Symptoms of chronic gastritis and gastroduodenitis

Chronic gastroduodenitis in children is characterized by a recurring course: exacerbations are usually provoked by eating disorders, stressful stresses, frequent respiratory-viral diseases, and medication. With the age of the patient, especially in the adolescent period, gastroduodenitis acquires a progressive course. The clinical symptoms of chronic gastritis or duodenitis in children do not have specific specific manifestations. Isolated duodenitis is a rare pathology in childhood. Precise localization of the inflammatory process is established endoscopically.

The clinical symptoms of gastroduodenitis depend on the phase of the flow. Clinical diagnostic marker is considered pain syndrome: the nature of pain (paroxysmal - burning, cutting, stitching, stupid - aching, pressing, bursting, indefinite); the time of the onset of pain and the connection with food intake (early - 1.5 hours after eating, late - 2 hours after eating); pain intensifies, facilitates or passes after eating or is not associated with its intake. Take into account the localization of pains (complaints of the patient and palpation): in the epigastric region - 98%, in the right upper quadrant - 60%, in the pyloroduodenal zone - 45%, in the corner of Treyts (left, above the navel) - 38%. Pain is more often irradiated in the back, in the lower back, in the left half of the abdomen and less often in the right scapula and lower abdomen. In 36% of patients pains increase after eating and physical activity; in 50-70% of patients, temporary relief of pain after eating was noted. Localization of pain in the right hypochondrium and pyloroduodenal zone with feeling of heaviness and raspiraniya in the upper half of the abdomen, arising at night, on an empty stomach (early) and 2 hours after eating (later), is more common in 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, cholecystoid, pancreatic, ulcerative and mixed. The most common option is ulcerative.

In chronic gastritis in children, aching pain is more often localized in the epigastric region, occurs after eating, lasts for 1 to 1.5 hours and is dependent on the quality and volume of food intake (fried, fatty, coarse, carbonated drinks). The nature, intensity, duration of pain indirectly reflect the endoscopic picture. Erosions on the gastroduodenal mucosa are clinically manifested by the ulcerative variant: recurring acute painful crises (early, night) of paroxysmal (cutting, stitching) and aching character against a background of sensation of heaviness and raspiraniya in the upper half of the abdomen; possible vomiting with an admixture of blood, a dark stain of feces, which confirms the possibility of developing hidden gastric bleeding.

With superficial and diffuse gastroduodenitis, symptoms can be erased without a clear localization of pain, with large calm intervals between the onset of pain; pain - more often of medium 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 the increase in acid formation, mainly in the inter-digestive phase of secretion, an increase in proteolytic activity, which is due to the influence of HP on the secretion of gastrin indirectly, by affecting the D cells (producing somatostatin) and through various inflammatory mediators. Pain syndrome is accompanied by dyspeptic disorders, which are often the result of a violation of duodenal motility (duodenostasis, reflux). The most common nausea (64%), decreased appetite, less often vomiting (24%), heartburn (32%), acid and bitterness in the mouth. A number of patients expressed hypersalivation, flatulence, constipation. Constant symptoms of gastroduodenitis are vegetative disorders: frequent headaches, fatigue, irritability.

The clinical symptoms of chronic gastroduodenitis in children with the course of the ulcerative variant differs from the manifestations of peptic ulcer. The majority of children lost a strict periodicity of the pain syndrome, less often they become night pains. Acute, paroxysmal nature of pain occurs in 2 times less often than with peptic ulcer. Acute pains are short and combined with aching. Moynigam rhythm of pain (hunger - pain - food intake - relief) occurs in 1/3 of children (more often with peptic ulcer). In the majority of children (67%) among the concomitant diseases of the digestive system, the pathology of the bile excretory system (dyskinesia, cholecystitis, gallbladder anomalies) is noted with the greatest frequency.

The main features of chronic gastroduodenitis are high prevalence, dependence on sex and age, the presence of a nonspecific symptom complex due to prolonged xenogeneic sensitization, the prevalence of severe variants of the disease with frequent, prolonged exacerbations and their seasonal dependence, the widespread nature and depth of morphofunctional changes in the mucous membrane of the stomach and duodenum, concomitant neuro-vegetative, endocrine, immunological, and dysbiotic disorders.

In children, the outcome of chronic gastroduodenitis is favorable: morphological changes against a background of complex treatment and systematically conducted rehabilitation measures are reversed. The structure of complications is dominated by bleeding, observed more often in patients with peptic ulcer disease (8.5%) and less often in patients with hemorrhagic gastritis. In the latter, the bleeding is diapered. With the development of endoscopic methods, it became possible to conduct therapeutic manipulations to stop gastrointestinal bleeding. The main clinical manifestations of bleeding - vomiting "coffee grounds", melena, increasing anemia, vascular collapse. In the process of ulcer healing, stenosis of the pylorobulbar zone (11%) can develop. Clinically, this is expressed by vomiting food eaten on the eve; an increase in the peristalsis of the stomach (the noise of splashing, which is determined by the trembling palpation of the abdominal wall). Cicatricial deformation of the bulb of the duodenum is noted 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 prolonged severe course of the disease and inadequate therapy. This is characterized by a sharp pain with irradiation in the back; vomiting, not bringing relief.

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

Classification of chronic gastroduodenitis in children

In 1990, the IX International Congress of Gastroenterologists in Australia proposed a classification 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).

Practical gastroenterology uses materials developed by leading pediatric clinics (AB Mazurin, AI Volkov 1984). First of all, the gastroduodenitis is distributed to the primary one - an independent disease caused by many etiopathogenetic factors, and the secondary one - occurs against the background of other diseases of the digestive organs, is caused by the close anatomical and physiological relationship between them (Crohn's disease, systemic diseases, granulomatosis, celiac disease, allergic diseases, sarcoidosis ).

[7], [8], [9]

Etiological features

Chronic gastritis for etiologic factors is classified into:

• autoimmune - type A - inflammation is associated with the presence of AT to parietal cells of the mucous membrane of the body and the bottom 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.), which have irritating effects 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 gastropathies (giant gastritis Menetries).

[10], [11], [12], [13], [14], [15], [16]

Topographical features

• Gastritis: antral, base, 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, the processes of atrophy, metaplasia, contamination by bacteria, as well as the degree of infiltration, dystrophic changes in villous enterocytes, crypt, foci of connective tissue proliferation, erosion (complete, incomplete, intermediate, hemorrhagic).

According to these characteristics, there are:

• superficial gastritis - initial manifestations;
• diffuse - marked manifestations;
• atrophic - with partial atrophy of villi and crypt;
• grainy;
• polyposis (patches of "semolina" formations up to 1 mm in diameter above the surface, lymphocytic-histiocytic infiltration);
• erosive - the presence of erosion of various types.

Histological signs reflect the activity of gastritis

• 1 degree - moderate leukocyte infiltration of the propria of the mucous membrane.
• 2 degree - expressed leukocyte infiltration in the surface and pit epithelium of the mucosa.
• 3 degree - the development of intramuscular abscesses, erosive and ulcerative mucosal defects (more often when colonizing HP). The degree of histological changes corresponds to the severity of the inflammation: mild, moderate, severe. In addition, the degree of severity by the presence of morphological signs and the degree of leukocyte and lymphocytic infiltration is estimated by the symbols: norm-0, weak-1 +, middle-2+, strong-3+. Morphological changes lead to a functional reorganization of the mucous membrane of the stomach and duodenum, to the violation 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 sharply increases in adolescence (associated with puberty). Of these, 40.4% have increased acidity, 23.3% - decreased and 36.3% - normal. Therefore, it is necessary to reflect the nature of the acid production of the stomach: elevated, unchanged, reduced.

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