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Lecture notes, cheat sheets
Hospital therapy. Diseases of the digestive tract. Stomach diseases. Chronic gastritis (lecture notes)
Directory / Lecture notes, cheat sheets Table of contents (expand) LECTURE No. 10. Diseases of the digestive tract. Diseases of the stomach. Chronic gastritis Chronic gastritis is a disease that is clinically characterized by gastric dyspepsia, and morphologically - by inflammatory and degenerative changes in the gastric mucosa, impaired cell renewal processes, and an increase in the number of plasma cells and lymphocytes in the mucous membrane's own membrane. Etiology and pathogenesis. At the present stage of development of gastroenterology, it has been established that the appearance of chronic gastritis is facilitated by the microbial expansion of Helicobacter pylori (HP), which causes antral gastritis in 95% of cases and pangastritis in 56% of cases. In turn, the so-called etiological factors for the occurrence of chronic gastritis can be attributed with a high degree of certainty to risk factors (irregular unbalanced diet, smoking, alcohol intake, hypersecretion of hydrochloric acid and pepsin). The leading role in the development of the disease also belongs to autoimmune mechanisms, accompanied by the accumulation of antibodies to the parietal cells of the gastric mucosa, aggravated heredity, as well as the use of drugs that have a damaging effect on the gastric mucosa. Classification. In 1990, at the IX International Congress of Gastroenterologists in Australia, a new systematization of chronic gastritis, called the Sydney system, was adopted. Histological bases of classification. 1) Etiology: chronic gastritis associated with HP, autoimmune, idiopathic, acute drug-induced gastritis. 2) Topography: antral, fundic, pangastritis. 3) Morphology: acute, chronic, special forms. Endoscopic basis of classification: 1) gastritis of the antrum of the stomach; 2) gastritis of the body of the stomach; 3) pangastritis; 4) changes in the gastric mucosa: edema, erythema, mucosal vulnerability, exudate, flat erosions, elevated erosions, fold hyperplasia, fold atrophy, visibility of the vascular pattern, supramucosal hemorrhages. clinical picture. Chronic gastritis is one of the most common diseases in the clinic of internal medicine. Its frequency among the world's inhabitants ranges from 28 to 75%. Chronic gastritis is more often manifested by symptoms of gastric dyspepsia and pain in the epigastric region. Rarely, it is asymptomatic. The pain is usually localized in the epigastric region. There is a clear connection between its occurrence with food intake and the localization of the inflammatory process in the stomach. In patients with gastritis of the subcardial and cardial sections of the stomach, pain in the epigastric region occurs 10-15 minutes after a meal, with pathology of the body of the stomach - 40-50 minutes after a meal. "Late", "hungry", pains are typical for gastritis of the output section of the stomach, or duodenitis. "Two-wave" pain - after eating and on an empty stomach - is observed with gastritis of the subcardiac and antrum. With a diffuse process, pain is localized in the epigastric region, occurs after eating and is of a pressing nature. They say about the asymptomatic course of gastritis when it is not possible to establish the relationship between pain in the epigastric region and the lesion, which occurs when it is endogenous in origin (gastritis becomes secondary to the pathology of other organs and systems). An equally important place in the clinical picture of chronic gastritis is dyspeptic syndrome: nausea, belching (sour, bitter, rotten), heartburn, constipation or diarrhea, unstable stools. With isolated antral gastritis, complaints of heartburn and constipation, arising from the hypersecretion of hydrochloric acid and pepsin, become paramount. With pangastritis with signs of severe atrophy, nausea, belching "rotten", unstable stools or diarrhea predominate, which is typical for hyposecretion of hydrochloric acid and pepsin. Persistent nausea is characteristic of secondary gastritis in chronic pancreatitis, chronic cholecystitis, occurring with hypomotor dyskinesia of the gallbladder. Diagnostics. Chronic gastritis lasts a long time, with an increase in symptoms over time. Exacerbations are provoked by nutritional disorders. The physical picture of chronic gastritis is rather poor. In 80-90% of patients during an exacerbation of the disease, an objective study determines only local pain in the epigastric region. When chronic gastritis is combined with duodenitis, cholecystitis or pancreatitis, localization of pain that is not typical for gastritis, but characteristic of the pathology of another organ, can be determined. General blood and urine tests, biochemical parameters of blood in patients with chronic gastritis do not differ from the corresponding parameters in healthy individuals. In a scatological study, there are no changes in the analyzes, or there may be signs of a digestive disorder. When studying the gastric contents of acid secretion by pH-metry, both signs of acid hypersecretion and a decrease in acid production are noted. Indicators of pepsin formation in chronic gastritis are more persistent and decrease against the background of persistent anacidity in diffuse organ damage. An x-ray examination is more likely to exclude other diseases of the stomach (ulcer, cancer), help in the diagnosis of Menetrier's disease than to confirm the diagnosis of chronic gastritis. Due to the paucity of clinical manifestations of the disease, as well as the non-specificity of laboratory tests, the diagnosis of chronic gastritis is based on the results of endoscopic and morphological studies. Endoscopy reveals changes in the gastric mucosa of varying severity: edema, erythema, mucosal vulnerability, exudate, flat erosions, raised erosions, hyperplasia or atrophy of the folds, visibility of the vascular pattern, submucosal hemorrhages. They speak of chronic gastritis with an increase in the number of plasma cells and lymphocytes in the own membrane of the mucous membrane (in contrast to acute gastritis, when polymorphonuclear leukocytes appear). In connection with the foregoing, the morphological identification of inflammation in gastritis may not coincide with the interpretation of the clinician's data. The activity of inflammatory changes in the gastric mucosa is assessed morphologically and morphometrically according to the degree of leukocyte infiltration of the lamina propria or epithelium. We must not lose sight of the fact that autoimmune gastritis is not active. Morphological changes (weak, moderate and severe) - inflammation, activity, atrophy, metaplasia - and the degree of HP contamination are quantified. Clinical manifestations characteristic of gastritis are also observed in other diseases of the digestive system, therefore, in the process of diagnosis, ultrasound of the abdominal cavity, a thorough endoscopic and morphological examination of the digestive organs are necessary. Differential diagnostics. The most difficult is the differential diagnosis of gastritis with functional diseases of the stomach, peptic ulcer of the stomach and duodenum, chronic cholecystitis and pancreatitis and stomach cancer. Functional diseases of the stomach, similar to chronic gastritis, can occur latently or be accompanied by pain and dyspeptic symptoms. They are characterized by a short duration, the presence of general neurotic symptoms that prevail in the clinical picture of the disease (such as weakness, fatigue, irritability, headache, unstable mood, sweating). With disorders of the function of the stomach, the pain does not depend on the quality of the food, or it occurs after the use of a strictly defined product. Often there is a syndrome of acidism (heartburn, sour eructation, sour taste in the mouth), which, unlike gastritis with increased secretory function, does not increase after eating, but with excitement, long breaks in food. Vomiting in functional pathologies of the stomach develops according to the mechanism of a conditioned reflex, brings relief to the patient and does not lead to a significant deterioration in the general condition. In chronic gastritis, it usually occurs during an exacerbation and does not bring relief to the patient. A frequent symptom of dysfunction of the stomach is a loud eructation of air. In chronic gastritis, it is associated with impaired digestion of food or gastric motility and may be acidic if secretion is preserved, or with the smell of rotten eggs if it is reduced. In the study of gastric secretion in gastritis, normal values of secretion are detected at the beginning of the disease, and in the future, a tendency to a decrease in the secretion of gastric juice. With functional diseases of the stomach, heterochilia is often observed. X-ray examination of the stomach makes it possible to confirm such forms of gastritis as rigid, angraal, giant hyperplastic, polyposis, and in case of violations of the motor-evacuation function of the stomach (gastroptosis, hypotension) indicates the functional nature of the disease. The most valuable research method for the differential diagnosis of chronic gastritis and functional diseases of the stomach is gastroscopy, which allows, in controversial cases, to ascertain changes in the gastric mucosa characteristic of gastritis or functional diseases of the stomach. The differential diagnosis of chronic gastritis with peptic ulcer is described in the next lecture. Gastric cancer has a very similar picture with gastritis with reduced secretory function. Early diagnosis of gastric cancer on the basis of clinical signs is difficult, especially in patients suffering from gastritis for a long time. Of great importance for the diagnosis of cancer are the appearance of persistent persistent pain, little dependent on food intake, unmotivated general weakness and fatigue, appetite perversion, as well as a progressive decrease in the patient's body weight. Detection of a tumor on palpation refers to the later stages of the cancer process. Symptoms such as a change in the patient's well-being, a rapid decrease in the acidity of gastric juice, a "deficiency" of hydrochloric acid, the appearance of atypical cells in the gastric juice, a positive reaction to occult blood in the feces should cause the doctor to suspect gastric cancer. Of decisive importance in the differential diagnosis are X-ray and gastroscopic studies with targeted biopsy of the gastric mucosa. In patients with chronic gastritis with reduced secretory function, X-ray examination reveals atrophy of its mucous membrane, which is also confirmed by gastroscopy. With targeted biopsy in such cases, structural changes and atrophy of the mucous membrane are revealed. For gastric cancer, X-ray examination is characterized by the presence of a filling defect, the absence of mucosal folds or a change in their nature, and the absence of peristalsis in certain areas. Endoscopy of the stomach makes it possible to detect a tumor at the earliest stage of its development, when the tumor is still within the gastric mucosa, and surgical treatment leads to recovery in more than 90% of cases. Chronic cholecystitis. In chronic cholecystitis, the pain is localized in the right hypochondrium and is dull in nature. With calculous cholecystitis, the pain is acute, colicky, radiating to the right subscapular region. The onset of pain is associated with eating fatty foods or jolting driving. In chronic gastritis, the pain in the epigastrium is diffuse, dull, there is no irradiation, it occurs immediately after eating dry food or in violation of the diet. With gastritis and cholecystitis, pain is accompanied by dyspeptic symptoms, but a feeling of heaviness in the epigastrium, fullness, belching of food or air, a metallic taste in the mouth are more characteristic of gastritis. Vomiting in chronic gastritis is rare. Objectively, in chronic cholecystitis, especially calculous, one finds tension in the anterior abdominal wall, hyperesthesia of the skin in the right hypochondrium, which is uncharacteristic of chronic gastritis. On palpation of the abdomen in the case of chronic cholecystitis, pain is noted in the localization of the gallbladder. Chronic gastritis is characterized by diffuse soreness. In patients with chronic cholecystitis, bile examination reveals an increase in the amount of mucus and leukocytes. Chronic gastritis is characterized by a normal picture of bile against the background of changes in the secretion and acidity of gastric juice, as well as other functions of the stomach (absorption, motor). X-ray examination of the gallbladder in patients with chronic cholecystitis reveals a change in its evacuation function, as well as stones. Chronic pancreatitis. In chronic pancreatitis, the pain is localized in the left half of the abdomen, radiating to the left subscapular region, to the lower back, and to the surrounding area. The occurrence of pain is associated with the consumption of abundant, often fatty foods, and alcohol. If chronic gastritis is characterized by a long, monotonous course of the disease, then in chronic pancreatitis it is stepwise. An objective examination in the case of chronic pancreatitis reveals hyperesthesia of the skin in the left hypochondrium, pain topographically corresponds to the location of the pancreas. In a laboratory study of pancreatic juice in chronic pancreatitis, a persistent change in alkalinity and enzymes is found: the level of diastase in the blood and urine may change, which is not the case with chronic gastritis. Radiologically, chronic pancreatitis is characterized by an increased reversal of the duodenal ring, a sharp increase in its major papilla (Frostberg's symptom), and sometimes the presence of areas of calcification of the pancreas. Intranosological diagnostics of various forms of chronic gastritis should also be carried out. Thus, the disease associated with HP clinically proceeds with symptoms of duodenal ulcers, and in some cases it can proceed latently. Endoscopic and morphological examination reveals antropylorhoduodenitis. Erosions in Helicobacter pylori gastritis are usually localized in the area of severe inflammation (anthropyloric zone of the stomach). Autoimmune chronic gastritis is clinically characterized by a feeling of heaviness in the epigastric region, an unpleasant aftertaste in the mouth, rotten belching, and nausea. Due to insufficient production of hydrochloric acid, diarrhea appears. In 10% of cases, against the background of autoimmune gastritis, symptoms are found B12- deficiency anemia: weakness, pallor of the skin and mucous membranes, brittle nails, in blood tests - hyperchromic megaloblastic anemia. Special forms of the disease include granulomatous, eosinophilic, hypertrophic (Menetrier's disease), lymphocytic gastritis. Granulomatous gastritis acts as an independent form of the disease or more often - one of the components of a more serious pathology (Crohn's disease, tuberculosis, sarcoidosis). The diagnosis is always confirmed by the results of histological examination of biopsy specimens of the gastric mucosa. Eosinophilic gastritis is extremely rare and is caused by systemic vasculitis. A history of allergic reactions is mandatory. Histological examination reveals eosinophilic infiltration of the gastric mucosa. Hypertrophic gastritis (Menetrier's disease) is clinically manifested by pain in the epigastric region and nausea. Some patients may experience weight loss due to diarrhea. In endoscopic, radiological and morphological studies, giant hypertrophied mucosal folds are found, resembling the convolutions of the brain. Lymphocytic gastritis is clinically asymptomatic; morphologically, this form is characterized by a pronounced infiltration of the gastric mucosa by lymphocytes. Treatment. Patients with gastritis need general medical measures: regular balanced nutrition, normalization of work and rest schedules, leveling out stressful situations in everyday life and work. Drug therapy is indicated only in the presence of clinical manifestations of chronic gastritis. Patients with gastritis associated with HP are treated with a peptic ulcer program (see next lecture). Individuals with autoimmune gastritis need vitamin B supplementation12 (500 mcg once a day subcutaneously for 1 days, followed by a repetition of courses of treatment), folic acid (30 mg per day), ascorbic acid (up to 5 g per day). If necessary, substitution therapy is carried out with enzyme preparations (mezim-forte, festal, enzistal, creon, pancitrate, acidin-pepsin). The pain syndrome is usually stopped by the appointment of antacids (maalox, almagel, gastal) or H-histamine receptor blockers (ranitidine, famotidine) in medium therapeutic doses. With special forms of gastritis, treatment of the underlying disease is necessary. Prognosis and prevention. The prognosis for life and work is favorable. Patients with chronic gastritis should be registered with a gastroenterologist. They are examined clinically and endoscopically with a biopsy at least once a year to exclude tumor transformation. The most dangerous in terms of cancerous degeneration are hypertrophic, diffuse atrophic gastritis with epithelial dysplasia. In erosive forms of the disease complicated by bleeding, as well as in the decompensated form of Menetrier's disease, the prognosis is determined by the timeliness and adequacy of surgical treatment. Prevention of gastritis is reduced to rational nutrition, compliance with the regime of work and rest, limiting the intake of NSAIDs. Author: Mostovaya O.S. >> Forward: Diseases of the digestive tract. Diseases of the stomach. peptic ulcer
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