Symptoms of chronic gastritis and gastroduodenitis

Chronic gastroduodenitis in children is characterized by a recurrent course: exacerbations are usually provoked by nutritional disorders, stress loads, frequent respiratory viral diseases, and medication intake. With the age of the patient, especially in adolescence, gastroduodenitis acquires a progressive course. Clinical symptoms of chronic gastritis or duodenitis in children do not have characteristic specific manifestations. Isolated duodenitis is a rare pathology in childhood. The exact localization of the inflammatory process is established endoscopically.

Clinical symptoms of gastroduodenitis depend on the phase of the disease. The clinical diagnostic marker is considered to be pain syndrome: the nature of pain (paroxysmal - burning, cutting, stabbing, dull - aching, pressing, bursting, uncertain); time of pain onset and relationship with food intake (early - 1.5 hours after eating; late - 2 hours after eating); pain intensifies, relieves or goes away after eating or is not associated with eating. The localization of pain is taken into account (patient complaints and palpation examination): in the epigastric region - 98%, in the right hypochondrium - 60%, in the pyloroduodenal zone - 45%, in the Treitz angle (on the left, above the navel) - 38%. Pain often radiates to the back, lower back, left half of the abdomen and less often to the right shoulder blade and lower abdomen. In 36% of patients, the pain increases after eating and physical activity; in 50-70% of patients, temporary relief of pain after eating is noted. Localization of pain in the right hypochondrium and pyloroduodenal zone with a feeling of heaviness and distension in the upper half of the abdomen, occurring at night, on an empty stomach (early) and 2 hours after eating (late), is more often characteristic of duodenitis.

Taking into account the features of functional and morphological changes in the duodenum associated with the disorder of the intestinal hormonal system, the following clinical variants are distinguished: gastritis-like, cholecyst-like, pancreatic-like, ulcer-like and mixed. The most common variant is ulcer-like.

In chronic gastritis in children, aching pain is often localized in the epigastric region, occurs after meals, lasts for 1-1.5 hours and depends on the quality and volume of food consumed (fried, fatty, coarse, carbonated drinks). The nature, intensity, and duration of pain indirectly reflect the endoscopic picture. Erosions on the gastroduodenal mucosa are clinically manifested by an ulcer-like variant: periodically occurring acute pain crises (early, night) of a paroxysmal (cutting, stabbing) and aching nature against the background of a feeling of heaviness and distension in the upper abdomen; vomiting with blood, dark stool is possible, which confirms the possibility of latent gastric bleeding.

In superficial and diffuse gastroduodenitis, the symptoms may be vague, without clear localization of pain, with large calm intervals between the occurrence of pain; pain is often of moderate intensity. In this case, the course of the disease and the summation of clinical symptoms are more pronounced in patients infected with HP. This is due to an increase in acid formation, mainly in the interdigestive phase of secretion, an increase in proteolytic activity, which is due to the influence of HP on gastrin secretion indirectly, by affecting D-cells (producing somatostatin) and through various inflammatory mediators. Pain syndrome is accompanied by the presence of dyspeptic disorders, which are often a consequence of impaired motility of the duodenum (duodenostasis, reflux). The most typical are nausea (64%), decreased appetite, less often vomiting (24%), heartburn (32%), a feeling of acidity and bitterness in the mouth. A number of patients have hypersalivation, flatulence, and constipation. Constant symptoms of gastroduodenitis are autonomic disorders: frequent headaches, rapid fatigue, and irritability.

Clinical symptoms of chronic gastroduodenitis in children with ulcer-like course differ from manifestations of peptic ulcer disease. Most children have lost the strict periodicity of the pain syndrome, night pains become less frequent. Acute, paroxysmal pain occurs 2 times less often than with peptic ulcer disease. Acute pains are short-lived and combined with aching. Moynigham's rhythm of pain (hunger - pain - food intake - relief) occurs in 1/3 of children (more often with peptic ulcer disease). In most children (67%), among concomitant diseases of the digestive organs, pathology of the biliary system (dyskinesia, cholecystitis, gallbladder anomalies) is most often noted.

The main features of chronic gastroduodenitis are high prevalence, dependence on gender and age, the presence of a non-specific symptom complex caused by long-term xenogenic sensitization, the prevalence of severe variants of the disease with frequent, protracted exacerbations and their seasonal dependence, the widespread nature and depth of morphofunctional changes in the mucous membrane of the stomach and duodenum, concomitant neurovegetative, endocrine, immunological, dysbiotic disorders.

In children, the outcome of chronic gastroduodenitis is favorable: morphological changes are subject to regression against the background of complex treatment and systematic rehabilitation measures. Bleeding dominates in the structure of complications, observed more often in patients with peptic ulcer disease (8.5%) and less often in patients with hemorrhagic gastritis. In the latter, bleeding is of a diapedetic nature. With the development of endoscopic methods, it became possible to carry out therapeutic manipulations to stop gastrointestinal bleeding. The main clinical manifestations of bleeding are vomiting of "coffee grounds", melena, increasing anemia, vascular collapse. During the healing of the ulcer, stenosis of the pylorobulbar zone may develop (11%). Clinically, this is expressed by vomiting food eaten the day before; increased peristalsis of the stomach (splashing noise determined by jerky palpation of the abdominal wall). Cicatricial deformation of the duodenal bulb is observed in 34% of patients, on the gastric mucosa - in 12% of patients. Perforation of the ulcer is 2 times more common in gastric localization. The main clinical sign in such patients is a sharp, sudden ("dagger") pain in the epigastric region and in the right hypochondrium. Penetration (penetration of the ulcer into neighboring organs) is possible only in the case of a long-term severe course of the disease and inadequate therapy. In this case, sharp pain radiating to the back is characteristic; vomiting that does not bring relief.

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Classification of chronic gastroduodenitis in children

In 1990, at the IX International Congress of Gastroenterologists in Australia, a classification was proposed based on the systematization of morphological characteristics and etiology. This is the so-called Sydney classification, or "Sydney system", which was modified in 1994 (Houston) (Table 21-1).

In practical gastroenterology, materials developed by leading pediatric clinics are used (AV Mazurin, AI Volkov 1984). First of all, gastroduodenitis is divided into primary - an independent disease caused by many etiopathogenetic factors, and secondary - occurs against the background of other diseases of the digestive organs, caused by a close anatomical and physiological relationship between them (Crohn's disease, systemic diseases, granulomatosis, celiac disease, allergic diseases, sarcoidosis).

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Etiological signs

Chronic gastritis is classified according to etiological factors into:

• autoimmune - type A - inflammation is associated with the presence of antibodies to the parietal cells of the mucous membrane of the body and fundus of the stomach (achlorhydria, hypergastrinemia);
• Helicobacter (pyloric helicobacteriosis - type B);
• chemical - type C - reflux gastritis, when the pathological process is associated with prolonged exposure to substances (bile acids, etc.) that have an irritating effect on the mucous membrane;
• radiation (taking into account the presence of environmental factors);
• drug;
• stressful conditions;
• specific gastritis: lymphocytic, eosinophilic, granulomatous (tuberculosis, syphilis, Crohn's disease);
• hypertrophic gastropathy (giant Menetrier gastritis).

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Topographic features

• Gastritis: antral, fundal, pangastritis.
• Duodenitis: bulbitis, postbulbar, panduodenitis.
• Gastroduodenitis.

Endoscopic signs indicate the stage of the pathological process: erythematous, exudative, erosive, hemorrhagic, atrophic, hyperplastic, nodular.

Morphological signs reflect the degree and depth of inflammation, processes of atrophy, metaplasia, bacterial contamination, as well as the degree of infiltration, dystrophic changes in the enterocytes of the villi, crypts, foci of connective tissue proliferation, the presence of erosions (complete, incomplete, intermediate, hemorrhagic).

According to these characteristics, the following are distinguished:

• superficial gastritis - initial manifestations;
• diffuse - significantly pronounced manifestations;
• atrophic - with partial atrophy of the villi and crypts;
• grainy;
• polypous (areas of formations protruding above the surface like “semolina” with a diameter of up to 1 mm, lymphocytic-histiocytic infiltration);
• erosive - the presence of erosions of various types.

Histological signs reflect the activity of gastritis

• Grade 1 - moderate leukocyte infiltration of the lamina propria of the mucous membrane.
• 2nd degree - leukocyte infiltration is pronounced in the superficial and pit epithelium of the mucous membrane.
• 3rd degree - development of intra-pit abscesses, erosive and ulcerative defects of the mucosa (more often with HP colonization). The degree of histological changes corresponds to the severity of inflammation: mild, moderate, severe. In addition, the severity of the presence of morphological signs and the degree of leukocyte and lymphocytic infiltration is assessed by symbols: normal - 0, weak - 1 +, average - 2+, strong - 3+. Morphological changes lead to functional restructuring of the gastric and duodenal mucosa, to disruption of secretory processes (intestinal hydrolases, pepsin, hydrochloric acid). It is known that the level of free hydrochloric acid and total acidity increases by 8-10 years in both boys and girls and increases sharply in adolescence (associated with the processes of puberty). Of these, 40.4% have increased acidity, 23.3% have decreased acidity, and 36.3% have normal acidity. Therefore, it is necessary to reflect the nature of the acid production of the stomach: increased, unchanged, decreased.

Periods of the disease: exacerbation, incomplete clinical remission, complete clinical remission, clinical-endoscopic remission, clinical-endoscopic-morphological remission.