NURSING PROCESS is a method of scientifically based and practical implementation of nurses' duties in providing care to patients. This is the activity of a m/s, aimed at satisfying the physical, biological needs of the patient related to psychological, spiritual and social health, in which it is necessary to provide primary health care with available resources acceptable to both parties (m/s and the patient).
The nursing process (SP) determines the patient’s specific needs for care, helps to identify care priorities from a number of existing needs and the expected results of care, and also predicts its consequences. The SP determines the nurse's plan of action. A strategy aimed at meeting the needs of the patient, with its help, the effectiveness of the work carried out by the nurse and the professionalism of nursing intervention are assessed. And most importantly, the joint venture guarantees quality of care that can be monitored.
Patients in whom peptic ulcer disease is diagnosed for the first time, or patients with exacerbation of the disease, are treated in a hospital for 1-1.5 months.
During an exacerbation, the patient must remain in bed (you can go to the toilet, wash, sit down at the table to eat) for 2-3 weeks. With a successful course of the disease, the regime gradually expands, but the mandatory limitation of physical and emotional stress remains.
It is necessary to monitor the general condition of the patient: skin color, pulse, blood pressure, stool.
Dieting. During an exacerbation, diets No. 1A and 1B are indicated
Food must be mechanically, chemically and thermally gentle. Meals should be small, frequent (6 times a day), food should be chewed thoroughly. All dishes are prepared pureed, using water or steam, with a liquid or mushy consistency. The intervals between meals should be no more than 4 hours; a light dinner is allowed an hour before bedtime. It is necessary to avoid taking substances that increase the secretion of gastric and intestinal juices (concentrated meat broths, pickles, smoked meats, canned fish and vegetables, strong coffee). The diet should contain a sufficient amount of proteins, fats, carbohydrates, vitamins and microelements.
Monitoring the complete and timely intake of medications prescribed by a doctor.
Must be avoided psychological stress. The patient should not worry or be irritated. For increased excitability, sedatives are prescribed medicines.
It is necessary to create conditions for deep and good sleep. Sleep duration should be at least 8 hours a day.
Smoking and drinking alcohol should be prohibited.
If there is no bleeding and suspicion of ulcer degeneration, physiotherapeutic procedures are performed (paraffin baths, short-wave diathermy on the epigastric region).
In case of stomach bleeding, first of all, you need to call a doctor. The patient should be provided with complete rest and reassurance. Place an ice pack on the stomach area. To stop bleeding, hemostatic agents are administered. If all these measures do not produce results, then the patient is subject to surgical treatment.
After discharge from the hospital, the patient is advised to undergo spa treatment in a specialized sanatorium.
It is necessary to organize clinical observation; frequency of inspections - 2 times a year.
To prevent relapse of the disease, it is necessary to carry out special anti-relapse courses of treatment twice a year for 12 days (spring, autumn).
Proper organization of work and rest.
Preventive treatment for 3-5 years.
Nursing care is of considerable importance in solving these problems, however main role non-drug and drug therapy, which are prescribed by a doctor, plays a role.
Nursing care for patients includes:
Food must be mashed, crushed, squeezed, thermally, chemically processed.
Meat and fish broths;
Spicy, fried and pickled foods are prohibited;
Nursing process
Nursing process for gastric ulcer and twelve duodenum carried out in 5 stages.
The first stage is a nursing examination.
Before nursing interventions, it is necessary to question the patient and his relatives, conduct an objective study - this will allow the nurse to assess the patient’s physical and mental condition, as well as identify his problems and suspect diseases of the stomach and duodenum, including peptic ulcers, and formulate a care plan. When interviewing the patient and his relatives, it is necessary to ask questions about past illnesses and the presence of pain in the abdominal area.
Analysis of the data obtained helps to identify the patient's problems - nursing diagnosis.
Nursing examination is carried out using two methods:
· Subjectively, the patient has complaints of: severe pain in the epigastric region, occurring 30-60 minutes after eating, belching, constipation, bloating, vomiting is observed “ coffee grounds", weight loss.
· an objective method is an examination that determines the patient’s current status.
General condition of the patient:
· extremely difficult;
· moderate severity;
· satisfactory.
Patient position in bed:
· active;
· passive;
· forced.
State of consciousness (five types are distinguished):
· clear - the patient answers questions specifically and quickly;
· confused - the patient answers questions correctly, but late;
· stupor - numbness, the patient does not answer questions or does not answer meaningfully;
· stupor - pathological sleep, lack of consciousness;
coma - complete suppression of consciousness, with absence of reflexes;
· respiratory rate (RR).
· Arterial pressure(HELL).
· Pulse (Ps).
The second stage is identifying the patient’s problems
Patient problems:
· Real: pain in the epigastric region, occurring 3-4 hours after eating, night pain, weight loss, heartburn, constipation, bad dream, general weakness.
· Potential: risk of complications (gastric bleeding, perforation, penetration, pyloric stenosis, malignancy).
· Priority issue: pain in the epigastric region.
Stage three - planning nursing intervention
· To draw up a plan, the nurse needs to know: the patient’s complaints, the patient’s problems and needs, the patient’s general condition, state of consciousness, the patient’s position in bed, self-care deficits.
· Short-term goals (the patient notes that the pain has subsided) and long-term goals (the patient has no complaints at the time of discharge)
Stage four - nursing intervention
Nursing care is of considerable importance in solving these problems, but the main role is played by non-drug and drug therapy, which are prescribed by a doctor.
The nurse informs the patient and his family members about the essence of the disease, the principles of treatment and prevention, explains the progress of certain instrumental and laboratory tests and preparation for them.
Nursing care for patients with gastric and duodenal ulcers includes:
Monitoring diet compliance (table 1a, 1b, 1)
food must be mashed, crushed, squeezed, thermally, chemically processed.
Exclude rye and any fresh bread;
Meat and fish broths;
Spicy, fried and pickled foods are prohibited
The patient's symptoms: pain in the epigastric region, loss of appetite, weakness, malaise, night pain, weight loss, heartburn, constipation, poor sleep.
Actions of the nurse: create conditions for protective regime, monitor the patient’s diet, feed if necessary, follow the doctor’s orders clearly and in a timely manner.
The fifth stage is evaluating the results.
At this stage the nurse:
· ·determines goal achievement;
· · compares with the expected result;
· ·formulates conclusions;
· ·makes appropriate notes in documents (nursing medical history) about the effectiveness of the care plan.
Practical part
I conducted a practical study at the Alapaevsk ACCH in the therapeutic department. Over the past 6 months, about 15 patients diagnosed with gastric or duodenal ulcer have been admitted to the therapeutic department at the ACGB. They received help (relieved pain in the epigastric region, nausea, vomiting, heartburn)
Observation from practice
Patient B., 58 years old, is undergoing inpatient treatment in the gastroenterology department with a diagnosis of gastric ulcer, exacerbation phase.
Complaints of severe pain in the epigastric region, occurring 30-60 minutes after eating, belching of air, sometimes food, constipation, bloating, single vomiting of the color of “coffee grounds” was observed. The patient considers himself sick for 1.5 years, and the patient associates the deterioration that has occurred over the last 5 days with stress.
Objectively: the condition is satisfactory, consciousness is clear, the position in bed is active. Skin pale, subcutaneous fat is developed satisfactorily. Pulse 64 beats/min. Blood pressure 110/70 mm Hg. st, respiratory rate 18 per minute. The tongue is covered with a white coating, the abdomen is of regular shape, there is moderate tension in the anterior abdominal wall in the epigastric region.
The patient is scheduled to have a stool test for occult blood.
Based on the results obtained, we move on to the implementation of stage II of the nursing process - disrupted needs are identified, problems are identified - real, potential, priority.
Patient problems:
Present: epigastric pain; belching, flatulence; poor sleep; general weakness.
Potential:
Risk of complications (gastric bleeding, perforation, penetration, pyloric stenosis, malignancy).
Priority: pain in the epigastric region.
Short-term goal: The patient reports pain subsiding by the end of the 7th day of hospital stay.
Long-term goal: the patient does not complain of epigastric pain at the time of discharge.
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Motivation |
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1. Provide a therapeutic and protective regime. |
To improve the patient’s psycho-emotional state and prevent gastric bleeding. |
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2. Provide the patient with nutrition in accordance with diet No. 1a. |
For physical, chemical and mechanical sparing of the patient's gastric mucosa. |
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3. Teach the patient how to take prescribed medications. |
To achieve complete mutual understanding between medical personnel both the patient and the effectiveness of the drugs. |
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4. Explain to the patient the essence of his disease, talk about modern methods of diagnosis, treatment and prevention. |
To relieve anxiety and increase confidence in a favorable outcome of treatment. |
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5. Ensure proper preparation of the patient for FGDS and gastric intubation. |
To improve the efficiency and accuracy of diagnostic procedures. |
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6. Conduct a conversation with relatives about providing food with sufficient vitamins and food antacids. |
To increase the body's immune forces and reduce the activity of gastric juice. |
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7. Observe the appearance and condition of the patient (pulse, blood pressure, stool character). |
For early detection and timely provision of emergency care for complications (bleeding, perforation). |
Evaluation of effectiveness: the patient notes the disappearance of pain, demonstrates knowledge of preventing exacerbation of peptic ulcer disease.
INTRODUCTION…………………………………………………………….………3 CHAPTER 1. PROBLEMS OF Peptic Ulcer Disease of the Stomach and Duodenum at the Present Stage 5 1.1. Concept, causes of gastric and duodenal ulcers 5 1.2. Symptoms of gastric and duodenal ulcers, diagnosis 9 1.3. Treatment of peptic ulcer of the stomach and duodenum 16 CHAPTER 2. PHYSICAL PROCESS FOR Peptic ulcer of the stomach and duodenum 18 2.1. Tasks of a paramedic according to the Standards for diagnosing gastric and duodenal ulcers 18 2.2. The tasks of a paramedic in addressing issues of treatment of gastric and duodenal ulcers 20 2.3. The tasks of a paramedic in addressing issues of primary and secondary prevention of gastric and duodenal ulcers 22 CONCLUSION 24 LIST OF SOURCES USED 26
Introduction
Relevance: according to statistics today peptic ulcer duodenal ulcer affects approximately 10% of the population. It usually appears at the age of 20-30. In men, this pathology occurs approximately twice as often as in women. And the incidence among residents of megacities is several times higher than among residents of villages. 150 years have passed since Cruvelier’s classic description of gastric ulcers, but still, despite numerous studies in this area, disputes regarding both the ethnology of peptic ulcer disease and its treatment do not subside. Peptic ulcer disease - quite frequent illness. According to various statistics, it affects from 4 to 12% of the adult population. The majority of diseases occur in the 3rd-4th decade of life, and duodenal ulcers are more common in young people, and gastric ulcers are more common in young people. mature age. It has been noted that men suffer from peptic ulcers 4 times more often than women. Purpose of the work: to study and reveal the main points of the role of the paramedic in the diagnosis and treatment of peptic ulcer of the stomach and duodenum Objectives: 1. consider the problems of peptic ulcer of the stomach and duodenum at the present stage 2. reveal the concept, causes of peptic ulcer of the stomach and duodenum 3. describe symptoms of peptic ulcer of the stomach and duodenum, diagnosis 4. reveal the main points of treatment of peptic ulcer of the stomach and duodenum 5. consider the paramedic process for peptic ulcer of the stomach and duodenum. 6. reveal the tasks of a paramedic according to the standards for diagnosing gastric and duodenal ulcers. 7. consider the tasks of a paramedic in addressing issues of treatment of gastric and duodenal ulcers. 8. reveal the tasks of a paramedic in addressing issues of primary and secondary prevention of gastric and duodenal ulcers. Draw fundamental conclusions. Object of study: the problem of peptic ulcer of the stomach and duodenum. Subject of study: diagnosis and treatment of peptic ulcer of the stomach and duodenum by a paramedic. Methods used: theoretical, study of scientific and methodological literature. In the process of writing the work, 13 literary sources were studied. The structure of the work is represented by an introduction, main part, conclusion and bibliography.
Conclusion
Peptic ulcer of the stomach and duodenum is a chronic relapsing disease in which, as a result of disturbances in the nervous and humoral mechanisms that regulate secretory-trophic processes in the gastroduodenal zone, an ulcer (less often two or more ulcers) forms in the stomach or duodenum. Its course is characterized by alternating asymptomatic periods with stages of exacerbation, which usually occur in spring or autumn. Causes of peptic ulcer disease The main source of the disease is the bacterium Helicobacter Pylori, which produces substances that damage the mucous membrane and cause inflammation. Other factors predispose to the development of pathology. In conclusion, we will say once again that to prevent the appearance of Ya.B. not difficult. Compliance with personal hygiene rules, a balanced diet, refusal bad habits, a healthy lifestyle, the ability to relax and avoid stress is a guarantee wellness. Of course, infectious infection or the influence of heredity cannot be ruled out, but these reasons are less common than banal overeating or dry snacks. In the process of writing the work, we studied and revealed the main points of the role of the paramedic in the diagnosis and treatment of gastric and duodenal ulcers. We examined the problems of gastric and duodenal ulcers at the present stage. We revealed the concept and causes of gastric and duodenal ulcers. We described the symptoms of gastric and duodenal ulcers, diagnosis. We revealed the main points of treatment for gastric and duodenal ulcers. We examined the paramedic process for gastric and duodenal ulcers. The tasks of a paramedic were revealed according to the standards for diagnosing gastric and duodenal ulcers. We analyzed the tasks of a paramedic in solving the problems of treating gastric and duodenal ulcers. We analyzed the tasks of a paramedic in solving the issues of primary and secondary prevention of gastric and duodenal ulcers. The special role of the paramedic is to use modern technologies prevention, including the formation of medical activity of the population. They help to increase the motivation of patients to move from theoretical knowledge of prevention to its practical application, to become focused on active disease prevention based on a healthy lifestyle.
Bibliography
1. Beloborodova E. I., Kornetov N. A., Orlova L. A. Pathophysiological aspects of duodenal ulcer in individuals young// Clinical medicine. - 2002. - No. 7. - P. 36-39. 2. Belkov Yu. A., Shinkevich E. V., Makeev A. G., Bogdanova M. G., Dudnik A. V., Kyshtymov S. A. Treatment tactics for patients with chronic ischemia of the lower extremities with erosive-ulcerative duodenitis // Surgery. - 2004. - No. 3. - P. 38-41. 3. Belyaev A.V., Spizhenko Yu.P., Belebezev G.I. et al. Intensive therapy for gastrointestinal bleeding // Ukr. magazine minimally invasive and an endoscope. surgery. - 2001. - T. 5, No. 1. - P. 24-25. 4. Vertkin A. L., Masharova A. A. Treatment of peptic ulcer in modern clinic// Attending physician, October 2000, No. 8. - pp. 14-19. 5. Isakov V. A, Shcherbakov P. L. Comments on the Maastricht Agreement." - 2, 2000//V International Symposium "Diagnostics and Treatment of Diseases Associated with H. pylori"., Pediatrics, No. 2, 2002. - C 5-7. 6. Kokueva O. V., Stepanova L. L., Usova O. A. et al. Pharmacotherapy of peptic ulcer disease taking into account concomitant pathology gastrointestinal tract // Experimental and practical gastroenterology, 1/2002. - P. 49-52. 8. Lapina T. L. Modern approaches to the treatment of acid-dependent and H. pylori - associated diseases // Clinical perspectives of gastroenterology, hepatology. 1, 2001. - 21-27. 12. Pimanov S.I. Esophagitis, gastritis, and peptic ulcer - N. Novgorod, 2000. - 376 p. 13. Collection dietary nutrition sanatoriums of the gastrointestinal tract for peptic ulcer M 2011 - 303 p.
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GBOU SPO "Krasnodar Regional Basic Medical College» Ministry of Health of the Krasnodar Territory
Cyclic commission “General Medicine”
Graduate work
Study of the role of the paramedic in the early diagnosis, treatment and prevention of gastric and duodenal ulcers in rural areas
Krasnodar 2015
ANNOTATION
INTRODUCTION
1.1.1 Stomach
1.2 Etiology and pathogenesis
1.3 Classification
1.5 Diagnostics
1.6 Differential diagnosis
1.7 Complications
1.8 Treatment
1.9 Prevention
CHAPTER 2. STUDY OF THE ROLE OF THE FEDERAL SHER IN EARLY DIAGNOSIS, TREATMENT AND PREVENTION OF GASTRIC AND DUODENAL ULCER IN RURAL CONDITIONS
2.1 Analysis of the incidence of gastric and duodenal ulcers according to Art. Novokorsunskaya for 2013-2014
2.2 Activities of a paramedic for the prevention of peptic ulcers in the Novokorsun district hospital
LIST OF SOURCES USED
ANNEX 1
APPENDIX 2
ANNOTATION
The research was carried out in the thesis professional activity paramedic in the early diagnosis, treatment and prevention of gastric and duodenal ulcers in rural areas. Currently, the issues of studying peptic ulcer disease in rural areas are very relevant. This determined the choice of this research topic.
The hypothesis of the study was the assumption that the paramedic, due to his professional duties, has closer contact with patients, therefore he has a leading role in the prevention of peptic ulcer disease.
Practical part thesis was carried out on the basis of the Novokorsun district hospital.
The thesis consists of content, introduction, two chapters, conclusions, conclusion, list of sources used and applications. The total volume of the thesis was 73 pages of typewritten text, including appendices. The work contains 13 figures, 1 table, 3 appendices. The list of used literature includes 17 titles.
ulcerative diagnosis prevention paramedic
INTRODUCTION
Relevance of the problem.
In the general structure of diseases of the digestive system, the leading place is occupied by the pathology of the stomach and duodenum. Approximately 60-70% of adults develop peptic ulcers, chronic gastritis, duodenitis begins in childhood and adolescence, but they are especially often observed at a young age (20-30 years) and mainly in men.
Peptic ulcer of the stomach and duodenum is a common disease of the gastrointestinal tract. Available statistics indicate a high percentage of patients in all countries. Over the course of a lifetime, up to 20% of the adult population suffers from this disease. In industrialized countries, 6-10% of the adult population suffers from peptic ulcers, with duodenal ulcers predominating compared to gastric ulcers. In Ukraine, about 5 million people are registered with peptic ulcers of the stomach and duodenum. Peptic ulcer of the stomach and duodenum affects people of the most working age - from 20 to 50 years. The disease is more common in men than women (male to female ratio is 4:1). At a young age, duodenal ulcers are more common, and at older ages, gastric ulcers are more common. Among city residents, peptic ulcer disease is more common than among the rural population.
Currently, given the relevance of the problem, its not only medical, but also social significance, the pathology of the stomach and duodenum, pathogenesis, new methods of diagnosis, treatment and prevention of gastric diseases attract the attention not only of clinicians and therapists, but due to significant “rejuvenation” » diseases and pediatricians, and geneticists, pathophysiologists, immunologists, and other specialists.
Considerable experience has been accumulated in the study of gastric and duodenal ulcers. Meanwhile, many aspects of this problem have not yet been resolved. In particular, the issues of studying peptic ulcer disease in rural areas are very relevant. This determined the choice of this research topic.
Area of research: professional activity of a paramedic in rural areas.
The objects of the study were:
Scientific and educational literature;
Materials from specialized Internet sites;
Data from the report of the chief therapist Art. Novokorsunskaya;
Patient questionnaires therapeutic department Novokorsun district hospital suffering from peptic ulcer of the stomach and duodenum.
Subject of the study: statistical data on the incidence of gastric and duodenal ulcers for 2013-2014 in Art. Novokorsunskaya.
Purpose of the work: to analyze the impact of the professional activity of a paramedic on the effectiveness of early diagnosis, treatment and prevention of gastric and duodenal ulcers in rural areas.
Research hypothesis: qualitatively conducted preventive actions lead to the prevention of the development of gastric and duodenal ulcers.
1. Study educational and scientific literature on the problem of peptic ulcer disease;
2. Conduct an analysis of the incidence of gastric and duodenal ulcers based on statistical data according to Art. Novokorsunskaya for 2013-2014;
3. Create a booklet with information about the prevention of peptic ulcers for the population living in the village. Novokorsunskaya.
Research methods:
General theoretical;
Statistical;
Analytical.
Practical significance: a detailed disclosure of the material on the topic of the thesis “Study of the role of the paramedic in the early diagnosis, treatment and prevention of gastric and duodenal ulcers in rural areas” will improve the quality of paramedic care.
Scientific novelty:
1. For the first time, a survey was conducted of patients in the therapeutic department of the Novokorsun district hospital suffering from peptic ulcer disease.
2. A booklet was created with information on the prevention of peptic ulcers for the population living in the village. Novokorsunskaya.
3. Memos for patients have been developed: “Diet for patients with gastric and duodenal ulcers in the acute stage.”
Work structure.
The thesis consists of an introduction, two chapters, conclusions, a conclusion, a list of sources used and applications. The total volume of the thesis was 73 pages of typewritten text, including appendices. The work contains 1 table, 13 figures, 3 appendices. The list of sources used includes 17 items.
CHAPTER 1. GENERAL CHARACTERISTICS OF Peptic Ulcer of the Stomach and Duodenum
Peptic ulcer is a chronic, cyclical disease characterized by the occurrence during an exacerbation of an ulcerative defect in the mucous membrane of the stomach or duodenum.
1.1 Anatomical and physiological features of the stomach and duodenum
Before moving on to a direct examination of gastric and duodenal ulcers, it is necessary to recall the anatomy and physiology of the initial section of the gastrointestinal tract.
1.1.1 Stomach
Structure. Stomach, ventriculus (Greek - gaster) - a hollow muscular organ located in abdominal cavity, mainly in the left hypochondrium. Its lumen is much wider than that of other hollow organs digestive system. The shape of the stomach is individual and depends on the body type. In addition, for the same person it varies depending on the degree of filling. The capacity of the stomach in an adult varies from 1.5 to 4 liters.
The stomach has two surfaces: anterior and posterior, which merge into one another along the edges. The edge facing upward is called the lesser curvature, the edge facing downwards is called the greater curvature. The stomach has several parts. The part bordering the esophagus is called the cardiac part. To the left of it is a dome-shaped part protruding upward, called the fundus of the stomach. The largest section, the body of the stomach, borders the cardiac part and the bottom. The pyloric (pyloric) part passes into the duodenum. At the junction there is a sphincter that regulates the process of moving food into the small intestine - the pyloric sphincter.
The wall of the stomach has three membranes: mucous, muscular and serous. The mucous membrane forms numerous folds. It is lined with single-layer prismatic epithelium. It contains a large number (up to 35 million) glands. There are glands of the cardiac part, the body and the pyloric region. They consist of various types cells: chief cells secrete pepsinogen; parietal, or parietal, cells produce hydrochloric acid; mucous, or accessory, cells (mucocytes) - secrete mucus (prevail in the cardiac and pyloric glands).
In the lumen of the stomach, the secretions of all glands mix and gastric juice is formed. Its amount per day reaches 1.5-2.0 liters. This amount of juice allows you to liquefy and digest incoming food, turning it into pulp (chyme).
The muscular lining of the stomach is composed of three layers of smooth muscle tissue, located in different directions. The outer layer of the muscle membrane is longitudinal, the middle layer is circular; oblique fibers are adjacent to the mucous membrane.
The serous membrane (peritoneum) covers the stomach from the outside on all sides, therefore, it can change its shape and volume.
Composition of gastric juice. The acidity of gastric juice (pH) at the peak of digestion is 0.8-1.5; at rest - 6. Consequently, during digestion it represents a highly acidic environment. The composition of gastric juice includes water (99-99.5%), organic and inorganic substances.
Organic substances are represented mainly by various enzymes and mucin. The latter is produced by mucous cells and promotes better envelopment of food bolus particles, protects the mucous membrane from the effects of aggressive factors of gastric juice.
The main enzyme in gastric juice is pepsin. It is produced by chief cells as the inactive proenzyme pepsinogen. Under the influence of hydrochloric acid of gastric juice and air located in the fundus, a certain amino acid sequence is cleaved from pepsinogen, and it becomes an active enzyme capable of catalyzing reactions of hydrolysis (breakdown) of proteins. Pepsin activity is observed only in a strongly acidic environment (pH 1-2). Pepsin breaks the bonds between two adjacent amino acids (peptide bonds). As a result, the protein molecule is split into several molecules of smaller size and mass (polypeptides). However, they do not yet have the ability to pass through the epithelium of the gastrointestinal tract and be absorbed into the blood. Their further digestion occurs in the small intestine. It should be mentioned that 1 g of pepsin within 2 hours is capable of hydrolyzing 50 kg of egg albumin and curdling 100,000 liters of milk.
In addition to the main enzyme - pepsin, gastric juice also contains other enzymes. For example, gastrixin and rennin, which are also enzymes that break down proteins. The first of them is active at moderate acidity of gastric juice (pH 3.2-3.5); the second - in a slightly acidic environment, with an acidity level close to neutral (pH 5-6). Gastric lipase breaks down fats, but its activity is insignificant. Renin and gastric lipase are most active in infants. They ferment the hydrolysis of proteins and fats in mother's milk, which is facilitated by the close to neutral environment of the gastric juice of infants (pH about 6).
Inorganic substances of gastric juice include: HC1, SO42-, Na+, K+, HCO3-, Ca2+ ions. The main inorganic substance in juice is hydrochloric acid. It is secreted by the parietal cells of the gastric mucosa and performs a number of functions necessary to ensure the normal digestion process. Hydrochloric acid creates an acidic environment for the formation of pepsin from pepsinogen. It also ensures the normal functioning of this enzyme. It is this level of acidity that ensures denaturation (loss of structure) of food proteins, which facilitates the work of enzymes. The bactericidal properties of gastric juice are also due to the presence of hydrochloric acid in its composition. Not every microorganism is able to withstand such a concentration of hydrogen ions, which is created in the lumen of the stomach due to the work of parietal cells.
The glands of the stomach synthesize a special substance - intrinsic Castle factor. It is necessary for the absorption of vitamin B12: the intrinsic factor of Castle combines with the vitamin, and the resulting complex passes from the lumen of the gastrointestinal tract into the epithelial cells of the small intestine and then into the blood. In the stomach, iron is processed with hydrochloric acid and converted into easily absorbed forms, which plays a large role in the synthesis of hemoglobin in red blood cells. With a decrease in the acid-forming function of the stomach and a decrease in the production of Castle factor (with gastritis with reduced secretory function), anemia often develops.
Motor function of the stomach. Thanks to contractions of the muscular membrane, food in the stomach is mixed, processed by gastric juice, and passes into the small intestine. There are tonic and peristaltic contractions. Tonic contractions adapt the stomach to the volume of incoming food, and peristaltic contractions are necessary for mixing and evacuation of the contents. The latter process occurs gradually. The chyme passes into the duodenum in portions as the hydrochloric acid contained in the food gruel is neutralized by the secretions of the liver, pancreas, and intestinal juice. Only after this the pyloric sphincter opens for the next portion. Muscle movements in the opposite direction are observed when eating poor quality food, containing a large amount of aggressive substances that irritate the mucous membrane. As a result, a gag reflex occurs. Food stays in the human stomach from 1.5-2 to 10 hours, depending on its chemical composition and consistency.
In addition, there are so-called hungry contractions, which are observed in an empty stomach with a certain frequency. They are believed to be involved in the formation of hunger.
It should be especially emphasized that between the body and the pyloric part there is a physiological antral sphincter, which separates these parts. It is formed due to tonic contraction of the circular layer of the muscular layer. Thanks to this distinction, the main processes of food digestion in the stomach occur above the pyloric region (the cardial part, the fundus and the body of the stomach form the so-called digestive sac). From the digestive sac, digested food enters in small portions into the pyloric region, which is called the evacuation canal. Here, the incoming food is mixed with mucus, which leads to a significant decrease in the acidic reaction of the chyme. The food then moves into the small intestine. Thus, the following processes occur in the stomach:
1) accumulation of food;
2) mechanical processing of food masses (their mixing);
3) denaturation of proteins under the influence of hydrochloric acid;
4) digestion of proteins under the influence of pepsin;
5) continuation of the breakdown of carbohydrates inside the bolus of food under the action of salivary amylase (when this enzyme comes into contact with gastric juice, it is inactivated);
6) bactericidal treatment of food with hydrochloric acid;
7) formation of chyme (food gruel);
8) conversion of iron into easily absorbed forms and synthesis internal factor Kastla - antianemic function;
9) advancement of chyme into the small intestine.
I. P. Pavlov identified three main phases of gastric juice secretion:
1) the brain phase, in which “appetizing gastric juice” is secreted by the sight, smell of food, or its presence in the oral cavity; the qualitative and quantitative composition of gastric juice in this phase does not depend on the type and quantity of food;
2) the gastric phase, when juice is released during the digestion of food in the stomach; the qualitative and quantitative composition of the juice in this phase directly depends on the type and quantity of food;
3) the intestinal phase, which is ensured by the influence of intestinal receptors on the gastric glands; stimulation of the gastric glands occurs as a result of the entry into the duodenum of insufficiently physically and chemically processed chyme, which allows making the necessary adjustments to gastric secretion.
Regulation of the activity of the stomach occurs due to nervous and humoral mechanisms. The parasympathetic nervous system increases the secretion of the gastric glands and the motor activity of the muscular membrane, the sympathetic has the opposite effect.
Humoral regulation consists in changing the amount of juice secreted under the influence of various chemical substances. Glucose and amino acids absorbed into the blood reduce secretion. Substances that increase the secretion of gastric juice are gastrin and histamine. They are produced by cells of the gastric mucosa. Substances such as secretin and cholecystokinin inhibit secretion. The quantity and quality of juice also depend on the nature of the food taken. For example, when eating protein foods, the amount of pepsin and hydrochloric acid increases.
1.1.2 Duodenum
Structure. The duodenum is the initial section small intestine, which starts from the pylorus of the stomach and ends at the confluence with jejunum. It received the name “duodenum” due to its length, as it has about 12 finger diameters. Its length is about 30 cm, the diameter of the widest part (ampull) is about 4.7 cm. The duodenum has the shape of a horseshoe, covering the pancreas, so it has several parts: the upper part, the descending part, the horizontal part and the ascending part (terminal section ). The upper part forms the ampulla of the duodenum, it is the initial section and starts from the pylorus of the stomach, it goes to the right and back, in relation to the stomach, forms a bend and passes into the next section of the intestine. The descending part, located to the right of the spinal column, descends down to the level of the 3rd lumbar vertebra, the next bend is formed, directing the intestine to the left and forming the horizontal part of the intestine. The horizontal part, after crossing the inferior vena cava and the abdominal aorta, makes a bend, rising up to the level of the 2nd lumbar vertebra; this part is called the ascending part of the duodenum.
The wall of the duodenum contains 3 membranes:
1. The serous membrane, which is the outer membrane, is a continuation of the serous membrane of the stomach;
2. The muscular layer, which is the middle layer, consists of muscle bundles located in two directions, therefore it is represented by 2 layers: the outer layer is the longitudinal layer and the inner layer is circular;
3. The mucous membrane is inner layer. In the upper part of the duodenum, the mucous membrane forms longitudinal folds, and in the horizontal and descending part, circular folds are formed. The longitudinal fold on the descending part ends with a tubercle, which is called the major duodenal papilla (Papilla of Vater), and at its apex the common bile duct and pancreatic duct. The flow of bile or pancreatic juice through the nipple of Vater into the duodenum is regulated by the sphincter of Oddi. Also, the mucous membrane of the duodenum forms cylindrical outgrowths, which are called intestinal villi. Each villus, in its central part, contains blood vessels and lymphatic vessels, which are involved in the suction function. At the base of the villi, intestinal glands open, which produce duodenal juice (it contains enzymes necessary for digestion) and hormones (secretin, gastrin, cholecystokinin).
Functions of the duodenum:
1. Secretory function is the secretion of intestinal juice by the intestinal glands, which contains enzymes (enterokinase, alkaline peptidase and others) and hormones (secretin, gastrin, cholecystokinin) involved in digestion;
2. Motor function is carried out through contraction of the muscular layer of the intestine, as a result of which the chyme is mixed with digestive juice (intestinal juice, bile, pancreatic juice), it contains everything necessary for the final digestion of fats and carbohydrates received from food;
3. Evacuation function consists of evacuation (promotion) of intestinal contents to the following sections of the intestine.
1.2 Etiology and pathogenesis
Currently, a group of factors has been identified that predispose to the development of gastric and duodenal ulcers.
Group I is associated with functional and morphological changes in the stomach and duodenum, leading to disruption gastric digestion and a decrease in mucosal resistance with subsequent formation of peptic ulcers.
Group II includes disorders of regulatory mechanisms: nervous and hormonal.
Group III is characterized by constitutional and hereditary characteristics.
Group IV is associated with exposure to environmental factors.
Group V is associated with concomitant diseases and medications.
Currently, a number of exogenous and endogenous factors are known that contribute to the occurrence and development of gastroduodenal ulcers.
Exogenous factors include:
Eating disorder;
Bad habits (smoking, alcohol);
Neuropsychic stress;
Professional factors and lifestyle;
Drug effects (the following drugs have the greatest damaging effect on the gastric mucosa: non-steroidal anti-inflammatory drugs - aspirin, indomethacin, corticosteroids, antibacterial agents, iron, potassium supplements, etc.).
Endogenous factors include:
Genetic predisposition;
Chronic Helicobacter gastritis;
Metaplasia of the gastric epithelium of the duodenum, etc.
Among them, the most significant is hereditary predisposition. It is detected in 30-40% of patients with duodenal ulcers and much less frequently in cases of gastric ulcers. It has been established that the prevalence of peptic ulcer disease in relatives of probands is 5-10 times higher than in relatives healthy people(F.I. Komarov, A.V. Kalinin, 1995). Hereditary ulcers are more likely to worsen and bleed more often. Predisposition to duodenal ulcers is transmitted through the male line.
The following genetic markers of peptic ulcer disease are identified:
An increased number of parietal cells in the gastric glands and, as a result, persistent high level hydrochloric acid in gastric juice; high blood serum content of pepsinogens I, II and the so-called “ulcerogenic” fraction of pepsinogen in the gastric contents;
Increased release of gastrin in response to food intake; increased sensitivity of parietal cells to gastrin and disruption of the mechanism feedback between the production of hydrochloric acid and the release of gastrin;
The presence of 0 (I) blood group, which increases the risk of developing gastric and duodenal ulcers by 35% compared to persons with other blood groups;
Genetically determined deficiency in gastric mucus of fucoglycoproteins - the main gastroprotectors;
Product Violation secretory immunoglobulin A;
Absence of the intestinal component and decreased alkaline phosphatase B index.
The main etiological factors of gastric and duodenal ulcers are the following:
Helicobacter infection. Currently, this factor is recognized by most gastroenterologists as leading in the development of peptic ulcer disease. Helicobacter infection is one of the most common infections. This microorganism is the cause of chronic Helicobacter pylori gastritis, as well as a leading factor in the pathogenesis of gastric and duodenal ulcers, low-grade gastric lymphoma and gastric cancer. Helicobacter are considered class I carcinogens. The occurrence of duodenal ulcers in almost 100% of cases is associated with infection and colonization of Helicobacter, and gastric ulcers are caused by this microorganism in 80-90% of cases.
Acute and chronic psycho-emotional stressful situations. Domestic pathophysiologists have long paid great attention to this etiological factor in the development of peptic ulcer disease. With the clarification of the role of Helicobacter, neuropsychic stressful situations began to be given much less importance, and some scientists began to believe that peptic ulcer disease is not associated with this factor at all. However, clinical practice knows many examples of the leading role of nervous shocks, psycho-emotional stress in the development of peptic ulcer disease and its exacerbations. Theoretical and experimental substantiation of the enormous importance of the neuropsychic factor in the development of peptic ulcer disease was made in the fundamental works of G. Selye on the general adaptation syndrome and the influence of “stress” on the human body.
Nutritional factor. Currently, it is believed that the role of the nutritional factor in the development of gastric and duodenal ulcers is not only not decisive, but has not been strictly proven at all. However, it is assumed that irritating, very hot, spicy, coarse, too hot or cold foods cause excessive gastric secretion, including excessive formation of hydrochloric acid. This may contribute to the implementation of the ulcerogenic effects of other etiological factors.
Abuse of alcohol and coffee, smoking. The role of alcohol and smoking in the development of peptic ulcer disease has not been definitively proven. The leading role of these factors in ulcerogenesis is problematic, if only because peptic ulcer disease is very common among people who do not drink alcohol or smoke and, on the contrary, does not always develop in those who suffer from these bad habits.
However, it has been definitely established that peptic ulcers of the stomach and duodenum occur 2 times more often in smokers compared to non-smokers. Nicotine causes constriction of gastric vessels and ischemia of the gastric mucosa, enhances its secretory ability, causes hypersecretion of hydrochloric acid, increases the concentration of pepsinogen-I, accelerates the evacuation of food from the stomach, reduces pressure in the pyloric region and creates conditions for the formation of gastroduodenal reflux. Along with this, nicotine inhibits the formation of the main protective factors of the gastric mucosa - gastric mucus and prostaglandins, and also reduces the secretion of pancreatic bicarbonates.
Alcohol also stimulates the secretion of hydrochloric acid and disrupts the formation of protective gastric mucus, significantly reduces the resistance of the gastric mucosa and causes the development of chronic gastritis.
Excessive coffee consumption has an adverse effect on the stomach, which is due to the fact that caffeine stimulates the secretion of hydrochloric acid and contributes to the development of ischemia of the gastric mucosa.
Alcohol abuse, coffee and smoking may not be the root causes of gastric and duodenal ulcers, but they undoubtedly predispose to its development and cause exacerbation of the disease (especially alcoholic excesses).
The influence of drugs. There is a whole group of drugs known that can cause the development of acute gastric or (less commonly) duodenal ulcers. This acetylsalicylic acid and other non-steroidal anti-inflammatory drugs (primarily indomethacin), reserpine, glucocorticoids.
Currently, a point of view has emerged that the above-mentioned drugs cause the development of acute gastric or duodenal ulcers or contribute to the exacerbation of chronic ulcers.
As a rule, after stopping taking the ulcerogenic drug, the ulcers heal quickly.
Diseases contributing to the development of peptic ulcer. The following diseases contribute to the development of peptic ulcers:
Chronic obstructive bronchitis, bronchial asthma, pulmonary emphysema (with these diseases respiratory failure, hypoxemia, ischemia of the gastric mucosa and a decrease in the activity of its protective factors develop);
Diseases of cardio-vascular system, accompanied by the development of hypoxemia and ischemia of organs and tissues, including the stomach;
Cirrhosis of the liver;
Diseases of the pancreas.
Pathogenesis. Currently, it is generally accepted that peptic ulcer of the stomach and duodenum develops as a result of an imbalance between the factors of aggression of the gastric juice and the factors of protection of the mucous membrane of the stomach and duodenum towards the predominance of aggression factors (Table 1). Normally, the balance between the factors of aggression and defense is maintained by the coordinated interaction of the nervous and endocrine systems.
Pathogenesis of peptic ulcer according to Ya. D. Vitebsky. The development of peptic ulcer according to Ya. D. Vitebsky (1975) is based on chronic disorder duodenal patency and duodenal hypertension. The following forms of chronic disturbance of duodenal patency are distinguished:
Arteriomesenteric compression (compression of the duodenum by the mesenteric artery or mesenteric lymph nodes);
Distal periduodenitis (as a result of inflammatory and cicatricial lesions of the Treitz ligament);
Proximal perijunitis;
Proximal periduodenitis;
Total cicatricial periduodenitis.
With subcompensated chronic disturbance of duodenal patency (depletion of duodenal motility and increased pressure in it), functional insufficiency of the pylorus, antiperistaltic movements of the duodenum, and episodic discharge of duodenal alkaline contents with bile into the stomach develop. Due to the need to neutralize it, the production of hydrochloric acid increases, this is facilitated by the activation of gastrin-producing cells by bile and an increase in gastrin secretion. Acidic gastric contents enter the duodenum, causing the development of first duodenitis, then duodenal ulcers.
Table 1 The role of aggressive and protective factors in the development of peptic ulcer disease (according to E.S. Ryss, Yu.I. Fishzon-Ryss, 1995)
|
Protective factors: |
Aggressive factors: |
|
|
1. Resistance of the gastroduodenal system: Protective mucous barrier; Active regeneration of the surface epithelium; Optimal blood supply. 2. Antroduodenal acid brake. 3. Anti-ulcerogenic nutritional factors. 4. Local synthesis of protective prostaglandins, endorphins and enkephalins. |
1. Hyperproduction of hydrochloric acid and pepsin not only during the day, but also at night: Parietal cell hyperplasia; Chief cell hyperplasia; Vagotonia; Increasing the sensitivity of the gastric glands to nervous and humoral regulation. 2. Helicobacter pylori infection. 3. Proulcerogenic nutritional factors. 4. Duodenogastric reflux, gastroduodenal dysmotility. 5. Reverse diffusion of H +. 6. Autoimmune aggression. |
Neuroendocrine regulation, genetic factors
In case of decompensated chronic disturbance of duodenal patency (depletion of duodenal motility, duodenal stasis), constant gaping of the pylorus and reflux of duodenal contents into the stomach are observed. It does not have time to be neutralized, alkaline contents dominate in the stomach, intestinal metaplasia of the mucous membrane develops, the detergent effect of bile on the protective layer of mucus is manifested, and a stomach ulcer is formed. According to Ya. D. Vitebsky, chronic disturbance of duodenal patency is present in 100% of patients with gastric ulcer, and in 97% of patients with duodenal ulcer.
1.3 Classification
In clinical practice, a working classification of peptic ulcer disease is used, reflecting its main characteristics.
1. By etiology:
Associated with Helicobacter pylori;
Not associated with Helicobacter pylori.
2. By localization:
Gastric ulcer: cardiac and subcardial sections, body of the stomach, antrum, pyloric canal;
Duodenal ulcer: bulb, sub-bulb (extra-bulb ulcers);
Combined ulcers of the stomach and duodenum.
3. By type of ulcers:
Singles;
Multiple.
4. By size (diameter) of ulcers:
Small, up to 0.5 cm in diameter;
Medium, with a diameter of 0.5-1 cm;
Large, 1.1-2.9 cm in diameter;
Giant ulcers, with a diameter of 3 cm or more - for stomach ulcers, more than 2 cm - for duodenal ulcers.
5. According to the clinical course:
Typical;
Atypical:
· atypical pain syndrome;
painless, but with other clinical manifestations;
· asymptomatic.
6. According to the level of gastric secretion:
With increased secretion;
Normal secretion;
Decreased secretion.
7. According to the nature of the flow:
Newly diagnosed peptic ulcer;
Relapsing course:
· with rare, 1-2 times every 2-3 years or less, exacerbations;
· annual exacerbations;
Frequent exacerbations (2 times a year or more often).
8. According to the stage of the disease:
Exacerbation;
Remission:
· clinical;
· anatomical: epithelization, scarring (red scar stage and white scar stage);
· functional.
9. Based on the presence of complications:
Bleeding;
Penetration;
Perforation;
Stenosis;
Malignization.
1.4 Clinical picture and course
Pre-ulcerative period. In most patients, the development of a typical clinical picture of the disease with a formed ulcer of the stomach and duodenum is preceded by a pre-ulcer period (V. M. Uspensky, 1982). The pre-ulcer period is characterized by the appearance of ulcer-like symptoms, however, during endoscopic examination it is not possible to determine the main pathomorphological substrate of the disease - the ulcer. Patients in the pre-ulcer period complain of pain in the epigastric region on an empty stomach ("hungry" pain), at night ("night" pain) 1.5 - 2 hours after eating, heartburn, and sour belching.
On palpation of the abdomen, local pain is noted in the epigastrium, mainly on the right. High secretory activity of the stomach (hyperaciditis), increased content of pepsin in gastric juice on an empty stomach and between meals, a significant decrease in antroduodenal pH, accelerated evacuation of gastric contents into the duodenum (according to FEGDS and fluoroscopy of the stomach) are determined.
As a rule, such patients have chronic Helicobacter pylori gastritis or gastroduodenitis.
Not all researchers agree with the identification of the pre-ulcer period (condition). A. S. Loginov (1985) suggests calling patients with the above-described symptom complex a group increased risk for peptic ulcer disease.
Typical clinical picture.
Subjective manifestations. The clinical picture of peptic ulcer disease has its own characteristics associated with the location of the ulcer, the age of the patient, the presence of concomitant diseases and complications. However, in any situation, the leading subjective manifestations of the disease are pain and dyspeptic syndromes.
Pain syndrome. Pain is the main symptom of peptic ulcer and is characterized by the following features.
Localization of pain. As a rule, pain is localized in the epigastric region, and with a gastric ulcer - mainly in the center of the epigastrium or to the left of the midline, with an ulcer of the duodenum and prepyloric zone - in the epigastrium to the right of the midline.
With ulcers of the cardiac part of the stomach, atypical localization of pain behind the sternum or to the left of it (in the precordial region or the region of the apex of the heart) is quite often observed. In this case, a thorough differential diagnosis of angina pectoris and myocardial infarction should be carried out, with mandatory electrocardiographic examination. When the ulcer is localized in the postbulbar region, pain is felt in the back or right epigastric region.
Time of onset of pain. In relation to the time of eating, pain is distinguished between early, late, night and “hungry”. Early are pains that occur 0.5-1 hour after eating, their intensity gradually increases; the pain bothers the patient for 1.5-2 hours and then gradually disappears as the gastric contents are evacuated. Early pain is typical for ulcers localized in the upper parts of the stomach.
Late pain appears 1.5-2 hours after eating, night pain - at night, hungry pain - 6-7 hours after eating and stops after the patient eats again and drinks milk. Late, night, hungry pains are most typical for the localization of ulcers in the antrum and duodenum. Hunger pain is not observed in any other disease.
It should be remembered that late pain can also occur with chronic pancreatitis, chronic enteritis, and nighttime - for pancreatic cancer.
Nature of pain. Half of the patients have pain of low intensity, dull, in approximately 30% of cases it is intense. The pain can be aching, drilling, cutting, cramping. The pronounced intensity of pain during exacerbation of peptic ulcer disease requires differential diagnosis with an acute abdomen.
Frequency of pain. Peptic ulcer disease is characterized by periodic occurrence of pain. An exacerbation of peptic ulcer disease lasts from several days to 6-8 weeks, then a remission phase begins, during which patients feel well and are not bothered by pain.
Pain relief. Characteristic is a decrease in pain after taking antacids, milk, after eating (“hunger” pain), often after vomiting.
Seasonality of pain. Exacerbations of peptic ulcer disease are more often observed in spring and autumn. This “seasonality” of pain is especially characteristic of duodenal ulcers.
The appearance of pain during peptic ulcer disease is due to:
Irritation by hydrochloric acid of sympathetic nerve endings in the area of the bottom of the ulcer;
Motor disorders of the stomach and duodenum (pylorospasm and duodenospasm are accompanied by increased pressure in the stomach and increased contraction of its muscles);
Vasospasm around the ulcer and the development of ischemia of the mucous membrane;
Reducing the threshold of pain sensitivity during inflammation of the mucous membrane.
Dyspeptic syndrome. Heartburn- one of the most common and characteristic symptoms peptic ulcer disease. It is caused by gastroesophageal reflux and irritation of the esophageal mucosa by gastric contents rich in hydrochloric acid and pepsin.
Heartburn can occur at the same time after eating as pain. But in many patients it is not possible to note the connection between heartburn and food intake. Sometimes heartburn may be the only subjective manifestation of a peptic ulcer.
Therefore, in case of persistent heartburn, it is advisable to perform FEGDS to exclude peptic ulcer disease. However, we must remember that heartburn can occur not only with peptic ulcer disease, but also with calculous cholecystitis, chronic pancreatitis, gastroduodenitis, isolated cardiac sphincter insufficiency, and diaphragmatic hernia. Persistent heartburn can also occur with pyloric stenosis due to increased intragastric pressure and the manifestation of gastroesophageal reflux.
Belching- enough common symptom peptic ulcer disease. The most typical belching is sour; it occurs more often with a mediogastric ulcer than with a duodenal ulcer. The appearance of belching is caused simultaneously by insufficiency of the cardia and antiperistaltic contractions of the stomach. It should be remembered that belching is also extremely common with diaphragmatic hernia.
Vomiting and nausea. As a rule, these symptoms appear during the period of exacerbation of peptic ulcer disease. Vomiting is associated with increased tone vagus nerve, increased gastric motility by gastric hypersecretion. Vomiting occurs at the “height” of pain (during the period of maximum pain), vomit contains acidic gastric contents. After vomiting, the patient feels better, the pain significantly weakens and even disappears. Repeated vomiting is characteristic of pyloric stenosis or severe pylorospasm. Patients often induce vomiting to relieve their condition.
Nausea is characteristic of mediogastric ulcers (but is usually associated with concomitant gastritis), and is also often observed with postbulbar ulcers. At the same time, nausea, as E. S. Ryss and Yu. I. Fishzon-Ryss point out (1995), is completely “uncharacteristic of an ulcer of the duodenal bulb and rather even contradicts this possibility.”
Appetite in case of peptic ulcer it is usually good and may even be increased. With pronounced pain syndrome patients try to eat rarely and even refuse to eat for fear of pain after eating. A decrease in appetite is observed much less frequently.
Impaired motor function of the large intestine.
Half of patients with peptic ulcer experience constipation, especially during exacerbation of the disease. Constipation is caused by the following reasons:
Spasmodic contractions of the colon;
A diet poor in plant fiber and, as a result, lack of intestinal stimulation;
Decreased physical activity;
Taking antacids calcium carbonate, aluminum hydroxide.
Data from an objective clinical study. On examination, an asthenic (usually) or normosthenic body type attracts attention. The hypersthenic type and excess body weight are not very typical for patients with peptic ulcer disease.
Signs of autonomic dysfunction with a clear predominance of the tone of the vagus nerve are extremely characteristic: cold, wet palms, marbling of the skin, distal limbs; tendency to bradycardia; tendency to arterial hypotension. The tongue of patients with peptic ulcer is usually clean. With concomitant gastritis and severe constipation, the tongue may be coated.
Palpation and percussion of the abdomen with uncomplicated peptic ulcer reveals the following symptoms:
Moderate, and in the period of exacerbation, severe pain in the epigastrium, usually localized. With a gastric ulcer, the pain is localized in the epigastrium along the midline or on the left, with a duodenal ulcer - more on the right;
Percussion pain is Mendel's symptom. This symptom is detected by abrupt percussion with a finger bent at a right angle along symmetrical areas of the epigastric region. According to the localization of the ulcer, local, limited pain appears during such percussion. Sometimes the pain is more pronounced when you inhale. Mendel's symptom usually indicates that the ulcerative defect is not limited to the mucous membrane, but is localized within the wall of the stomach or duodenum with the development of a peri-process;
Local protective tension of the anterior abdominal wall, more typical for duodenal ulcers during exacerbation of the disease. The origin of this symptom is explained by irritation of the visceral peritoneum, which is transmitted to the abdominal wall through the mechanism of the viscero-motor reflex. As the exacerbation subsides, the protective tension of the abdominal wall progressively decreases.
1.5 Diagnostics
A peptic ulcer should be suspected if the patient has pain associated with eating food in combination with nausea and vomiting in the epigastric, pyloroduodenal areas or right and left hypochondrium. The clinical picture may depend on the location of the ulcerative defect, its size and depth, the secretory function of the stomach, and age. You should always keep in mind the possibility of asymptomatic exacerbation of peptic ulcer disease.
Survey plan
1. History and physical examination.
2. Mandatory laboratory tests: general blood test; general urine analysis; general stool analysis; stool occult blood test; level of total protein, albumin, cholesterol, glucose, serum iron in the blood; blood type and Rh factor; fractional study of gastric secretion.
3. Mandatory instrumental studies:
FEGDS with taking 4-6 biopsies from the bottom and edges of the ulcer when it is localized in the stomach and with their histological examination;
Ultrasound of the liver, pancreas, gall bladder.
4. Additional laboratory tests: determination of Helicobacter pylori infection - endoscopic urease test, morphological method, enzyme immunoassay or breath test; determination of serum gastrin level.
5. Additional instrumental studies (according to indications): intragastric pH-metry; endoscopic ultrasonography; X-ray examination of the stomach; CT scan.
History and physical examination
It should be understood that anamnestic data on a previously identified Helicobacter pylori infection and long-term use of NSAIDs by patients cannot be used decisive factor to establish a diagnosis of peptic ulcer. Anamnestic identification of risk factors for peptic ulcer disease in patients taking NSAIDs may be useful in establishing indications for FEGDS.
Pain is the most typical symptom. It is necessary to find out the nature, frequency, time of onset and disappearance of pain, and the connection with food intake.
Early pain occurs 0.5-1 hour after eating, gradually increases in intensity, persists for 1.5-2 hours, decreases and disappears as the gastric contents move into the duodenum; characteristic of ulcers of the body of the stomach. In case of damage to the cardiac, subcardial and fundic regions painful sensations occur immediately after eating.
Late pain occurs 1.5-2 hours after eating, gradually intensifying as the contents are evacuated from the stomach; characteristic of ulcers of the pyloric stomach and duodenal bulb.
Hunger (night) pain occurs 2.5-4 hours after eating and disappears after the next meal; characteristic of ulcers of the duodenum and pyloric stomach. A combination of early and late pain is observed with combined or multiple ulcers.
The intensity of pain may depend on age (more pronounced in young people) and the presence of complications.
The most typical projection of pain, depending on the localization of the ulcerative process, is considered to be the following: for ulcers of the cardial and subcardial parts of the stomach - the area of the xiphoid process; for ulcers of the body of the stomach - the epigastric region to the left of the midline; for ulcers of the pylorus and duodenum - the epigastric region to the right of the midline.
Palpation of the epigastric region may be painful.
The absence of a typical pattern of pain does not contradict the diagnosis of peptic ulcer.
Nausea and vomiting are possible. It is imperative to check with the patient for episodes of vomiting blood or black stools (melena). Additionally, during the physical examination, a deliberate attempt should be made to identify signs of a possible malignant nature of the ulceration or the presence of complications of a peptic ulcer.
Laboratory examination
There are no laboratory signs pathognomonic for peptic ulcer. Research should be carried out to exclude complications, primarily ulcer bleeding: complete blood count (CBC); stool occult blood test.
Instrumental studies
FEGDS allows you to reliably diagnose and characterize a peptic ulcer. Additionally, FEGDS allows you to monitor its healing, conduct a cytological and nosological assessment of the morphological structure of the gastric mucosa, and exclude the malignant nature of ulceration. In the presence of a gastric ulcer, it is necessary to take 4-6 biopsies from the bottom and edges of the ulcer, followed by histological examination to exclude the presence of a tumor
Contrast X-ray examination of the upper gastrointestinal tract also makes it possible to identify an ulcerative defect, however, in terms of sensitivity and specificity, the x-ray method is inferior to the endoscopic one.
1. Symptom of a “niche” - a shadow of a contrasting mass that has filled the ulcerative crater. The silhouette of the ulcer can be seen in profile (contour “niche”) or in front against the background of folds of the mucous membrane (“relief niche”). Small "niches" are indistinguishable under fluoroscopy. The contours of small ulcers are smooth and clear. In large ulcers, the outlines become uneven due to the development of granulation tissue, accumulation of mucus, and blood clots. The relief “niche” has the appearance of a persistent round or oval accumulation of contrasting mass on the inner surface of the stomach or duodenum. Indirect signs are the presence of fluid in the stomach on an empty stomach, accelerated advancement of the contrast mass in the ulcer area.
2. Symptom of the “pointing finger” - in the stomach and bulb, a spasm occurs at the level of the ulcer, but on the opposite side of the pathological process.
Intragastric pH-metry. In case of peptic ulcer, increased or preserved acid-forming function of the stomach is most often found.
Ultrasound of the abdominal organs to exclude concomitant pathology.
Detection of Helicobacter pylori
Invasive tests
At least 5 biopsies of the gastric mucosa are taken: two each from the antrum and fundus and one from the angle of the stomach. To confirm the success of eradication of the microbe this study performed no earlier than 4-6 weeks after completion of therapy.
Morphological methods- “gold standard” for diagnostic Helicobacter pylori - staining of bacteria in histological sections of the gastric mucosa.
Cytological method- staining of bacteria in smears-imprints of biopsies of the gastric mucosa according to Romanovsky-Giemsa and Gram (currently considered insufficiently informative).
Histological method- sections are stained according to Romanovsky-Giemsa, according to Warthin-Starry, etc.
Biochemical method(rapid urease test) - determination of urease activity in a biopsy of the gastric mucosa by placing it in a liquid or gel-like medium containing urea and an indicator. If Helicobacter pylori is present in the biopsy specimen, its urease converts urea into ammonia, which changes the pH of the medium and, consequently, the color of the indicator.
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It should be noted that treating peptic ulcer disease is much more difficult than preventing it. The basis for the prevention of gastric and duodenal ulcers is, first of all, taking into account the risk factors for developing the disease in each patient and their constant correction.
I have developed booklets with information on the prevention of peptic ulcers for the population living in the village. Novokorsunskaya.
The booklet “On the prevention of peptic ulcer disease” provides the following information:
- 1. You are at risk of developing peptic ulcers if:
- 1) you are 50 years old or older;
- 2) eat improperly for a long time;
- 3) drink alcohol excessively;
- 4) smoke;
- 5) your family members suffered from peptic ulcer disease, since Helicobacter pylori infection is transmitted by contact.
- 2. You are at risk of developing peptic ulcers if you take NSAIDs and:
- 1) you are over 60 years old (with age, the gastric mucosa becomes fragile);
- 2) take NSAIDs for a long time;
- 3) taking larger doses of NSAIDs than your doctor prescribed;
- 4) take several medications containing aspirin or NSAIDs;
- 5) appeared side effects NSAIDs, such as indigestion or heartburn;
- 6) accept steroid drugs, for example prednisolone;
- 7) are taking anticoagulants (blood thinning medications), such as warfarin;
- 8) previously had an ulcer or ulcer bleeding;
- 9) regularly drink alcohol or smoke.
- 3. The peptic ulcer prevention program includes five main points. You are doing the right thing if:
- 1) eat rationally and follow a diet;
- 2) do not smoke or abuse alcohol;
- 3) avoid stress, cope with emotional tension;
- 4) do not abuse non-steroidal anti-inflammatory drugs;
- 5) observe the rules of personal hygiene (given the high prevalence of Helicobacter pylori infection among the population).
- 4. Secondary prevention (prevention of relapse of the disease) includes the mandatory implementation of points 1-5 primary prevention, and :
- 1) strict adherence to the instructions of the attending physician when treating an exacerbation;
- 2) compliance with dietary recommendations even outside the period of exacerbation: frequent split meals (small portions, 5-6 times a day), exclusion from the diet of spicy, smoked, pickled, fatty foods, strong coffee and tea, carbonated drinks;
- 3) adherence to work and rest schedule (avoid work associated with frequent and long business trips, night shifts, and severe stress);
- 4) sanitation of the oral cavity (treatment of caries, prosthetics);
- 5) drug therapy as a continuous preventive therapy(carried out for several months and even years with an antisecretory drug in half the dose) and “on demand” therapy (when symptoms of exacerbation appear, the antisecretory drug is taken in full for 2-3 days daily dose, and then at half for two weeks).
In the practical part of the work, an analysis of the incidence of gastric and duodenal ulcers according to Art. Novokorsunskaya for 2013-2014, and booklets with information on the prevention of peptic ulcer disease were developed for the population living in the station. Novokorsunskaya. From this it was revealed:
- 1. Analysis of the dynamics of the incidence of gastric and duodenal ulcers according to Art. Novokorsunskaya in 2013-2014 showed an increase in the number of patients by 3%.
- 2. Analysis of similar morbidity indicators for 2012 allowed us to state an increase in morbidity by 1%.
- 3. Based on the analysis of the survey results, it was established:
- - men are more likely to suffer from peptic ulcers;
- - this pathology affects persons mainly aged from 30-39 to 40-49 years;
- - the largest number of patients have blood group I;
- - the number of patients with duodenal ulcer prevails over the number of patients with gastric ulcer.
- - exacerbation of the disease in 23% of patients occurs 2 times a year;
- - among the symptoms of peptic ulcer, pain in the epigastric region is observed in 100% of cases.
- - the majority of patients (76%) are not registered as “D”;
- - 56% of patients undergo inpatient treatment once a year;
- - not all patients with exacerbation of the disease undergo inpatient treatment;
- - patients following the diet and daily routine recommended by the doctor, the predominant number;
- - bad habits are observed in 68% of patients.
- 4. The basis for the prevention of peptic ulcer disease is, first of all, taking into account the risk factors for developing the disease in each patient and their constant correction.
INTRODUCTION 3
CHAPTER I. SCIENTIFIC REVIEW OF THE THEORETICAL FOUNDATIONS OF THE TEACHING ABOUT GASTOM ULCER 6
1.1. General characteristics of gastric ulcer. 6
1.2. Basic principles of diagnosis and treatment of gastric ulcer. eleven
1.3 Basics of preventing exacerbations of gastric ulcer. 15
CHAPTER II MATERIALS AND RESEARCH METHODS 18
2.1. Characteristics of the surgical department No. 2 of the Municipal Budgetary Institution of the Yeisk District "CRH". 18
2.2. Patient survey. 19
CHAPTER III PARTICIPATION OF A PHYSICAL SHER IN THE PREVENTION OF EXACERBATIONS OF GASTRIC ULCER 27
CONCLUSION 37
LIST OF SOURCES USED 40
APPENDIX 42
Introduction
Among diseases of the digestive system, peptic ulcer takes a leading place. In the structure of hospitalized gastroenterological patients, as well as those who often use sick leave, patients with peptic ulcer disease predominate. This indicates that this pathology becomes not only a medical, but also a major social problem.
Gastric ulcer affects approximately 10% of the world's population. The incidence of peptic ulcer disease in the Russian Federation in 2013 was 1268.9 (per 100 thousand population). The highest figure was registered in Privolzhsky federal district and in the Central Federal District. It should be noted that over the past five years the incidence rate of peptic ulcer disease has not changed significantly. In Russia, about 3 million such patients are registered at dispensaries. According to reports from the Ministry of Health of the Russian Federation, in last years the proportion of patients with newly diagnosed gastric ulcer in Russia increased from 18 to 26%. The mortality rate from diseases of the digestive system, including peptic ulcers, in the Russian Federation in 2013 was 183.4 per 100 thousand population.
The relevance of the problem of gastric ulcer is determined by the fact that it is the main cause of disability in 68% of men and 31% of women among all those suffering from diseases of the digestive system.
Despite advances in the diagnosis and treatment of peptic ulcer disease, this disease continues to affect an increasingly younger population, showing no trends towards stabilization or reduction in incidence rates.
Peptic ulcer disease develops during life in 5-10% of people, approximately half of them experience an exacerbation within 5 years. With massive preventive examinations of the population of the Russian Federation, ulcers and cicatricial changes in the stomach wall were found in 10-20% of those examined. In men, peptic ulcer disease develops more often in working age up to 50 years, and according to other authors, this disease affects men aged 18-22 years. Most authors believe that as we age, the number of patients with gastric ulcer increases and a relatively high number of patients require surgical treatment Moreover, these changes are more pronounced in women than in men.
The most important task of clinical medicine is to reduce the number of relapses and achieve long-term remission. According to various authors, the relapse rate of the disease reaches 40-90%. This, undoubtedly, is also due to the fact that insufficient attention is paid to the diagnosis and rational treatment of this pathology during the period of remission.
Many people do not have information about the risk factors for peptic ulcer disease, cannot recognize the first signs of the disease, therefore, do not seek medical help in a timely manner, and cannot avoid complications.
Peptic ulcer disease is one of the most common and widespread diseases that medical workers encounter in their daily work.
Gastric ulcer causes suffering to many patients, so I believe that a paramedic should carry out extensive preventive measures to prevent and reduce morbidity, including relapse prevention, medical examination and provide qualified medical care.
The purpose of this work is to identify the role of the paramedic in the prevention of exacerbations of gastric ulcer.
In accordance with this goal, the following tasks were solved during the study:
1) conduct a scientific review of the fundamentals of the doctrine of gastric ulcer;
2) conduct a study of patients in the surgical department No. 2 of the Municipal Budgetary Healthcare Institution of the Yeisk District Central District Hospital;
3) study the capabilities of a paramedic in the prevention of exacerbations of gastric ulcers, develop practical recommendations.
Subject of the study: patients with gastric ulcer in the acute stage of the surgical department No. 2 of the Municipal Budgetary Institution of the Yeisk District "Central District Hospital".
Subject of the study: the participation of a paramedic in the prevention of exacerbations of gastric ulcers in patients of the surgical department No. 2 of the Municipal Budgetary Institution of the Yeisk District "CRH".
The work consists of: introduction, three chapters, conclusion, list of sources used, applications
Conclusion
In this work, the goal was to identify the role of the paramedic in the prevention of exacerbations of gastric ulcer; in the first chapter, a scientific review was carried out theoretical foundations teachings about gastric ulcers. Having analyzed the material in Chapter 1, we can conclude that peptic ulcer disease is one of the most frequent and widespread diseases that medical workers encounter in their daily work, and in recent years there has been a trend towards an increase in incidence
The second chapter reveals and analyzes the results of a study of patients with exacerbation of gastric ulcer who were treated as inpatients in the surgical department No. 2 of the Municipal Budgetary Healthcare Institution of the Yeisk District Central District Hospital. Today, more and more often people develop and worsen gastric ulcers, especially men of working age who are susceptible to this disease.
Lack of patient awareness of risk factors for exacerbation leads to frequent relapses of the disease and its complications. This provision proves that a paramedic must regularly and fully conduct sanitary education with patients about risk factors for the development of exacerbations, and give recommendations on measures to prevent exacerbations.
The third chapter reveals the participation of a paramedic in the prevention of exacerbations of gastric ulcers. The main task of the paramedic is to prevent the occurrence of an exacerbation of the disease, for this he must give the patient maximum information about proper nutrition, convince to give up existing bad habits, if necessary, recommend massage courses, physical therapy classes, physiotherapeutic procedures, sanatorium-resort treatment.
Based on the results of the studied material and the research conducted, recommendations have been developed for patients in the surgical department with exacerbation of gastric ulcer:
1. In progress physical rehabilitation for gastric ulcers at the inpatient stage, use an integrated approach: drug therapy, nutritional therapy, herbal medicine, physiotherapeutic and psychotherapeutic treatment, therapeutic physical training, taking into account compliance with therapeutic and motor regimens.
2. At the inpatient stage of rehabilitation, patients with this pathology, taking into account the capabilities of the medical institution and the prescribed motor regimen, can be recommended all means of therapeutic physical culture: physical exercises, natural factors of nature, motor regimens, therapeutic massage, mechanotherapy and occupational therapy. Forms of exercise include morning hygienic exercises, therapeutic exercises, dosed therapeutic walking (on the hospital premises), training walking on the steps of stairs, dosed swimming (if there is a swimming pool), and independent exercises. All these classes can be conducted individually, small group (4-6 people) and group (12-15 people) methods.
3. An important therapeutic measure is diet therapy. Medical nutrition in patients with gastric ulcers, it is necessary to strictly differentiate depending on the stage of the process, its clinical manifestation and associated complications. The basis of dietary nutrition for patients with gastric and duodenal ulcers is the principle of sparing the stomach, that is, creating maximum rest for the ulcerated mucous membrane.
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