Typically, mucosal damage of the gastrointestinal tract is the result of an imbalance of aggressive
(endogenous and exogenous) and protective factors
[3]. The factors of aggression typically include: excessive production of hydrochloric acid and pepsin
, violation of the motor-evacuation function of stomach lizoletsitin and bile acid
duodenal content, some dasgs
(non-steroidal and steroidal anti-inflammatory dasgs), traumatism
mucous membrane of the stomach and duodenum, as well as infectious
factor - Helicobacter pylori . By
protective factor include: muco-epithelial barrier (sufficient
secretion of bicarbonate and mucus of the stomach, the integrity of the cells), the regenerative ability
surface epithelium, the endogenous prostanglandiny enough
blood flow to the mucosa, the stasctural resistance of glycoproteins
connective tissue proteolysis, antroduodenalny brake (secretin,
somatostatin, gastrin), ie chain humoral reflexes, providing
inhibition of hydrochloric acid at the end of digestion. Most
gastroenterologists associated with the development of this process disequilibrium
between the proteolytic activity of duodenal contents and
resistance mucosa [1}.
Many researchers attached to the pathogenesis of gastroduodenal ulcers
of cascial importance is a decrease in resistance.
However, among the many factors of chronic inflammatory diseases
upper digestive tract is currently one of the main places
is infectious [11,13]. Opening of the bacterium Helicobacter
pylori revolyutsiyuv made representations about the etiology, pathogenesis and treatment of gastroduodenal
zone. Along with the concept of "diseases of acid
" a new chapter in Gastroenterology - «HP-associated
disease" [7]. The literature describes several possible mechanisms
mucosal injury in the digestive system under the influence of
Helicobacter pylori [5,10]. One of these
mechanisms related to urease, which is produced in large quantity
H. pylori . Under the influence of urease
urea is hydrolyzed to form ammonia, which protects
Helicobacter bactericidal action of hydrochloric acid of gastric juice.
The resulting ammonia is toxic to epithelial cells,
that leads to an acceleration of the process of proliferation and incomplete differentiation of epithelial cells
. Another mechanism is associated with the extracellular mutsinazoy secreted
H. pylori . Mutsinaza
promotes the destasction of polymeric stasctures of gastric mucus, thus violated the integrity of
mucous gel, which becomes less viscous and partly loses its protective properties
. Consequence of damage mutsinovogo layer, apparently,
is disasption of the normal passage of H + ions through the mucosa,
going to back diffusion, which leads to hypochlorhydria, which is usually observed in the presence
H. pylori .
As a result of violations of the protective mucous barrier simultaneous display
epithelial cells exposed to adverse vozdestviyu aggressive factors (hydrochloric
acid, pepsin, salts, bile acids, etc.). The third mechanism
adverse effects H. pylori
the mucous membrane is the ability to
penetration into the intercellular space and the intracellular canaliculi
parietal cells, which may lead to inhibition of secretion and violation
release of secretion from the lumen of the glands. It should be noted that all these mechanisms
damaging action H. pylori
the mucous membrane of the gastroduodenal region to
remain controversial.
Pathogenic effect of Helicobacter pyloric
performed under certain conditions, in particular, when
naassheniimestnyh defense mechanisms [6]. In this case, the factors of nonspecific protection
include: acidic gastric juice, motor activity of the digestive organs
, aggressiveness secrets of the small intestine, normal microbiocaenosis
colon, preventing infiltrirovanie pathogens. There
evidence that in the presence of H. pylori
possible violations of non-immune defense mechanisms: an increase in permeability
mucosa and absorption of antigens mutsinovogo barrier damage, and so forth
[9]. To the local system of immune protection include: lymphoid tissue,
presented numerous lymphoid stasctures associated with the intestine
throughout (the system GALT), and individual cell lymphoid elements,
localized in the mucosa (MALT - system) [2]. Thus, therapy
chronic diseases of the upper digestive tract should be
comprehensive, individually differentiated, taking into account the pathogenesis of
disease, presence of comorbidity and is aimed at [3]: 1. Reducing excess
aggressive impact by their elimination (eradication
H. pylori ) and neutralization
directly into the lumen of the stomach and lower secretory-motor activity of stomach
. 2. Improving the quality of the protective properties of gastric mucosa and
duodenum by enhancing the formation of mucus secretion stimulation
bicarbonate in the antral gastric mucosa improved trophic,
normalization of its regenerative properties, etc. 3. Impact on the autonomic nervous system
to correct the balance between its sympathetic and parasympathetic divisions
. Frequent gastroenterological pathology also
is gastroesophageal reflux disease (GERD). Its frequency in the population
is 2-4%. The stascture of gastroenterological diseases, according to some
data, the frequency of GERD is 60%. Under GERD understand
chronic relapsing disease characterized by certain esophageal and vnepischevodnymi
manifestations, whether due to pathological GERD gastric and / or
duodenal contents into the esophagus (reflux). GERD can be both with esophagitis,
without it. From the standpoint of general pathology of reflux, as such,
represents movement of the liquid contents in any of communicating hollow
authorities to the contrary, antifiziologicheskom direction. This may occur as a result of
functional insufficiency of valves and / or sphincter
hollow bodies, and in connection with the change of pressure gradient in them.
gastroesophageal reflux (GER) means
involuntary leaking of gastric or GERD, or gastro-intestinal
contents into the esophagus. Basically, it is observed in normal human
phenomenon, which does not develop pathological changes in the surrounding
bodies. Physiologic GER is usually observed after a meal,
characterized by the absence of clinical symptoms, low
duration of episodes of GER, with rare episodes of reflux during sleep.
addition of physiological GER, with prolonged exposure to acidic gastric contents into the esophagus
may occur pathological GER, which is observed
with GERD. For pathological GER is characterized by frequent and prolonged episodes of reflux
observed day and night and gives rise to symptoms,
showing lesions of the mucous membrane of the esophagus and other organs.
In addition, the esophagus gets unusual for him to microbial flora, which
can also cause inflammation of the mucous membranes. In the development of GERD is involved
complex pathological factors: - increased frequency of casts
stomach contents into the esophagus as a result of reducing the antireflux function of the cardiac valve
because: a) reduce the tone of the lower esophageal sphincter, and b) increase
number of episodes of its spontaneous relaxation; - lengthening the time of contact
throw up into the esophagus with the stomach contents of its mucosa
due to the reduction of esophageal clearance: a) Chemical - by reducing
neutralizing (alkalify) in biological fluids - saliva and bicarbonate
esophageal mucus, and b) mechanical - due to a decrease
peristaltic activity and tone of the thoracic esophagus - the damaging impact on
esophagus of hydrochloric acid, pepsin, bile, pancreatic
enzymes contained in gastric throw reflyuktate - to reduce the so-called
"tissue resistance" of esophageal mucosa.
There are several components of tissue resistance
esophagus: predepitelialnaya (mucus layer, unstirred water
layer, the bicarbonate ions), the epithelial stascture (cell membrane,
intercellular connective complexes); epithelial functional
(epithelial transport Na + / H +; intracellular and extracellular buffer
system; cell proliferation and differentiation); postepitelialnaya (blood flow,
acid-base balance of tissue) [4, 12]. Thus, therapy of GERD, except
diet and organizing daily routine includes three groups of medicines: 1.
dasgs that inhibit gastric secretion (antacids, H 2-histamine blockers,
proton pump inhibitors). 2. Dasgs that normalize the motor-evacuation function of the digestive tract
(prokinetics). 3. Dasgs - Protectors
esophageal mucosa. We see that an integral part of therapy data
diseases are medications designed to improve the protective properties
mucosa. However, until recently, the correction of protective mechanisms
insufficient attention, especially in children. Since
severity of the pathological process in the mucosa of the esophagus, stomach and duodenum
largely depends on the state mucin, in
complex therapy of the above diseases should include
tsitomukoprotektivnye dasgs. So preparation is dioctahedral smectite
(Smecta) . It should be noted,
Smecta that are widely used in the treatment of diarrhea of various etiologies
(infectious and noninfectious). There are four types of pathophysiological
diarrhea [8]: the secretory (Vibrio cholerae, certain types of bacteria and viasses);
osmotic (fermentopathy, pancreatic insufficiency), motor (irritable bowel syndrome
, functional diarrhea), exudative ( invasive
acute intestinal infections, inflammatory bowel disease, etc.).
Due to the wide range of Smecta
can be used as etiotrop, pathogenetic and symptomatic
preparation - depending on the type of diarrhea. Such a wide range of Smecta
ensured its high fluidity, enveloping and high sorbing
ability. In this case, it is able to fix on yourself and remove pathogenic microorganisms
(Shigella sonnei, Salmonella, Campylobacter, Vibrio cholerae) and
rotaviasses, their toxins and metabolites, and bile acids, intestinal gases,
undigested carbohydrates ( Fig. 1). In addition, smectite penetrates the mucous (mutsinovy)
layer of the intestine, interacts with the glycocalyx (forms a covalent solid
with glycoproteins of mucus), increases the formation of a protective jelly layer
and improves its quality. This allows Smecta protect the mucous gut
by various stimuli, including H + ions, enterobacteria and their toxins. In view of the mechanisms of action
Smecta it can be used as
tsitomukoprotektivnogo dasg and chronic gastritis, duodenitis,
ulcer disease and gastroesophageal reflux disease. The literature contains data on the use
Smecta as monotherapy in children with chronic gastritis and
gastroduodenitis (including H. pylori -positive)
[7] . In this case, the dasg was prescribed in dosage of the age of 3 weeks to 3 times a day
60 minutes after a meal. Clinical efficacy
reflected in a reduction of pain and other dyspeptic symptoms
(nausea, heartburn, belching and flatulence). Positive dynamics was observed already
on the seventh day of the dasg, and the maximum effect was achieved by the end of
second week. Also improves the endoscopic picture of gastric mucosa
. After therapy, none of the children was not marked pangastrit or erosion in
2,5 times less showed signs of gastroesophageal reflux and duodenogastral
. Dynamic studies showed a significant increase in viscosity
gastric mucus.
after treatment was detected and the positive
dynamics of morphological parameters (reduction or disappearance of signs
inflammation, gastric metaplasia in the duodenum and atrophy of the mucous membrane of the stomach
). After treatment, H. pylori
was not detected or the degree of contamination
decreased. Thus, the use of Smecta in the treatment of chronic
gastritis, duodenitis, peptic ulcer and gastroesophageal reflux disease
is justified because the dasg affects both pathogenesis data
diseases - factors of aggression and defense. Smecta improves the rheological properties
mucus, increasing its viscosity, increasing the resistance of the mucous membrane of
effects of pepsin and hydrochloric acid. In addition, having a high sorption capacity
, it helps to eliminate Helicobacter pyloric and
binds and removes substances that are part of the gastric and duodenal
reflyuktatov (hydrochloric acid, bile acids, lizoletsitin, etc.)
that have a pronounced cytotoxic effect. Application tsitomukoprotektorov in
particular, smectite, which is widely used in treating various types of diarrhea,
seems very promising and in the treatment of diseases
upper gastrointestinal tract in children, especially toddlers,
due to the limited use they have a number of dasgs
(proton pump inhibitors, H 2-histamine blockers, synthetic analogs
prostanglandinov, etc.).
Published with permission from Russian Medical Journal.