Tuberculosis and gastrointestinal diseases

Among chronic non-specific diseases accompanying pulmonary tuberculosis, diseases of the digestive organs occupy one of the central places. Most often, these are gastritis, gastric ulcer and duodenal ulcer, duodenitis. The combination of diseases creates new complex disease states that are difficult to diagnose and treat. The appearance of symptoms of dysfunction of the digestive organs in patients with tuberculosis during treatment is usually interpreted as a side effect of anti-tuberculosis drugs, which causes late recognition of diseases of the gastrointestinal tract.

Symptoms of diseases of the stomach and duodenum in tuberculosis

Atrophic gastritis is associated mainly with chronic processes in the lungs of middle-aged and elderly patients. They are manifested by severe weakness, loss of appetite, asthenoneurotic syndrome. Belching, nausea, and a feeling of fullness in the stomach are common. Young people with newly diagnosed pulmonary tuberculosis and antral forms of chronic gastritis are more likely to experience acidism syndromes (heartburn, sour belching, nausea).

Clinical manifestations of chronic duodenitis are similar to the symptoms of duodenal ulcer. Pain that occurs 1-2 hours after eating may be accompanied by nausea and belching. Vegetative disorders are characteristic.

Significant difficulties in the treatment of patients with tuberculosis are created by its combination with peptic ulcer disease. In most patients, peptic ulcer disease precedes tuberculosis, but in 1/3 of them it develops against its background.

The occurrence of tuberculosis in patients with peptic ulcer disease is caused by pronounced neurohumoral disorders and metabolic disorders caused by frequent exacerbations. Changes in absorption processes, vitamin metabolism, secretory and motor functions of the gastrointestinal tract after gastric resection reduce the body's resistance and create prerequisites for the development of a secondary disease.

Predisposing factors for ulcer formation in patients with pulmonary tuberculosis are circulatory disorders in the stomach and duodenum, developing tissue hypoxia and hypercapnia, decreased regenerative capacity of the mucous membrane, and local immunity deficiency. The significance of functional disorders of the gastrointestinal tract is undeniable; long-term use of anti-tuberculosis drugs also has an adverse effect.

Various disorders of immune homeostasis play an important role in the pathogenesis of tuberculosis, peptic ulcer disease and their combination, especially in patients with pronounced symptoms of exacerbation of diseases, long-term, recurrent course. The significant frequency of combined diseases is explained not only by pathogenetic factors and the adverse effect of drugs on the gastrointestinal tract of patients with tuberculosis, but also by the spread of aggravating social and behavioral factors among the latter.

The most dangerous periods in terms of the development of pulmonary tuberculosis are the first 5-10 years of the ulcer or the period immediately after its surgical treatment. Gastric resection promotes the activation or development of tuberculosis in 2-16% of cases.

The sequence of disease development determines the specific clinical manifestation and prognosis. Primary disease is characterized by greater severity of symptoms. The combination in all cases worsens the course of both diseases.

Pulmonary tuberculosis, occurring in combination with peptic ulcer, even with timely detection, is characterized by a tendency to progress, destruction of lung tissue and development of fibro-cavernous process. Progression is slow but persistent. Recovery is characterized by the formation of more pronounced residual changes. In patients, resistance of mycobacteria to drugs and their poor tolerance are often determined. Tuberculosis is especially unfavorable in its primary occurrence, in elderly people, in cases of localization of ulcerative lesion in the stomach, in combination with other chronic diseases. For tuberculosis in people who have undergone gastric resection, a tendency to rapid progression with the occurrence of multiple destructive changes and bronchogenic dissemination is typical.

Peptic ulcer disease in combination with tuberculosis occurs in two types. When it first occurs during periods of exacerbation, it is characterized by a more severe course with pronounced clinical manifestations. The leading symptom is pain in the epigastric region, which is characterized by intensity, periodicity, rhythm, and is associated with food intake and the localization of the lesion. Early pain after eating under the xiphoid process with possible irradiation behind the sternum, to the left half of the chest is typical for ulcers of the cardiac and subcardial sections of the stomach. Nausea and belching are common.

Paroxysmal pain in the right half of the epigastrium, accompanied by nausea, is typical of a pyloric ulcer. Pain in the right half of the epigastric region radiating to the back, to the right half of the chest or the right hypochondrium is typical of an antral ulcer and duodenal ulcer. Pain of varying intensity occurs 1-3 hours after eating, on an empty stomach, at night. Vomiting is possible at the height of the pain. A pronounced seasonality of exacerbations is noted. Palpation reveals resistance of the abdominal muscles, point tenderness in the projection zone of the stomach and duodenum.

In cases of tuberculosis, peptic ulcer disease is characterized by a low-symptom course. Pain syndrome and dyspeptic symptoms are often weakly expressed. Periodicity of pain and its connection with food intake may be absent. The disease often manifests itself with symptoms of developed complications: bleeding, penetration, perforation, perivisceritis, pyloric stenosis, malignancy.

In patients with a combination of diseases, an increase in the secretory function of the stomach is most often detected. However, in cases of ulcer disease development against the background of tuberculosis in its chronic course, a normal or reduced content of hydrochloric acid is more often noted. The hypokinetic type is most characteristic of the motor function of the stomach.

Ulcer disease is especially unfavorable in elderly people. Expressed local trophic changes in the mucous membrane, slowing down of reparative processes cause difficulty in healing ulcer defects, and the low symptomatology of the disease - its late diagnosis.

In cases of combined pulmonary tuberculosis and peptic ulcer, the clinical picture consists of symptoms of both diseases. But to a greater extent than in their isolated course, weakness, sleep and appetite disorders, vegetative disorders, and weight loss are expressed. More often, other organs and systems are involved in the process.

Features of diagnostics of diseases of the stomach and duodenum in tuberculosis

Patients with peptic ulcer disease and those who have undergone gastric resection are at risk for tuberculosis and are subject to careful clinical observation with annual fluorographic examination. If they develop symptoms of intoxication or respiratory symptoms, sputum should be tested for Mycobacterium tuberculosis and X-ray examination of the lungs is necessary.

In order to detect gastrointestinal diseases early in patients with tuberculosis, the anamnesis and objective examination data are carefully analyzed. If there is an indication of dysfunction of the digestive organs or a suspicion of the development of a pathological process in them, a targeted examination is carried out.

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Treatment of tuberculosis in diseases of the gastrointestinal tract

For effective treatment of patients with combined processes, it is necessary first of all to eliminate the exacerbation of the gastrointestinal disease and ensure the possibility of continuous, long-term, full anti-tuberculosis therapy. This can be achieved by observing the basic principles of complex treatment:

• Gastroenterological diseases associated with tuberculosis are not a contraindication for the administration of anti-tuberculosis drugs;
• treatment should take into account the individual characteristics of the patient, be comprehensive and include both anti-tuberculosis drugs and therapy for gastrointestinal diseases;
• the treatment regimen is developed taking into account the form, stage, phase and prevalence of the process, the functional state of organs and systems, the nature of absorption and metabolism of drugs, drug resistance, the presence of complications and other concomitant diseases;
• during periods of exacerbation of diseases, treatment is carried out in hospital conditions;
• in case of exacerbation of gastrointestinal diseases, preference should be given to parenteral (intramuscular, intravenous, intratracheal, intracavernous, rectal) administration of anti-tuberculosis drugs. Severe disturbances in absorption processes during exacerbation of peptic ulcer disease and gastric resection necessitate the use of parenteral methods of administration of anti-tuberculosis drugs, creating high concentrations in the blood and foci of tuberculosis lesions;
• it is advisable to prescribe medications that simultaneously have a positive effect on each of the combined diseases;
• During remission of gastroduodenal diseases, anti-tuberculosis therapy is carried out using generally accepted methods; outpatient treatment is possible;
• In patients during periods of exacerbation of diseases, extensive surgical interventions should be avoided if possible.

Anti-tuberculosis therapy is carried out in accordance with basic principles.

Side effects of anti-tuberculosis drugs develop mainly when they are used during periods of exacerbation of gastrointestinal diseases and when using drugs that irritate the mucous membrane.

Kanamycin, streptomycin, and metazid have the least side effects on the stomach. Ethambutol causes abdominal pain and dyspeptic disorders in 3% of cases: isoniazid and ftivazid - in 3-5%. Rifampicin, thioacetazone - in 6-10%. Pyrazinamide - in 12%.

Objectives of treatment of gastrointestinal diseases:

• relief of symptoms of exacerbation of the disease, suppression of active inflammation of the gastric mucosa and duodenum, healing of ulcerative lesions;
• prevention of exacerbations, complications and relapses of diseases.

Correctly conducted therapy allows to relieve exacerbation of gastroduodenal disease within 1.5-2 months. The basis of complex therapy is:

• a regimen that creates mental and functional peace;
• diet;
• medicinal and non-medicinal treatments;
• spa treatment:
• dispensary observation.

During the period of exacerbation of diseases, the patient is prescribed semi-bed rest for 7-10 days; fractional meals five times a day, mechanically, thermally and chemically gentle. The diet is expanded gradually, but even in the remission phase, it is necessary to follow the fractional meals regimen with the exclusion of spicy, smoked, fried foods, rich broths.

In the case of development of functional disorders of post-resection syndrome in the postoperative period, therapeutic nutrition should be physiologically complete, but not mechanically sparing. Dairy products, sweets, and irritating foods should be avoided.

The main significance in the development of gastroduodenitis and peptic ulcer disease is currently attributed to Helicobacter pylori infection. The inflammation resulting from the impact of these bacteria reduces the resistance of the gastric and duodenal mucosa, creating prerequisites for the enhancement of endogenous factors of aggression (excessive formation of acid and pepsin, an increase in the concentration of hydrogen ions with their reverse diffusion). The consequence is a violation of the mucous barrier, blood circulation, and antroduodenal acid barrier. H. pylori is detected in gastritis and peptic ulcer disease in 90-100% of cases. The microorganism persists in humans for a long period, causing inflammatory changes, and under appropriate conditions - relapses of the ulcer process.

Predisposing factors for the development of gastrointestinal diseases include:

• heredity;
• food poisoning;
• disturbances in the rhythm and quality of nutrition;
• long-term use of medications;
• neuroreflex effects on the stomach and duodenum from other organs and systems;
• neuropsychic and physical overload.

The basis of basic drug therapy is antacids and antisecretory drugs. These primarily include antacids. They are characterized by a rapid but very short-term effect, so they are used as symptomatic agents (to relieve pain and dyspeptic disorders). Non-absorbable antacids (magnesium hydroxide, aluminum phosphate, gastal, gastropharm, etc.) are recommended. They also have an enveloping, adsorbing and some reparative effect.

The following antisecretory drugs are used: H2-receptor blockers _ranitidine (150 mg 2 times a day); famotidine (20 mg 2 times a day). They suppress the production of hydrochloric acid, pepsin; increase the production of gastric mucus, bicarbonate secretion, improve microcirculation in the mucous membrane, and normalize gastroduodenal motility.

The most effective at present are considered to be proton pump inhibitors; omeprazole (20-40 mg); pantoprazole (40-80 mg); lansoprazole (30 mg). Their antisecretory activity is maintained for 18 hours, which allows the use of drugs once a day. In addition to antisecretory, this group of drugs also has some antibacterial action, enhancing the activity of "anti-Helicobacter" drugs.

"Anti-Helicobacter" therapy is the second component of treatment. Eradication of H. pylori using adequate antibacterial drugs promotes regression of inflammatory and ulcerative changes in the gastrointestinal mucosa, restoration of its protective properties, and prevents complications and relapses. The main list of drugs with anti-Helicobacter action includes metronidazole (500 mg 3 times a day); bismuth tripotassium dicitrate (120 mg 4 times a day); clarithromycin (250-500 mg 2 times a day); amoxicillin (500 mg 3 times a day); tetracycline (500 mg 4 times a day).

It is recommended to use 7-day triple eradication therapy options with the inclusion of bismuth tripotassium dicitrate, metronidazole and tetracycline (classical triple therapy) and options with one antisecretory drug in combination with an antibiotic and metronidazole. If the therapy is insufficiently effective or the course of the disease is complicated, a 7-10-day four-component treatment regimen is used (antisecretory drug, bismuth tripotassium dicitrate, antibiotic, metronidazole). Further treatment is continued with one antisecretory drug in half the dose until the ulcerative lesion is scarred, the exacerbation of the tuberculosis process is eliminated and it is possible to take anti-tuberculosis drugs orally.

The treatment regimen for gastroduodenal disease in a patient with pulmonary tuberculosis is determined in each individual case, taking into account the drug load and the severity of gastritis or peptic ulcer disease. In the case of a favorable course, short-term and rare exacerbations, small ulcerative defects, drugs with less antisecretory activity are used. In cases of pronounced clinical symptoms, large ulcerative defects and in the presence of complications, it is advisable to use drugs with a long-term antisecretory effect in combination with the most effective anti-Helicobacter agents.

The effectiveness of treatment should be confirmed by endoscopic examination with targeted biopsy and establishment of H. pylori eradication.

A fundamentally different approach to the treatment of chronic gastritis with secretory insufficiency. In this form, the following is used:

• replacement therapy agents (natural gastric juice, betaine + pepsin, etc.);
• drugs that stimulate the secretory function of the stomach (insulin, aminophylline, calcium preparations);
• drugs that affect tissue metabolism, trophism and regeneration processes of the mucous membrane (sodium nucleinate, enzymes, vitamins); in cases of megaloblastic anemia - vitamins B ₁₂, hydroxocobalamin, cyanocobalamin.

Treatment in a sanatorium is indicated for patients with remission or a state of fading exacerbation of tuberculosis and gastrointestinal diseases.

Treatment is also possible for diseases of the stomach and duodenum that are first diagnosed in the sanatorium, with a low-symptom, uncomplicated course and a small ulcer defect.

Sanatorium treatment is aimed at consolidating previously achieved results, mobilizing the body's adaptive capabilities, increasing performance, and completing the patient's preparation for active professional activity.

During the period of dispensary observation before carrying out prophylactic anti-tuberculosis treatment, it is advisable to prescribe a dietary regimen, antacids and reparants.