Childhood diseases. Diseases of the digestive system in children. Chronic gastroduodenitis. Gastric ulcer (lecture notes)

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Childhood diseases. Diseases of the digestive system in children. Chronic gastroduodenitis. Gastric ulcer (lecture notes)

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LECTURE No. 8. Diseases of the digestive system in children. Chronic gastroduodenitis. Stomach ulcer

1. Chronic gastroduodenitis

Chronic gastroduodenitis is a chronic inflammation of the mucous membrane of the antrum of the stomach and duodenum, accompanied by a violation of the physiological regeneration of the epithelium, the secretory and motor functions of the stomach.

Etiological factors: endogenous factors (hereditary predisposition, high type of acid formation, impaired mucus formation, chronic diseases accompanied by hypoxia, local vascular disorders, intoxication, chronic diseases of the liver and biliary tract); exdogenic factors (malnutrition, poor-quality roughage, eating dry, in a hurry, long breaks in eating; past food poisoning, prolonged and frequent medication, psycho-emotional stress, neurogenic stress, colonization of the mucous membrane of the antrum of the stomach and duodenum with bacteria). Classification according to the period of the disease: exacerbations, subremissions, remissions. According to the mechanism of development, there are: chronic gastritis type A, based on an autoimmune mechanism of development with the production of antibodies to the parietal cells of the mucous membrane and the internal factor; chronic type B gastritis develops as a result of the action of various factors (long-term medication, nutritional disorders, persistence in the mucosa of Helicobacter pylori); chronic gastritis type C has a reflux mechanism of development or medication as a result of taking NSAIDs.

Clinic. Abdominal pain is localized in the epigastric and pyloroduodenal zones, most often occurs on an empty stomach and decreases after eating. Sometimes early pain is observed, appearing 20-30 minutes after eating; hunger pain is less common - 1,5-2 hours after eating. The rhythm of pain in older children: hunger - pain - eating - relief - hunger. Eating a small amount of food helps reduce pain, but overeating, eating spicy, sour foods, and physical activity increases the pain. Dyspeptic syndrome is caused by a violation of the motor and secretory functions of the stomach and duodenum, manifested by nausea, vomiting, belching, heartburn, bowel dysfunction in the form of constipation, or unstable stool with polyfecal matter. Asthenovegetative syndrome is manifested by weakness, fatigue, and neurosis-like conditions. Palpation of the abdomen reveals moderate diffuse pain in the epigastric and pyloroduodenal areas.

Diagnostics performed on the basis of anamnesis of clinical and laboratory data. In the blood test - a decrease in erythrocytes, hemoglobin, moderate leukocytosis. During endoscopic examination, superficial gastroduodenitis is isolated, where hyperemia and mucosal edema are revealed. With hypertrophic gastroduodenitis, the mucosa is edematous, hyperemic, has a granular appearance, small punctate hemorrhages. With erosive gastritis against the background of hyperemia, there are multiple, less often single, erosions with a flat bottom. With atrophic (subatrophic) gastroduodenitis, the mucosa is pale, the folds are thinned, smoothed, the vascular pattern is enhanced. In all forms, there may be signs of duodenogastric reflux (pylorus gaping, an admixture of bile in the contents of the stomach).

Carry out tests for the determination of Helicobacter pylori. This is enzyme immunoassay, determination of antibodies in blood, urine, saliva, microscopy of smears - prints of the gastric mucosa. X-ray examination - according to indications, if there are changes in the folds, a large amount of contents on an empty stomach, spasms of the pylorus, duodenum, a change in the shape of the stomach.

Differential diagnostics. It is carried out with chronic pancreatitis, in which pain is localized on the left above the navel with irradiation to the left (sometimes girdle pain), in blood and urine tests there is an increase in amylase, an increase in trypsin activity in the stool, steatorrhea, creatorrhea, and on ultrasound examination - an increase in the size of the pancreas and changes in its echo density. With chronic cholecystitis, in which pain is localized in the right hypochondrium, upon palpation there is pain in the projection of the gallbladder; ultrasound examination shows thickening of the wall of the gallbladder and flakes of mucus in it. With chronic enterocolitis, in which pain is localized throughout the abdomen and decreases after defecation, there is bloating, poor tolerance of milk, vegetables, fruits, unstable stools, in the coprogram - amilorrhea, steatorrhea, mucus, creatorrhoea, possibly leukocytes, erythrocytes, dysbacteriosis. With peptic ulcer disease, in which pain occurs acutely, 1-2 hours after eating, including severe pain on palpation of the abdomen, tension in the abdominal muscles; endoscopic examination reveals a deep mucosal defect surrounded by a hyperemic shaft; there may be multiple ulcers.

Treatment. You should adhere to a therapeutic and protective regime, sleep at least 8 hours at night, the head of the bed should be higher than the foot. Sharp physical exertion and heavy physical labor are contraindicated; timely treatment of carious teeth, nasopharyngeal diseases, and giardiasis is necessary. Diet therapy: nutrition should be complete and varied, contain a sufficient amount of vegetables, fruits, and dairy products. Food is taken 5-6 times a day, the last meal no later than 19.00. Dry food is not allowed. You should not take a horizontal position for 2-3 hours after eating. Highly carbonated drinks and chewing gum are contraindicated for consumption, especially on an empty stomach. Antacid therapy is carried out (Almagel, Maalox, Phosphalugel are prescribed) and antisecretory therapy (N₂-histamine blockers, ranitidine 150 mg morning and evening, M-anticholinergics, gastrocepin 35 mg 2 times a day before meals). Prescribed drugs that improve the protective properties of the mucosa. These are protective basic drugs (Venter, de-nol, before meals and at night, the tablet is chewed and washed down with water); synthetic prostaglandins (Cytotec); nonspecific mucosal protectors (actovegin, folic acid, vitamins A, E, B). Anti-Helicobacter therapy is carried out, using bismuth preparations (denol, bismofalk), antibacterial drugs (amoxacillin), antimicrobial drugs (metronidazole). If the motor-evacuation function is impaired, motilium is used; to correct the pathological reflux of duodenal contents into the stomach, adsorbents (smecta, enterosgel, wheat bran) are prescribed. Physiotherapy is prescribed: UHF, laser therapy, inductothermy.

2. Peptic ulcer of the stomach or duodenum

Peptic ulcer of the stomach or duodenum is a chronic disease, a characteristic feature of which is the formation of ulcers in the digestive tract during the period of exacerbation. The main etiological factor is Helicobacter pylori infection. An important role in the formation of pathology is played by psychosocial factors (stress, psychotrauma, conflicts in the family and school), toxic-allergic factors (frequent medication, substance abuse, smoking, food and drug allergies), hereditary-constitutional factors (genetic predisposition, asthenic physique) .

Pathogenesis. An imbalance between aggressive factors (hydrochloric acid, bile, pepsin, nicotine, NSAIDs) and protective factors of the gastric and duodenal mucosa (a mucosal barrier consisting of three layers of protection - a layer of mucus and bicarbonates, a layer of epithelial cells producing bicarbonates and mucus). Classification by localization: stomach, duodenal bulb, mixed localization; by phase: exacerbation, incomplete clinical remission, clinical remission by form: complicated, uncomplicated (bleeding, perforation, penetration, pyloric stenosis); according to the course: newly identified, often recurrent for less than 3 years, rarely recurrent for more than 3 years; according to the nature of the acid-forming function: with preserved function, with increased function, with decreased function. Clinical and endoscopic stage: fresh ulcer, beginning of epithelization of the ulcerative defect, healing of the ulcerative defect of the mucous membrane with preserved duodenitis, clinical and endoscopic remission.

Clinic. Pain of a persistent and persistent nature, localized in the epigastric or pyloroduodenal zone. The rhythm of pain in older children: hunger - pain - eating - relief - hunger. The appearance of pain at night and pain in the early morning hours is typical. The course of a peptic ulcer can be latent, and for a long time children do not complain of abdominal pain; nausea, vomiting, belching, a feeling of rapid satiety, and heaviness in the abdomen are occasionally observed. Asthenovegetative syndrome is manifested by sleep disturbance, emotional lability, irritability, arterial hypotension, and loss of appetite.

Diagnostics. Based on anamnesis, clinical and laboratory data, fibrogastroduodenoscopy with biopsy can identify an ulcer. Tests are carried out to determine Helicobacter pilori. This is enzyme immunoassay diagnostics, determination of antibodies in blood, urine, saliva, microscopy of smears - imprints of the gastric mucosa. X-ray examination is used in cases where there is a suspicion of an abnormal structure of the organs of the upper digestive tract.

1. Direct signs - niche, convergence of folds.

2. Indirect - fasting hypersecretion, bulb deformity, pyloroduodenospasm, spastic peristalsis.

Differential diagnosis performed with chronic gastritis, gastroduodenitis, hernia of the esophageal opening of the diaphragm, pathology of the biliary tract.

Treatment. Bed rest, diet No. 1a, No. 1b, then No. 1.

Treatment is directed to:

1) to suppress the aggressive properties of gastric juice. Selective blockers are used₁-cholinergic receptors: gastrocepin, pirenzepine; H blockers₂- histamine receptors: ranitidine, famotidine; antacids: almagel, phosphalugel, gastrogel;

2) to increase the protective layer of the mucous membrane. Cytoprotectors are prescribed: bismuth preparations, cytotec, sucralfate;

3) on neurohumoral regulation. Psychotropic drugs, dopamine receptor blockers are shown.

In addition, antibacterial and antiprotozoal drugs are prescribed; physiotherapy (EHF, magneto and laser therapy, hyperbaric oxygenation).

Treatment regimens for anti-Helicobacter therapy for children under 5 years of age are not prescribed. First-line therapy for newly diagnosed infection: children under 7 years old: de-nol (120 mg 2 times a day) + metronidazole (250 mg 2 times a day) + amoxacillin (500 mg 2 times a day). For children over 7 years old: de-nol (240 mg 2 times a day) + metronidazole (500 mg 2 times a day) + amoxacillin (1000 mg 2 times a day). Quality control of eradication after 6 months using endoscopic techniques.

Second-line therapy (in the absence of eradication or recurrence of peptic ulcer): children under 7 years old: de-nol (120 mg 2 times a day) + metronidazole (250 mg 2 times a day) + amoxacillin (500 mg 2 times a day) + ranitidine (150 mg 2 times a day). For children over 7 years old: de-nol (240 mg 2 times a day) + metronidazole (500 mg 2 times a day) + amoxacillin (1000 mg 2 times a day) + omeprazole (10 mg 2 times a day).

Author: Gavrilova N.V.

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