Tuberculosis and diseases of the gastrointestinal tract

Among chronic nonspecific diseases associated with pulmonary tuberculosis, diseases of the digestive organs occupy one of the central places. Most often these are gastritis, peptic ulcer and duodenal ulcer, duodenitis. The combination of diseases creates new complex painful conditions that are difficult to diagnose and treat. The appearance in patients with tuberculosis of symptoms of dysfunction of the digestive system against the background of treatment is usually treated as a side effect of anti-tuberculosis drugs, which causes later recognition of diseases of the gastrointestinal tract.

Symptoms of stomach and duodenal ulcers with tuberculosis

Atrophic gastritis is associated mainly with chronic processes in the lungs in patients of middle and old age. They manifest a pronounced weakness. Deterioration of appetite, asthenoneurotic syndrome. Frequent belching, nausea, a feeling of overflow of the stomach. Young people with newly diagnosed lung tuberculosis and antral forms of chronic gastritis are more characteristic of acidism syndromes (heartburn, sour eructation, nausea).

Clinical manifestations of chronic duodenitis are similar to those of duodenal ulcer. Emerging 1-2 hours after eating, pain can be accompanied by nausea, eructation. Vegetative disorders are characteristic.

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

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

Predisposing factors of ulcer formation in patients with pulmonary tuberculosis are circulatory disorders in the stomach and duodenum, developing tissue hypoxia and hypercapnia, a decrease in the regenerative capacity of the mucosa, and a deficit of local immunity. The significance of functional disorders of the gastrointestinal tract is undoubtedly significant; The long-term use of antituberculous drugs also has an adverse effect.

An important role in the pathogenesis of tuberculosis, peptic ulcer and their combination is played by various disorders of immune homeostasis, especially in patients with severe symptoms of exacerbation of the disease, prolonged, recurrent course. The significant frequency of co-morbid diseases is explained not only by pathogenetic factors and the adverse effects of drugs on the gastrointestinal tract of tuberculosis patients, but also by the spread among the latter burdening social and behavioral factors.

The most dangerous for the emergence of pulmonary tuberculosis are the first 5-10 years of peptic ulcer disease or the period immediately after its surgical treatment. Resection of the stomach contributes to the activation or development of tuberculosis in 2-16% of cases.

From the sequence of the development of diseases depends the peculiarity of their clinical manifestation and prognosis. The primary manifestation of a disease is characterized by a greater degree of symptoms. The combination in all cases worsens the course of both diseases.

Tuberculosis of the lungs, which occurs in combination with a peptic ulcer, even with timely detection, is characterized by propensity to progress, destruction of the pulmonary tissue and development of the fibrous-cavernous process. Progression is slow, but hard. Cure is characterized by the formation of more pronounced residual changes. Patients often determine the resistance of mycobacteria to drugs, their poor tolerability. Especially unfavorable is the tuberculosis at its primary occurrence, in the elderly, in cases of localization of ulcerative lesions in the stomach, when combined with other chronic diseases. For tuberculosis in individuals. Who underwent resection of the stomach, a typical tendency to rapid progression with the emergence of multiple destructive changes and bronchogenic dissemination.

The peptic ulcer in combination with tuberculosis proceeds according to two types. At its primary occurrence during periods of exacerbations, it is characterized by a more severe course with marked clinical manifestations. The leading symptom - pain in the epigastric region - is characterized by intensity, periodicity, rhythmicity, associated with food intake and localization of the lesion. Early pain after eating under the xiphoid process with possible irradiation of the sternum, in the left half of the chest are typical for cardiac and subcardial ulcers of the stomach. Nausea and eructation are frequent.

Paroxysmal pains in the right half of the epigastrium, accompanied by nausea, are peculiar to the ulcer of the pyloric department. Pain in the right half of the epigastric region with irradiation in the back, the right half of the thorax or the right hypochondrium are typical for ulcers of the antrum and duodenum. Pain of varying intensity occurs 1-3 hours after eating, on an empty stomach, at night. Possible vomiting at the height of pain. They note a pronounced seasonality of exacerbations. Palpation revealed the resistance of the abdominal muscles, point soreness in the zone of the projection of the stomach and duodenum.

In cases of adherence to tuberculosis, peptic ulcer is characterized by a low-symptomal course. Pain syndrome and dyspepsia are often mild. There may be no periodicity of pain and their relationship to food intake. The disease often manifests itself with the symptoms of developing complications: bleeding, penetration, perforation, perivisceritis, stenosis of the gatekeeper, malignancy.

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

Especially unfavorable is the peptic ulcer in the elderly. Expressed local trophic changes in the mucosa, slowing of the reparative processes cause the difficulty of healing ulcerative defects, and the low symptomatology of the disease - its late diagnosis.

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

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

Patients with peptic ulcer and resected stomach resection are at risk for tuberculosis and are subject to careful follow-up care with an annual fluorographic examination. When they have symptoms of intoxication or the development of respiratory symptoms, sputum examination on mycobacterium tuberculosis and radiological examination of the lungs are necessary.

With the purpose of early detection of diseases of the gastrointestinal tract in patients with tuberculosis, the data of anamnesis and objective examination are carefully analyzed. When specifying the manifestations of dysfunction of the digestive organs or suspicion of the development of a pathological process in them, a targeted examination is carried out.

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

Treatment of tuberculosis in diseases of the gastrointestinal tract

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

• Concomitant tuberculosis gastroenterological diseases are not contraindications for the appointment of anti-TB drugs;
• treatment should take into account the individual characteristics of the patient, be comprehensive and include both anti-tuberculosis drugs and gastrointestinal therapy;
• the treatment regimen is built 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 co-morbidities;
• in the period of exacerbation of diseases treatment is carried out under stationary conditions;
• with exacerbation of diseases of the gastrointestinal tract, preference should be given to parenteral (intramuscular, intravenous, intratracheal, intracavernous, rectal) administration of antituberculous drugs. Sharp disturbances of absorption processes during exacerbation of peptic ulcer and gastrectomy necessitate the use of parenteral methods of administration of antituberculous drugs that create high concentrations in the blood and foci of tuberculosis;
• it is advisable to designate therapeutic agents that simultaneously have a positive effect on each of the combined diseases;
• during the remission of gastroduodenal diseases, anti-tuberculosis therapy is performed by conventional methods; possibly outpatient treatment;
• In patients during the period of exacerbation of diseases, whenever possible, extensive surgical interventions should be avoided.

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

Adverse events of antituberculosis drugs develop mainly in the case of their use in the period of exacerbation of gastrointestinal diseases and when using drugs of irritant effect on the mucous membrane.

The smallest side effect on the stomach is kanamycin, streptomycin, and metazide. Etambutol causes abdominal pain and dyspeptic disorders in 3% of cases: isoniazid and ftivazid - in 3-5%. Rifampicin, thioacetazone - in 6-10%. Pyrazinamide - in 12%.

Problems of treatment of diseases of the gastrointestinal tract:

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

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

• mode with the creation of mental and functional rest;
• diet;
• medicamentous and non-medicinal remedies;
• Spa treatment:
• dispensary observation.

During the period of exacerbation of the disease for 7-10 days, the patient is shown a semi-postal regime; fractional five meals a day, mechanically, thermally and chemically sparing. Expansion of the diet is carried out gradually, but even in the phase of remission it is necessary to observe the mode of fractional nutrition with the exception of sharp, smoked, fried foods, rich broths.

With the development in the postoperative period of functional disorders of post-resection syndrome, therapeutic nutrition should be physiologically complete, but not mechanically sparing. Avoid dairy dishes, sweets, irritating foods.

The main significance in the development of gastroduodenitis and peptic ulcer is currently given to Helicobacter pylori infection. The inflammation resulting from the action of these bacteria reduces the resistance of the mucous membrane of the stomach and duodenum, creating the prerequisites for enhancing endogenous aggression factors (excessive acid and pepsin formation, increase in the concentration of hydrogen ions with their reverse diffusion). The consequence is a violation of the mucous barrier, blood circulation, anthroduodenal acid barrier. H. Pylori is detected in gastritis and peptic ulcer in 90-100% of cases. The microorganism persists in a person for a long period, causing inflammatory changes, and under appropriate conditions, recurrences of the ulcerative process.

To predisposing factors of occurrence of diseases of the gastrointestinal tract are:

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

The basis of basic drug therapy is antioxidant and antisecretory drugs. First of all, they include antacids. They are characterized by a rapid but very short-acting effect, therefore they are used as symptomatic agents (for relief of pain and dyspeptic disorders). Recommended non-absorbable antacids (magnesium hydroxide, aluminum phosphate, gastal, gastropharm, etc.). They also have an enveloping, adsorbing and some reparative effect.

As antisecretory drugs, blockers of H ₂ -receptor ranitidine (150 mg twice daily) are used; famotidine (20 mg twice daily). They suppress the production of hydrochloric acid, pepsin; increase the production of gastric mucus, the secretion of bicarbonates, improve microcirculation in the mucosa, normalize gastroduodenal motility.

The proton pump inhibitors are currently considered to be the most effective; 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 the antisectoral, this group of drugs also has some antibacterial action, which enhances the activity of "antihelicobacter" drugs.

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

Recommended 7-day triple options for eradication therapy with the inclusion of bismuth tricalium dicitrate, metronidazole and tetracycline (classical triple therapy) and variants with one antisecretory drug in combination with an antibiotic and metronidazole. With insufficient effectiveness of therapy or a complicated course of diseases, a 7-10-day four-component regimen is used (antisecretory drug, bismuth tricalium dicitrate, antibiotic, metronidazole). Further treatment is continued with a single antisecretory drug in half the dose until scarring of the ulcerative lesion, elimination of the exacerbation of the tuberculosis process and the possibility of taking anti-tuberculosis drugs inside.

The scheme of therapy of gastroduodenal disease in a patient with pulmonary tuberculosis is determined in each individual case, taking into account the drug load and severity of gastritis or peptic ulcer. With their favorable course, short and rare exacerbations, small ulcerative defects use drugs with less antisecretory activity. In cases of severe clinical symptoms, large ulcerative defects and in the presence of complications, it is advisable to use drugs with a long antisecretory action in combination with the most effective antihelikobakternymi means.

The effectiveness of treatment should be confirmed by endoscopy with targeted biopsy and eradication of H. Pylori.

A fundamentally different approach to the treatment of chronic gastritis with secretory insufficiency. With this form use:

• means of substitution therapy (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 mucosal regeneration processes (sodium nucleate, enzymes, vitamins); in cases of development of megaloblastic anemia - vitamins B ₁₂, hydroxokobalamin, cyanocobalamin.

Treatment in a sanatorium is shown to patients with remission or the state of a ceasing exacerbation of tuberculosis and diseases of the gastrointestinal tract.

It is also possible to treat a stomach and duodenum with a small, asymptomatic, uncomplicated course and a small-sized ulcerative defect for the first time in the sanatorium.

Sanatorium treatment is aimed at fixing the results achieved earlier, mobilizing the adaptive capabilities of the body, increasing efficiency, completing the patient's preparation for active professional work.

In the period of dispensary follow-up before the implementation of preventive anti-tuberculosis treatment, it is expedient to prescribe the diet regime, antacids and reparants.