How is peptic ulcer treated?

The purpose of treatment of peptic ulcer disease is the coping of clinical symptoms of the disease and healing of the ulcerative defect, and subsequently - the carrying out of rehabilitation measures aimed at restoring the structural and functional disorders of the gastroduodenal zone and preventing the recurrence of ulcerative process.

An important task is to solve the problem of the place of treatment of peptic ulcer in children. It is generally acknowledged that with a newly diagnosed peptic ulcer, it is mandatory to have an in-patient examination and treatment, adjusted taking into account the history, peculiarities of the child's mental state and psychological climate in the family, school or kindergarten.

Some children develop a strong resistance to stay in the hospital. The emergence of such a response does not depend on either sex or age of the child. In this case, finding a child in a hospital becomes a stress factor, contributing to the preservation of complaints and the progression of the disease.

Thus, the following patients are subject to mandatory admission:

• with the first discovered peptic ulcer in the stage of exacerbation;
• with complicated and often relapsing course of the disease;
• with significant severity or difficulty coping pain during a week of outpatient treatment;
• if it is impossible to organize treatment and control in outpatient settings.

General principles of treatment of peptic ulcer disease include compliance with diet and protective regimen.

Health food is an important area of complex treatment. Currently, they dispute the advisability of appointing a "sparing" diet under the condition of adequate drug correction. The inexpediency of using tables No. 1a and No. 16 according to Pevzner is related to their aphysiology in terms of protein, fat, carbohydrate and trace elements, as well as adverse effects on the psychoemotional state of the child. When peptic ulcer is aggravated, accompanied by severe pain in the abdomen, it is advisable to administer bed rest and a diet based on mechanical, thermal and chemical sparing of the mucous membrane of the stomach and duodenum. The results of the research show that ulcer disease is characterized by disturbances in the processes of lactose utilization, which progress as the morphological changes in the gastroduodenal zone deepen, the duration and severity of the course of the inflammatory process. The use of diet number 1, which includes significant amounts of milk, is limited by the incompatibility of the product with the intake of bismuth preparations. In such cases, the purpose of a dairy-free diet (table No. 4) is shown.

The appointment of medications for the correction of gastroduodenal pathology, described in the previous chapter, fully corresponds to that for peptic ulcer.

Based on the above concepts of the pathogenesis of peptic ulcer of the duodenum, the following areas of treatment are distinguished:

• eradication of H. Pylori infection;
• suppression of gastric secretion and / or neutralization of acid in the lumen of the stomach;
• protection of the mucous membrane from aggressive influences and stimulation of reparative processes;
• correction of the state of the nervous system and the mental sphere.

The expediency of anti-Helicobacter treatment for peptic ulcer is determined by the following factors.

• In 90-99% of patients with duodenal ulcer, scarring of the ulcerative defect is accelerated.
• Eradication of H. Pylori leads to a decrease in the frequency of recurrences of peptic ulcer from 60-100 to 8-10%.
• Eradication can reduce the frequency of recurrences of gastrointestinal bleeding in the course of a complicated course of peptic ulcer.

In the initial detection of H. pylori infection, a triple regimen of treatment based on proton pump inhibitors or bismuth tricalium dicitrate (first line of treatment) is prescribed. Indications for quadrotherapy in this category of patients are large or multiple ulcers, as well as the threat or presence of gastrointestinal bleeding. Quadrotherapy is also indicated for patients with peptic ulcer, if eradication as a result of the first line of treatment failed.

Questions of supportive treatment of duodenal ulcer are currently being discussed extensively. Seasonal treatment of patients with duodenal ulcer (in spring and autumn), many researchers estimate as inefficient and economically unjustified.

To prevent exacerbations of peptic ulcer disease, clinical endoscopic control is necessary (in the first year after diagnosis - once every 3-4 months, on the second and third - once every 6 months, then every year).

If the eradication treatment is ineffective for healing mucosal defects, preventing frequent recurrences of the disease (3-4 times a year) and complications of peptic ulcer and associated diseases requiring the use of NSAIDs, supportive administration of antisecretory drugs in a half dose is indicated. Another option is prophylactic treatment "on demand", in case of clinical symptoms of an exacerbation providing for the administration of one of the antisecretory drugs in a full daily dose for 1-2 weeks, and then in a half dose for the same period.

The modern approach to the treatment of duodenal ulcer in children allows to achieve complete repair of the ulcerative defect in 12-15 days, the frequency of relapses of the disease is significantly reduced. Clinical and endoscopic remission in 63% of children with duodenal ulcer, who received adequate anti-Helicobacter treatment, continues on average 4.5 years. The transformation of the course of peptic ulcer under the influence of modern methods of treatment is also indicated by the frequency of complications of the disease, which for the last 15 years has decreased by half for deformation of the bulb of the duodenum, from 8 to 1.8% for gastrointestinal bleeding.

Surgical treatment of peptic ulcer is indicated when:

1. perforations;
2. ulcer penetration, not amenable to conservative therapy;
3. unceasing massive bleeding;
4. subcompensated scar pyloroduodenal stenosis.

Forecast

Timely detection of peptic ulcer disease in children, adequate therapeutic treatment, regular dispensary observation and prevention of relapses allow achieving persistent clinico-endoscopic remission of the disease for many years, which significantly improves the quality of life of patients.

Prevention of peptic ulcer along with the exclusion of external factors of its formation requires the timely detection and treatment of pre-ulcer states. The child has hereditarily conditioned morphofunctional features of the stomach and duodenum, capable of transforming into a peptic ulcer under certain conditions, and are considered as a pre-ulcer state. The criteria are established, in the aggregate of which the formation of peptic ulcer is very likely:

1. weighed heredity for peptic ulcer, especially cases of peptic ulcer among relatives of the first degree of kinship;
2. increased acid-peptic, especially basal, stomach aggression;
3. increased levels of pepsinogen I in blood and urine;
4. dominance in the pepsinogen phenotype of the Pg3 fraction;
5. Reduction of mucin and bicarbonates in duodenal juice.

It is also important to belong to the I (ABO) blood group and the signs of vagotonia.

Since the realization of hereditary predisposition in peptic ulcer occurs through HP-associated gastroduodenitis, the latter should also be considered an important criterion for the prepulses state.

The pre-ulcer state requires the same diagnostic, therapeutic and dispensary approaches as peptic ulcer.

Clinical follow-up is carried out for life, in the first year after exacerbation of peptic ulcer it is carried out 4 times a year, from the second year - 2 times a year. The main method of dynamic observation, except for survey and examination, is endoscopic. You should also evaluate the dynamics of HP infection and achieve eradication.

[1], [2], [3], [4], [5], [6], [7]