least 3 years. During the period of remission it is necessary:

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

Sanatorium and spa treatment is indicated during the period of remission no earlier than 3 months after an exacerbation.

Once a year, EGDS and HP eradication control are performed. Patients are removed from the dispensary register after complete clinical remission lasting for 3 years.