Stomach ulcer in a child treatment. Medical and surgical treatment
peptic ulcer- a chronic relapsing disease, accompanied by the formation of an ulcer in the stomach and / or duodenum, due to an imbalance between the factors of aggression and protection of the gastroduodenal zone.
In recent years, cases of peptic ulcer in children have become more frequent, at present the disease is registered with a frequency of 1 case per 600 children. Also noted is the "rejuvenation" of the disease, an increase in the proportion of pathology with a severe course and a decrease in the effectiveness of therapy. As a result, stomach ulcers and duodenum in children presents serious problem clinical medicine.
Etiology
The disease develops as a result of several unfavorable factors affecting the body, including hereditary predisposition and emotional overload, combined with permanent alimentary errors (irregular meals, abuse of spicy foods, dry food, etc.). The main causes are thought to be disorders of the nervous and hormonal mechanisms regulation of the activity of the stomach and duodenum, imbalance between aggression factors (hydrochloric acid, pepsins, pancreatic enzymes, bile acids) and defense factors (mucus, bicarbonates, cellular regeneration, prostaglandin synthesis). Ulceration is associated with prolonged hyperchlorhydria and peptic proteolysis caused by vagotonia, hypergastrinemia and hyperplasia of the main gastric glands, as well as with gastroduodenal dysmotility and prolonged acidification of the antrobulbar zone.
plays an important role in the development of peptic ulcer Helicobacter pylori, found in 90-100% of patients in the mucous membrane of the antrum of the stomach.
The pathogenesis of peptic ulcer
There are several mechanisms leading to increased secretion of hydrochloric acid and pepsins, a decrease in the production of mucous substances and a violation of the motor regulation of the gastroduodenal zone. An important role in this process is assigned to the central nervous system, which has a dual effect on the secretion and motility of the stomach and duodenum.
Pathological changes in the central and autonomic nervous system play an important role in the imbalance between protective and aggressive factors, contributing to the formation of an ulcer.
Classification of peptic ulcer in children
|
Ulcer localization |
Clinical phase and endoscopic stage |
Flow |
Complications |
|
Into the stomach:
In the duodenum:
In the stomach and duodenum |
Aggravation:
Stage I - fresh ulcer II stage - the beginning epithelialization of the ulcer Exacerbation subsidence: III stage - ulcer healing Stage IV - clinical and endoscopic remission |
Medium |
Bleeding Perforation penetration |
Clinical picture
The clinical picture depends on the localization of the process and the clinical and endoscopic stage of the disease.
Stage I (fresh ulcer)
The leading clinical symptom is pain in the epigastric region and to the right of the midline, closer to the navel. Pain occurs on an empty stomach or 2-3 hours after eating (late pain). Half of the children report night pain. A clear "Moynigam" rhythm of pain is revealed: hunger - pain - food intake - relief. Expressed dyspeptic syndrome: heartburn (an early and most common symptom), belching, nausea, constipation. Superficial palpation of the abdomen is painful, deep - difficult due to the protective tension of the muscles of the anterior abdominal wall.
Endoscopic examination against the background of pronounced inflammatory changes in the mucous membrane of the gastroduodenal zone reveals a defect (defects) of a round or oval shape, surrounded by an inflammatory ridge, with a bottom covered with gray-yellow or white fibrin overlays.
In the stomach, ulcers are located mainly in the pyloroanthral region (found more often in boys).
In the duodenum, ulcers are localized on the anterior wall of the bulb, as well as in the zone of the bulboduodenal junction. Motor-evacuation disorders include duodenogastric reflux and spastic bulb deformity.
Stage II (beginning of epithelialization of the ulcer)
Most children have late pains in the epigastric region, but they occur mainly during the day, and after eating there is a lasting relief. Pains become more dull, aching. Belly is well accessible superficial palpation, but with deep muscle protection is preserved. Dyspeptic manifestations are less pronounced.
In endoscopic examination, the hyperemia of the mucous membrane is less pronounced, the edema around the ulcer is reduced, and the inflammatory shaft disappears. The bottom of the defect begins to clear of fibrin, the convergence of the folds to the ulcer is outlined, which reflects the healing process.
Stage III (ulcer healing)
Pain in this stage persists only on an empty stomach, at night their equivalent may be a feeling of hunger. The abdomen becomes accessible to deep palpation, soreness is preserved. Dyspeptic disorders are practically not expressed.
During endoscopy at the site of the defect, traces of repair are determined in the form of red scars that have different shape- linear, circular, stellate. Possible deformation of the wall of the stomach or duodenum. Signs of the inflammatory process of the mucous membrane of the stomach and duodenum, as well as motor-evacuation disorders, persist.
IV stage (remission)
The general condition is satisfactory. There are no complaints. Palpation of the abdomen is painless. Endoscopically, the mucous membrane of the stomach and duodenum is not changed. However, in 70-80% of cases, a persistent increase in the acid-forming function of the stomach is detected.
Complications
Complications of peptic ulcer are recorded in 8-9% of children. In boys, complications occur 2 times more often than in girls.
The structure of complications is dominated by bleeding, and with a duodenal ulcer they develop much more often than with a stomach ulcer.
Perforation of the ulcer in children often occurs with a stomach ulcer. This complication is accompanied by acute "dagger" pain in the epigastric region, often develops state of shock. The disappearance of hepatic dullness during percussion of the abdomen due to the entry of air into the abdominal cavity is characteristic.
Penetration (penetration of the ulcer into neighboring organs) occurs rarely, against the background of a long difficult process and inadequate therapy. Clinically, penetration is characterized by sudden pain radiating to the back and repeated vomiting. The diagnosis is clarified with the help of FEGDS.
Diagnostics
The diagnosis of peptic ulcer disease, in addition to the above clinical and endoscopic justification, is confirmed by the following methods.
Fractional probing of the stomach with the determination of the acidity of gastric juice, debit-hour of hydrochloric acid and pepsins. An increase in the pH of gastric juice on an empty stomach and with the use of specific stimuli, an increase in the content of pepsins are characteristic.
Every disease that appears in a child is a matter of concern for parents. A special place is occupied by peptic ulcer disease, since immunity in children is still not strong enough, and the appearance of an ulcer can negatively affect the formation of other organs and body systems.
It is very important not to miss the first symptoms of the disease, to identify the causes of its occurrence and begin appropriate treatment.
The appearance of a peptic ulcer in a child is not a sentence for the rest of his life. The child's body quickly responds to timely measures, and the likelihood of a complete cure for the ulcer is quite high.
However, it should be remembered that without the participation of a gastroenterologist, it is simply impossible to achieve a positive result.
Peptic ulcer is a violation of the integrity of the internal walls of the stomach or duodenum in the form of ulcers different sizes. They are the result of acids, digestive enzymes, bacteria and many other factors acting on the walls of the stomach.
Localization of these ulcerations can be in various departments. digestive tract. Such a disease is characterized by a long and persistent course, which is especially difficult for the child's body.
The appearance of ulcers on the lining of the stomach or duodenum in children (even very young ones) is no longer a rare occurrence. Therefore, parents should arm themselves with information regarding this pathology.
Classification
Treatment of any disease in a child requires a thorough examination. This is especially true of such a disease as an ulcer; her running form in children can become a serious problem in his later life. There is a medical classification of peptic ulcer according to various parameters.
By location:
- stomach;
- duodenum;
- double localization (in both organs).
According to the phase of the course of the disease:
- stage of exacerbation;
- phase of incomplete clinical remission;
- stage of clinical remission.
According to the course of the disease:
- uncomplicated;
- with complications.
When choosing a method of treatment, it is necessary to study and take into account each of these factors. The final result of the fight against the disease largely depends on this.
Causes of peptic ulcer in children
Identification of the causes of any disease is crucial in determining the method of its treatment. Is no exception and a stomach ulcer; The reasons for its appearance in children are similar to the reasons for its appearance in adults.
Even in the recent past, living conditions and diet (nervous strain and dry food) were considered the main factors in the development of chronic stomach ulcers. However, further medical research has shown that there are many other reasons for the development of the inflammatory process in the gastrointestinal tract. They are:
- Helicobacter pylori bacterium. Represents a unique pathogen living and multiplying in the digestive tract. The formation of most ulcers is associated with the effect on the walls of the stomach of this particular bacterium.
- Chronic gastritis. The appearance of it in a child should not be left without attention and treatment. In the future, it can provoke a weakening protective functions stomach and, as a result, the appearance of peptic ulcer.
- Violation of the process of gastric secretion. Under certain circumstances, in the child's body, the mechanisms involved in the formation of gastric secretion fail. In this case it starts increased secretion acid that irritates the walls of the stomach. The likelihood of an ulcer in this case is very high.
- Irregular meals and long breaks between meals. Lack of diet disrupts the ability of the stomach to protect itself from the aggressive effects of digestive enzymes.
- Non-steroidal anti-inflammatory drugs. Against the background of their uncontrolled use, a child often develops one or another pathology in the gastrointestinal tract. Continued unreasonable use of such drugs (Aspirin, Ibuprofen, Naproxen) can lead to the formation of an ulcer.
- Chronic diseases. Diabetes mellitus, gallbladder disease can cause an increase or decrease in gastric motility. Such disorders of the gastrointestinal tract contribute to the appearance of peptic ulcer.
There are other factors that provoke a weakening of the mucous layer of the stomach. They can be smoking, drinking alcohol, caffeinated drinks, prolonged physical activity, injuries. In order to save child health, parents should exclude their appearance in the life of the child.
Symptoms
The main alarming symptom of a peptic ulcer in a child is pain in any area of \u200b\u200bthe abdomen (depending on the location of the ulcer). They are not permanent: for some time the pain may be absent.
Pain attacks, as a rule, have a cramping appearance, so the child tries to pull his legs up to his stomach. His desire to take the “fetal position” with such pains should be a reason for the attention of parents.
In most cases, pain attacks appear immediately after eating (although there are variants of "hungry" pains), especially if the food was inappropriate and eaten in a hurry.
Sometimes pain in the presence of ulcers in a child are not observed. This is typical for the latent course of the disease, which may be a risk factor for gastrointestinal bleeding or other complications.
Except pain symptom a stomach ulcer is accompanied by other signs; in children they may be:
- heartburn;
- sour belching;
- bouts of nausea or vomiting;
- coated tongue;
- decrease in body weight and appetite;
- bowel dysfunction (usually constipation);
- black stool - with the development of complications.
The task of parents is not to disregard any of these factors if a child has it. In this case, in no case should you self-medicate. Only a consultation with a specialist and a survey will be able to confirm or refute their fears.
Complications
Among the most dangerous diseases includes gastric ulcer; the likelihood of complications in children is quite high. They can provoke a violation of the further development of the child's body. Common complications are:
- Bleeding (most often accompanied by vomiting). At the same time, there are also general symptoms blood loss: weakness, dizziness, low blood pressure, black liquid stools. Against the background of this condition, the appearance of vomiting with an admixture of blood clearly indicates gastrointestinal bleeding in a child.
- Penetration. With such a pathology, the ulcer grows into nearby organs. The appearance of pain in this case is not associated with any other cause, it is accompanied by severe heartburn and is permanent.
- Perforation. There is a breakthrough of the walls of the stomach at the site of the localization of the ulcer. All contents are poured into the peritoneal cavity. AT this case urgent surgical intervention is required; every hour of delay can cost the life of a child.
- Narrowing or obstruction. Swelling and scarring can narrow or completely close the patency of the intestine. This may necessitate surgery.
Parents should keep in mind that complications from such a disease can cause irreparable damage to the child's body.
Diagnostics
The first step in diagnosing gastrointestinal diseases in a child is to identify complaints (by interviewing parents and the child). Then a thorough examination of the small patient is carried out.
For the correct diagnosis, a study of the digestive organs is prescribed. The most accurate picture gives an examination using an endoscope. Others apply additional methods diagnostics:
- pH-metry of gastric secretion per day;
- blood tests (general and biochemistry);
- coprogram feces;
- fecal analysis for the detection of occult blood;
- if necessary, an allergy test.
Comparison of all the diagnostic data will help you choose the right method for treating ulcers in children.
Treatment of peptic ulcer in a child
Provision of many factors requires treatment of peptic ulcer; when such a disease is detected in children, these conditions fall on the shoulders of the parents. They should remember that ignoring children's complaints and symptoms can provoke an exacerbation of the disease. Uncontrolled reception medicines can also exacerbate the situation.
In the presence of an ulcer in a child, only a pediatric gastroenterologist can choose and change the method of treatment. Patient and careful adherence to all medical recommendations gives a chance for a complete cure. Depending on the severity and type of disease, it can be cured by applying various methods treatment.
Adjusting the diet in certain cases can give positive result. Basically, it applies to initial stage illness. In this case, it can be used as an independent method, and as part of a complex treatment. A diet for an ulcer should take into account all the nuances of the disease and the characteristics of the child's body.
Parents should adhere to frequent (up to 6 times a day) meals, but in small portions. At the same time, products that cause bile secretion are excluded - all fatty, spicy, sour, salty. Preference should be given to boiled, stewed, steamed food. It is desirable for a child to eat food in a pureed form, especially during an exacerbation.
It is also important to observe the temperature regime of children's dishes. Food should not be either hot or cold - to exclude any injury to the inflamed tissues of the mucous membrane.
An exact list of allowed products for each specific diet is given by the attending physician. The age and individual parameters of the child are reflected in the recommended diet.
Medications
In a more complex stage of the disease, drug therapy is prescribed. Its primary task is to stop the progression of the disease and all accompanying inflammation processes. The causes that caused the disease are established; for this, the following types of drugs are used:
- antibacterial;
- acid blockers;
- H2 blockers;
- enveloping (to protect the mucous membrane);
- drugs that promote the regeneration of the mucosa and the healing of ulcers.
May be given as a supplement sedatives(motherwort, valerian).
At the final stage of the process drug therapy drugs are used that can restore the functions of the digestive tract. Part complex therapy may also include:
- physiotherapy;
- herbal preparations for healing and scarring of ulcers;
- medicinal mineral waters.
All these activities are prescribed, focusing on the degree of the disease, the age and characteristics of the child's body.
Surgical intervention
If a change in diet and drug treatment did not work, then doctors apply surgical treatment. Depending on the situation, operations can be carried out:
- vagotomy (done to reduce the formation of acid within the stomach and to heal ulcers);
- resection (removal of the affected part of the stomach);
- gastroenterostomy (artificial connection of the stomach and small intestine);
- local excision (removal of ulcerative foci);
- palliative suturing of the opening (performed with perforated ulcer; the hole in the wall of the stomach is sutured with absorbable suture).
In the event of certain complications, surgical intervention should be immediate, as it is the only treatment.
Currently surgical interventions performed in most cases laparoscopic method- through several small punctures. In the absence of contraindications, it is recommended as a low-traumatic and effective method conducting operations.
Prevention
With a hereditary predisposition to this disease, parents should treat preventive measures With special attention. To do this, you must adhere to the following rules:
- Baby food should be regular and balanced.
- The diet is appropriate for the age of the child.
- Proper lifestyle: exclude smoking, alcohol; get involved in sports.
- A comfortable psychological atmosphere should reign in the family - without stress and conflicts.
Properly organized by the parents, the diet and life in general will help to avoid the appearance of a dangerous disease in the child.
One of the greatest medical discoveries recent years associated with the cause of peptic ulcer disease. Scientists have determined that in children (as in adult patients), the development of peptic ulcer in the duodenum is provoked by the microbe Helicobacter pylori, which has a spiral shape. However, this microbe is in the body of more than eighty percent of the inhabitants of our country. But not every one of these eighty percent suffers from the ailment under discussion.
A quite obvious conclusion suggests itself: in order for a representative of the younger generation to develop a duodenal ulcer, not only the presence of a microorganism is necessary, but also the presence in the life of a child of several (or at least one) provoking factors:
- constant presence in an environment of total stress (if the child is in prolonged depression or is subject to serious experiences, then the functions of his autonomic nervous system are violated; for this reason, the blood vessels of the stomach experience a spasm together with the muscles of this organ; as a result, there is a shortage in the body good nutrition, stomach and duodenum become vulnerable to the negative effects of hydrochloric acid, which simply corrodes the walls of these organs);
- bad heredity;
- the abuse of too spicy and rough food, due to which the volume of acid production in the child's stomach increases significantly (this is another reason why the younger generation should eat right);
- smoking (unfortunately, this bad habit has become increasingly common in children);
- uncontrolled intake of pharmacological agents.
Symptoms
The first complaints that a baby with a duodenal ulcer will voice to parents will be as follows:
- heartburn,
- burp,
- vomit,
- constipation,
- nausea.
As a rule, symptoms worsen immediately after breakfast or dinner. This occurs in the second or fourth hour after eating. Another characteristic symptom of the disease under discussion - pain that does not give the little patient rest. Doctors call this phenomenon “hunger pains.” This pain syndrome occurs in the baby's body at night, that is, when the child's stomach is completely empty. The pain goes away almost immediately after the child eats something.
What else distinguishes a baby who has a duodenal ulcer?
- stable appetite.
- The presence of a white coating around the entire circumference of the tongue.
- The inability to feel the abdomen, as the child begins to actively resist in tandem with his abdominal muscles.
- Headache.
- Irritability.
- Bad dream.
Diagnosis of duodenal ulcer
The most popular instrumental method, which is actively used to diagnose duodenal ulcers, is fractional sounding. During this study, doctors not only consider the internal structure of the stomach and intestines of a small patient. They also determine the acidity of the juice in the stomach. This procedure can hardly be called pleasant. Often the child has to a long period time to persuade him to swallow the probe. However, endoscopy is the most informative method.
Except endoscopic examination doctors prescribe:
- examination of feces, vomit and blood for the presence of a pathogen;
- x-ray (in most modern clinics from x-ray examination as diagnostic method with the disease under discussion, they have long been abandoned; but if the hospital does not have modern equipment, an x-ray can be ordered - for lack of anything else).
Complications
Complications that a duodenal ulcer brings to a child's life occur in about nine percent of children with the disease. Twice as often, complications encroach on the body of boys. Girls are less susceptible to the consequences of peptic ulcer than their peers - representatives of the opposite sex.
- Peptic ulcer disease is very dangerous for its bleeding. With a stomach ulcer, bleeding occurs much less frequently than with a similar lesion of the duodenum.
- Perforation of the ulcer is manifested by severe abdominal pain in a child.
- Penetration is a term that refers to the penetration of an ulcer into other internal organs little patient. This complication is very rare. As a rule, it takes place where the child long time treated not from that and not that.
Treatment
A duodenal ulcer is a disease that during the period of exacerbation should be treated in the inpatient department of the clinic. In other periods, the child can undergo drug therapy at home.
What can you do
Parents whose baby suffers from a duodenal ulcer should take care of his diet. Food should be sparing. Ideally, food should be in a semi-liquid state. Mom and dad are required to give up foods that provoke an intense secretion of gastric juice and irritate the gastrointestinal tract. A sick child should have at least five or six meals a day.
What can a doctor do
The ulcer is being treated complex methods. The first and most important thing that the doctor takes into account is the age of the little patient. Second, the period
the development of the disease. If the ulcer worsens, the baby is sent to the hospital. He will receive the following treatment:
- antibacterial drugs,
- antisecretory pharmacological agents,
- anthocytes,
- painkillers.
Prevention
The main preventive recommendation that will help avoid the development of duodenal ulcer in a child is proper and balanced nutrition. And since the ulcer - chronic illness, then for the purpose of prevention, doctors prescribe their patients taking antiulcer drugs during the off-season. That is, when the disease worsens.
Peptic ulcer (PU) is a chronic relapsing disease that occurs with alternating periods of exacerbation and remission, the leading manifestation of which is the formation of a defect (ulcer) in the wall of the stomach and duodenum.
Etiology and pathogenesis
Of great importance is hereditary burden (genetically determined high density of parietal cells, their increased sensitivity to gastrin, deficiency of trypsin inhibitors, congenital deficiency of antitrypsin, etc.). bad habits) is implemented genetic predisposition to the development of JAB.
The pathogenesis of PU is based on an imbalance between the factors of acid-peptic aggression of gastric contents and the protective elements of the mucous membrane (SO) of the stomach and duodenum.
Strengthening of factors of aggression or weakening of factors of protection lead to disturbance of this balance and emergence of an ulcer.
Factors of aggression include hyperproduction of hydrochloric acid, hyperexcitability parietal cells caused by vagotonia, infectious factors (Helicobacter pylori), impaired blood supply to the mucous membrane of the stomach and duodenum, impaired antroduodenal acid brake, bile acids and lysolecithin.
The protective factors are the mucous barrier, mucin, sialic acids, bicarbonates - back diffusion of hydrogen ions, regeneration, sufficient blood supply to the mucous membrane of the stomach and duodenum, and antroduodenal acid brake.
Ultimately, the formation of a peptic ulcer is due to the action of hydrochloric acid (the rule of K. Schwarz "No acid - no ulcer") on the mucous membrane of the stomach and duodenum, which allows us to consider antisecretory therapy as the basis for the treatment of exacerbations of peptic ulcer.
The decisive etiological role in the development of PU is currently assigned to H. pylori microorganisms. These bacteria produce a number of enzymes (urease, protease, phospholipases) that damage protective barrier mucous membrane, as well as various cytotoxins. Seeding of the gastric mucosa with H. pylori is accompanied by the development of superficial antral gastritis and duodenitis and leads to an increase in the level of gastrin, followed by an increase in the secretion of hydrochloric acid.
Excessive intake of hydrochloric acid into the lumen of the duodenum in conditions of relative deficiency of pancreatic bicarbonates contributes to increased duodenitis, the occurrence of intestinal metaplasia and the spread of H. pylori.
In the presence of a hereditary predisposition and the action of additional etiological factors (errors in nutrition, neuropsychic stress, etc.), an ulcerative defect is formed.
In children, unlike adults, infection with H. pylori is much less often accompanied by ulceration of the mucous membrane of the stomach and duodenum.
Classification
AT pediatric practice use the classification of peptic ulcer proposed by Professor Mazurin A.V. (Table 2) with additions .
The domestic medical school separates peptic ulcer and symptomatic ulcers - ulceration of the mucous membrane (SO) of the stomach and duodenum that occurs when various diseases and states. For example, ulcers with stress, taking non-steroidal anti-inflammatory drugs (NSAIDs). In the English-language literature, the term "peptic ulcer" is often used to refer to the actual peptic ulcer and symptomatic lesions of the mucosa of the stomach and duodenum.
Clinical picture
-Pain syndrome
Usually the pain is localized in the epigastric or paraumbilical region, sometimes it is diffused throughout the abdomen.
In a typical case, the pain occurs regularly, becomes intense, takes on a nocturnal and “hungry” character, and decreases with food intake. With duodenal ulcer, the so-called Moinigan rhythm of pain appears (hunger - pain - food intake - light gap - hunger - pain).
- Dyspeptic disorders(heartburn, belching, vomiting, nausea) are less common in children than in adults. With an increase in the duration of the disease, the frequency of dyspeptic symptoms increases. Appetite is reduced in some patients. They may have a delay in physical development (weight loss). Patients with PU often have a tendency to constipation or loose stools.
- Asthenic syndrome. As the PU develops, it intensifies emotional lability, due to pain sleep is disturbed, increased fatigue appears, an asthenic condition may develop. There may be hyperhidrosis of the hands and feet, arterial hypotension, a change in the nature of dermographism, sometimes bradycardia, which indicates a violation of the activity of the autonomic nervous system, with a predominance of the activity of the parasympathetic department.
Complications of PU in childhood
observed in 7-10% of patients. In boys, complications are observed more often than in girls in the case of duodenal ulcer.
The structure of complications is dominated by bleeding (80%), stenosis (11%), perforation (8%) and ulcer penetration (1.5%) are less common.
Bleeding is characterized by blood in the vomit (scarlet or coffee grounds vomit), black tarry stools.
At big blood loss characteristic weakness, nausea, pallor, tachycardia, lowering blood pressure, sometimes fainting. With hidden bleeding in the feces, a positive reaction to occult blood.
Stenosis of the pylorobulbar zone usually develops in the process of ulcer healing. As a result of food delay in the stomach, its expansion occurs, followed by the development of intoxication, exhaustion. Clinically, this is manifested by vomiting of food eaten the day before, increased peristalsis of the stomach, especially on palpation, and "splash noise", determined by jerky palpation of the abdominal wall.
Penetration (penetration of an ulcer into neighboring organs) usually occurs against the background of a long and severe course of the disease, inadequate therapy. Accompanied by amplification pain syndrome with radiation to the back. There is vomiting that does not bring relief, fever is possible.
Ulcer perforation is 2 times more common in gastric localization of the ulcer. Basic clinical sign perforation - a sharp sudden ("dagger") pain in the epigastric region and in the right hypochondrium, often accompanied by a state of shock. There is a weak pulse, a sharp pain in the pyloroduodenal zone, the disappearance of hepatic dullness due to the release of air into the free abdominal cavity. Nausea, vomiting, stool retention
Diagnostics
On examination, a white coating on the tongue is often detected, on palpation - soreness in the pyloroduodenal zone. Regardless of the localization of the ulcer in children, pain in the epigastric region and in the right hypochondrium is very often noted. The symptom of muscular protection is rare, more often during severe pain. In the acute phase, it is determined positive symptom mendel
Clinical manifestations of PU are diverse, a typical picture is not always observed, which greatly complicates the diagnosis. So, in young children, the disease often proceeds atypically. At the same time, than younger child the less specific the complaints. At an older age, the symptoms of duodenal ulcer are similar to those in adults, although they may be more blurred. Often there is no characteristic ulcerative anamnesis, which is partly due to the fact that children quickly forget the pains, do not know how to differentiate them, cannot indicate their localization and the cause that caused them.
The increase in the number of atypical forms of the disease, the lack of alertness in the formation of the ulcerative process, especially in children with aggravated heredity for the pathology of APTO, contributes to an increase in the percentage of patients with late diagnosis of PU. This leads to a more frequent recurrence of the disease in this category of patients and the early formation of its complications, leading to a decrease in the quality of life of children with PU.
Examination plan for gastric and duodenal ulcers:
History and physical examination.
Mandatory laboratory research
general analysis blood;
General analysis of urine;
general analysis of feces;
analysis of feces for occult blood;
levels of total protein, albumin, cholesterol, glucose, serum iron in blood;
blood type and Rh factor;
Mandatory instrumental research
FEGDS. When the ulcer is localized in the stomach - taking 4-6 biopsies from the bottom and edges of the ulcer with their histological examination in order to exclude cancer (more often in adults);
Ultrasound of the liver, pancreas, gallbladder.
determination of Helicobacter pylori infection by endoscopic urease test, morphological method, enzyme immunoassay or breath test;
Additional laboratory tests
determination of the level of serum gastrin.
Additional instrumental studies (according to indications)
intragastric pH-metry;
endoscopic ultrasonography;
x-ray examination of the stomach;
computed tomography.
Laboratory examination
There are no laboratory signs pathognomonic for peptic ulcer disease. Studies should be carried out in order to exclude complications, primarily ulcerative bleeding - a complete blood count and a fecal occult blood test.
Instrumental diagnosis of gastric and duodenal ulcers
FEGDS allows you to reliably diagnose and characterize the ulcer. Additionally, FEGDS allows you to control its healing, conduct a cytological and histological assessment of the morphological structure of the gastric mucosa, and exclude the malignant nature of ulceration.
Endoscopic picture of the stages of ulcerative lesions:
Aggravation phase:
Stage I - acute ulcer. Against the background of pronounced inflammatory changes in the gastric mucosa and duodenum - a defect (defects) round shape surrounded by an inflammatory shaft; pronounced edema. The bottom of the ulcer with a layer of fibrin.
Stage II - the beginning of epithelialization. The hyperemia decreases, the inflammatory shaft is smoothed out, the edges of the defect become uneven, the bottom of the ulcer begins to clear from fibrin, and convergence of the folds to the ulcer is outlined. Phase of incomplete remission:
Stage III - healing of the ulcer. At the site of repair, there are remnants of granulations, red scars of various shapes, with or without deformation. Signs of gastroduodenitis activity persist.
Remission:
Complete epithelialization of the ulcerative defect (or "calm" scar), there are no signs of concomitant gastroduodenitis.
Contrast x-ray examination of the upper gastrointestinal tract also reveals an ulcer, however, in terms of sensitivity and specificity X-ray method inferior to endoscopic.
Intragastric pH-metry. In case of peptic ulcer, an 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 diagnostics:
Cytological method - staining of bacteria in smears-imprints of biopsy specimens 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 Wartin-Starry, etc. This is the most objective method for diagnosing H. pylori, as it allows not only to detect bacteria, but also to determine their location on the mucous membrane, the degree of contamination, to assess the nature pathological process
Bacteriological method- Determination of the strain of a microorganism, identification of its sensitivity to the drugs used, is little used in routine clinical practice.
Immunohistochemical method using monoclonal antibodies: more sensitive because the antibodies used selectively stain H. pylori. Little used in routine clinical practice for the diagnosis of H. pylori.
Biochemical method(rapid urease test) - the presence of bacteria in the biopsy is confirmed by a change in the color of the medium, which reacts to the decomposition of urea by urease secreted by H. pylori.
Detection of H.pylori in the mucous membrane of the stomach and duodenum by polymerase chain reaction. This method has the highest specificity.
Non-invasive diagnostics:
Serological methods: detection of antibodies to H. pylori in blood serum. The method is most informative when conducting epidemiological studies. Clinical Application The test is limited by the fact that it does not allow to differentiate the fact of infection in history from the presence of H. pylori at the moment and to control the effectiveness of eradication. Not all serological tests are equal. Due to the variability in the accuracy of different commercial tests, only validated IgG serological tests should be used (level of evidence: 1b, grade of recommendation: B). A validated serological test can be used to make decisions about prescribing antimicrobials and antisecretory agents when ulcer bleeding, atrophy and gastric tumors (level of evidence: 1b, grade of recommendation: B, expert opinion (5D).
Urease breath test (URT) - determination of elevated ammonia concentration in the exhaled air of a patient after oral urea loading as a result of the metabolic activity of H. pylori.
Isotope urease breath test - determination in the patient's exhaled air of CO2 labeled with the isotope 14C or 13C, which is released under the action of H. pylori urease as a result of the breakdown of labeled urea in the stomach. Allows you to effectively diagnose the result of eradication therapy.
Determination of H. pylori antigen in feces using monoclonal antibodies. The diagnostic accuracy of the antigen stool test is equal to that of the urease breath test when validated first by a monoclonal laboratory test (LE: 1a; Grade of recommendation: A).
In patients treated with proton pump inhibitors (PPIs): 1) If possible, PPIs should be suspended for 2 weeks before testing by bacteriological, histological, rapid urease test, UDT, or detection of H. pylori in feces (level evidence: 1b, grade of recommendation: A);
2) If this is not possible, a validated serological diagnosis can be performed (level of evidence: 2b, grade of recommendation: B).
In pediatric practice, preference should be given to non-invasive methods for detecting H. pylori.
DIFFERENTIAL DIAGNOSIS
Peptic ulcer must be differentiated from symptomatic ulcers, the pathogenesis of which is associated with certain background diseases or specific etiological factors(Table 3). The clinical picture of exacerbation of these ulcers is erased, there is no seasonality and periodicity of the disease.
Gastric and duodenal ulcers in Crohn's disease, sometimes also referred to as symptomatic gastroduodenal ulcers, are an independent form of Crohn's disease affecting the stomach and duodenum.
Differential diagnosis of peptic ulcer with functional disorders gastrointestinal tract, chronic gastroduodenitis, chronic diseases liver, biliary tract and pancreas is carried out according to the anamnesis, examination, the results of laboratory, endoscopic, x-ray and ultrasound studies.
TREATMENT
Goals of therapy:
H. pylori eradication (if available).
Healing of the ulcer and rapid elimination of the symptoms of the disease.
Achievement of stable remission.
Prevention of development of complications.
Non-drug treatment
1.Mode physical activity. Protective mode with limitation of physical and emotional stress.
2. Diet.
Therapeutic nutrition of children with PU is aimed at reducing the action of aggressive factors, mobilizing protective factors, and normalizing gastric and duodenal motility.
AT acute phase or in case of recurrence of peptic ulcer, diet No. 1 is prescribed, or a variant of the diet with mechanical and chemical sparing (according to the new nomenclature of diets). initially wiped version, as the condition improves - not wiped version. Highly effective modern antisecretory therapy made it possible to abandon the previously used physiologically unbalanced diets 1a, 1b.
Products that irritate the gastric mucosa and stimulate the secretion of hydrochloric acid are excluded: strong meat and fish broths, fried and spicy foods, smoked meats and canned food, seasonings and spices (onion, garlic, pepper, mustard), pickles and marinades, nuts, mushrooms, refractory animal fats, vegetables, fruits and berries without prior heat treatment, fermented milk and carbonated drinks, coffee, cocoa, chocolate, citrus fruits.
Products with pronounced buffering properties are recommended: meat and fish (boiled or steamed), steam omelette, milk, unleavened mashed cottage cheese. The diet includes soups based on vegetables and cereals, milk porridges (except for millet and pearl barley), vegetables (potatoes, carrots, zucchini, cauliflower) boiled or in the form of mashed potatoes and steam soufflés; baked apples, mousses, jelly, jelly from sweet varieties of berries, weak tea with milk. Also allowed pasta, dried wheat bread, dry biscuit and dry biscuits. Dishes are served warm, a fractional diet is used, 5-6 times a day. Food is taken in a calm atmosphere, sitting, slowly, chewed thoroughly. This contributes to better impregnation of food with saliva, the buffering capabilities of which are quite pronounced.
The energy value of the diet should correspond to the physiological needs of the child. In order to influence the reparative processes, enhance the cytomucoprotection of the gastric mucosa, it is recommended to increase the quota of protein with a high biological value in the diet. It is advisable to supplement the diet with enteral nutrition - normocaloric or hypercaloric mixtures based on cow's milk proteins.
Diet #1 is recommended for 2-3 weeks, then the food ration is gradually expanded to match Diet #15 (or the main variant of the standard diet).
Medical treatment
Peptic ulcer of the stomach and duodenum associated with H. pylori Eradication therapy is shown.
According to the latest recommendations of the IV Maastricht Agreement (2010, Table 4, Table 5), ESPGHAN and NASPGHAN (2011), standard triple therapy:
PPI (esomeprazole, rabeprazole, omeprazole) 1-2 mg/kg/day + amoxicillin 50 mg/kg/day + clarithromycin 20 mg/kg/day
or
PPI + clarithromycin + metronidazole 20 mg/kg/day.
The duration of therapy is 10-14 days.
In order to increase the acceptability of therapy, it is possible to use the so-called. a "sequential" regimen where PPIs are given for 14 days and antibiotics are given consecutively for 7 days each.
Standard second-line quadruple therapy with bismuth: PPI + metronidazole + tetracycline + bismuth subcitrate 8 mg / kg / day - 7-14 days - is not used in children in Russia.
With the ineffectiveness of eradication therapy, an individual selection of the drug is carried out based on the sensitivity of H. pylori to antibacterial drugs - third-line therapy.
To assess the effectiveness of anti-Helicobacter therapy, standard non-invasive tests are used. Eradication efficiency control is determined after at least 6 weeks. after the end of treatment with tetracycline in children, according to the recommendations of Russian experts, the following schemes are used in children:
First line therapy.
PPI + amoxicillin + clarithromycin
PPI + amoxicillin or clarithromycin + nifuratel (30 mg/kg/day)
PPI + amoxicillin + josamycin (50 mg/kg/day, not more than 2g/day).
It is possible to use a "serial" scheme.
Quadrotherapy is used as second-line therapy:
bismuth subcitrate + PPI + amoxicillin + clarithromycin
bismuth subcitrate + PPI + amoxicillin or clarithromycin + nifuratel. The duration of treatment is 10-14 days.
In order to overcome the resistance of H. pylori to clarithromycin and reduce side effects from the use of antibacterial drugs, a scheme is used with the sequential prescription of antibiotics: PPI + bismuth subcitrate + amoxicillin - 5 days, then PPI + bismuth subcitrate + josamycin - 5 days. For the prevention and treatment of antibiotic-associated diarrhea, along with eradication therapy, it is recommended to prescribe probiotic preparations (Saccharomyces boulardii 250 mg 2 times a day). in children.
Peptic ulcer not associated with H. pylori In case of peptic ulcer not associated with H. pylori. pylori, the aim of treatment is to stop clinical symptoms disease and ulcer scarring. In this regard, the appointment of antisecretory drugs is indicated.
Currently, the drugs of choice are proton pump inhibitors: esomeprazole, omeprazole, rabeprazole, which are prescribed at a dose of 1-2 mg/kg/day. The duration of the PPI course is 4 weeks for DU, 8 weeks for DU.
H2-blockers have lost their position and are now rarely used, mainly when it is impossible to use PPIs or in combination with them in order to enhance the antisecretory effect.
Antacids (aluminum hydroxide or phosphate, magnesium hydroxide) are used in complex therapy for symptomatic purposes to relieve dyspeptic complaints. To enhance cytoprotection, bismuth subcitrate 8 mg/kg/day is prescribed for up to 2-4 weeks. In case of violations of the motility of the gastrointestinal tract, prokinetics, antispasmodics are prescribed according to indications. The effectiveness of treatment for gastric ulcers is controlled by the endoscopic method after 8 weeks, with duodenal ulcers - after 4 weeks.
Further tactics of drug therapy: Continuous maintenance therapy with PPI (duration is determined individually) is indicated for: complications of PU; availability concomitant diseases requiring the use of NSAIDs; concomitant PU erosive and ulcerative reflux esophagitis. Therapy on demand:
The indication for this therapy is the appearance of symptoms of peptic ulcer after successful eradication of H. pylori. On-demand therapy provides for the appearance of symptoms characteristic of an exacerbation of PU, taking PPIs for 2 weeks. If symptoms persist, conduct FEGDS, examinations, as in an exacerbation.
Surgery
Indications for surgical treatment of gastric ulcer - complications of the disease: ulcer perforation, decompensated cicatricial-ulcerative pyloric stenosis, accompanied by severe evacuation disorders; profuse gastrointestinal bleeding that cannot be stopped conservative methods, including the use of endoscopic hemostasis. When choosing a method of surgical treatment, preference is given to organ-preserving operations.
MANAGEMENT OF CHILDREN WITH ULCER
Indications for hospitalization:
YAB with clinical picture pronounced exacerbation (pronounced pain syndrome).
Signs of complications of PU.
PU with a history of complications.
PU with concomitant diseases.
Detection in the stomach of ulcers requiring differential diagnosis between benign ulcers and stomach cancer.
Children with exacerbation of peptic ulcer are treated in a pediatric or gastroenterological department.
The length of stay in the hospital averages 14-21 days at the debut and recurrence of peptic ulcer.
Children with uncomplicated course of peptic ulcer are subject to conservative treatment in an outpatient setting.
Children in remission are observed on an outpatient basis (Table 7).
Deregistration is possible with complete remission within 5 years
Experts believe that gastric ulcer at an early age can develop against the background of constant stressful situations and excessive susceptibility of the child's psyche.
However, the main reasons for which an ulcer can be are the following:
- genetic predisposition;
- non-compliance with the diet;
- fast food process; lack of first courses in the diet;
- use harmful products;
- violation of the functioning of the organs of the gastrointestinal tract;
- taking certain medications;
- the presence of concomitant diseases (gastritis, gastroenteritis, etc.).
Symptoms
The main symptom of a defect in the gastric mucosa is pain in the navel. It has the property of "given" to the back and lower back. It has a periodic rhythmic character. Depending on the progression of the disease, it either increases or subsides. In addition, an ulcer can be recognized by such common symptoms:
- bouts of nausea and vomiting;
- feeling of heartburn;
- frequent belching with a sour taste;
- lack or decrease in appetite;
- variability of the stool (constipation - diarrhea);
- autonomic dysfunction;
- predisposition to constipation.
In the presence of these symptoms, it is necessary to show the child to a pediatric gastroenterologist. If, against the background of ulcerative symptoms, frequent colds are observed, then you should also visit a pediatrician. The latter, in turn, depending on the results of the examination, can refer you for a consultation to such specialists as: an endocrinologist, an allergist, a cardiologist, etc.
Diagnosis of a stomach ulcer in a child
You can determine the presence of an ulcer in children in the following ways:
- examination by a doctor and physical examination (palpation of the abdomen);
- medical laboratory research. These include blood and stool tests. As a rule, they are carried out when there are suspicions of complications in the form of bleeding;
- fibroesophagogastroduodenoscopy (is a collection of material for histological examination for possible processes of tumor development);
- x-ray of the gastrointestinal tract;
- determination of the functions of the stomach using intraventricular pH-metry;
- CT scan;
- determination of the presence of the bacterium Helicobacter pylori;
- older children are duodenal sounding during an exacerbation, they take an analysis of gastric juice and additionally examine the liver.
Complications
The most basic and dangerous complication peptic ulcer is internal bleeding. With the bleeding that has opened, the following signs appear: the feces become black, vomiting of coffee grounds, a decrease in blood pressure and worsening general condition.
In addition, against the background of untimely treatment of the disease, the following consequences arise:
- Ulcer perforation. There is a strong sharp pain, which can lead to a state of shock. On palpation of the abdomen, due to the entry of air into the peritoneal cavity, hepatic dullness disappears.
- Penetration. In this case, the ulcer spreads to other organs. However, this complication is extremely rare. Only in cases of prolonged neglect of the disease and improper treatment.
- If there is a perforation of the ulcer, the mucosal defect becomes through and all the contents of the stomach fall into the peritoneum. It is accompanied by very strong painful sensations.
If a complication is suspected, it is urgent to call ambulance and before her arrival, do not give the patient to drink, eat and no medicines. You can put cold on the stomach to relieve the condition.
Treatment
If the disease is detected for the first time, then its treatment takes place only in the conditions of hospitalization. If it occurs repeatedly, then under the supervision and control of a doctor, the child can stay at home, taking into account the strict implementation of all recommendations.
What can you do
The main component of complex therapy is strict adherence to the diet. An ulcer diet includes the following items:
- fractional food. It is necessary to eat food in small quantities every two to three hours;
- between the last meal and sleep should be at least three hours;
- dishes should be mostly liquid (puree);
- on temperature regime all food should be warm (in no case hot);
- the diet should not contain fried, smoked, fatty, salty, sour, bitter foods that adversely affect digestive system and irritate the gastric mucosa;
- careful chewing;
- limiting salt intake to 8 grams per day;
- complete rejection of harmful products (fast food, carbonated drinks, chips, crackers, ketchups, mayonnaise, etc.).
In addition, the patient needs strict bed rest.
What can a doctor do
In addition to the diet in the treatment of stomach ulcers, a specialist prescribes complex treatment, which includes:
- taking drugs of the antacid group;
- antimicrobial agents (antibiotics); antihistamines;
- physiotherapeutic procedures (UHF, mud procedures, paraffin and ozocerite);
- rehabilitation. It is held for three years in a row, after which, in case of successful treatment, the child is removed from the register.
Prevention
To avoid the development of peptic ulcer in children, it is first necessary to monitor their diet and emotional state. Adhering to the following simple rules, you can prevent the development of an ulcer in a child:
- daily diet should include all essential vitamins, useful material and microelements;
- food must be of high quality;
- Avoid both overeating and hunger. Everything should be in moderation;
- food should be varied;
- the daily diet must be observed;
- meals should be appropriate for the age of the child;
- rejection of harmful products;
- adhere to the basics of fractional nutrition.
You will also learn how untimely treatment of a stomach ulcer in children can be dangerous, and why it is so important to avoid the consequences. All about how to prevent stomach ulcers in children and prevent complications.
And caring parents will find on the pages of the service full information about the symptoms of stomach ulcers in children. How do the signs of the disease in children at 1.2 and 3 years old differ from the manifestations of the disease in children at 4, 5, 6 and 7 years old? What is the best way to treat stomach ulcers in children?
Take care of the health of your loved ones and be in good shape!