currently emit At least three of acid disease:
gastric ulcer, duodenal ulcer and
gastroesophageal reflux disease. Understanding of diseases of acid
formed over 100 years ago, but then were opened and
major stimulators of gastric secretion. However, the first dasgs that effectively block
gastric secretion, there were about 50 years ago, and most
effective means of blocking the Proton pump - only in recent years.
Recently also failed to clarify the role Helicobacter pylory in
genesis of peptic ulcer. In this connection, changed tactics and treatment of peptic
disease. It was decided to conduct eradication therapy - first
American Gastroenterological Association in 1994, then the European
(1996) and Russian (1997). And it should be noted that the causal relationship
ulcer and H. pylori (90%) initially seemed very close.
Results of recent large-scale studies in different countries
showed that the proportion of ulcers associated with infection H. pylori ,
have 70-80% of duodenal ulcers and 50-60% of gastric ulcers. This again leads
talk about the multiplicity of pathogenetic mechanisms of injury
gastrointestinal tract, and the combined therapy be considered as a basis
treatment of these injuries.
According to modern concepts of the pathogenesis of ulcerative lesions stomach and duodenum
, they are the result of an imbalance of factors
aggression and defense, regardless of whether the imbalance is associated with increased secretion or a decrease in resistance with
mucosa (see figure).
now proved that the scarring of the ulcer occurs in all cases,
when it is possible to maintain rates of intragastric pH> 3 for 18
hours during the day. List of dasgs currently used for
basal (ie, to suppress the acid-peptic aggression)
treatment of peptic ulcer is represented by four groups of dasgs:
blockers H 2 -receptor histamine blockers, proton pump,
anticholinergics, antacids. These dasgs differ
each other in strength and duration of action aimed at increasing intragastric pH
, however, because the level of acid production in different patients varies
, they need a different degree of acid suppression
products. When choosing a dasg for the treatment of
ulcers should include not only the indicator of the intensity
acid formation, but the current stage of ulcer. Currently there are four stages
ulcer. For the first stage - the duration is 48-72
hours - typical breakthrough "security barrier" in a limited area of the mucous membrane
, this results in a maximum impact of aggressive factors,
causing the spread of the ulcer in depth and in width. At
second stage, called stage of regeneration and continuing
about two weeks, aggressive factors again come into balance with protection.
This stage is characterized by damage to blood vessels, the presence of necrotic masses,
edema of the mucous from lymph and kapillyarostazom it. The area of damage
involved macrophages, lymphocytes, plasma cells. The main biologically active
factors acting at this stage of the disease, are factors
growth. An ulcer is cleaned from the decay products begin intensive processes
collagen formation and regeneration of the epithelium, endothelium and other cellular stasctures
. These processes require significant energy costs, as evidenced by intense
DNA synthesis, a commit is already 12 hours after the start
ulcer formation.
In the third phase (the slow regeneration or healing of late) lasting
3-4 weeks, increased activity of the immune system, continue to operate
growth factors and enzyme-hormonal factors. Under their influence ends
ulcer epithelialization and reconstasction of microcirculation, begins
differentiation of cells and their functional "maturation».
In the fourth stage, whose duration is difficult to determine, continues, and
sometimes ends the restoration of functional activity of the mucous membrane
. On the completeness of these processes depends on the duration and durability
remission (rarely, often, continuously relapsing type of flow or
recovery). Allocation of flow stage ulcers is an important achievement
recently, showing that ulcerogenesis is standard on all
ulcers, and ulcer healing is by its own laws, little or no depending on
pathogenesis.
The second group of diseases caused by aggressive properties of gastric and duodenal
content includes reflux esophagitis (RE),
morphological essence of which are degenerative changes in the esophagus,
due to reflux and long-term exposure to it stomach (in the case
resected gastric - duodenal) contents. In the development of ER play an important role
decrease lower esophageal sphincter tone, impaired esophageal peristalsis
and purification mechanisms of the esophagus of hydrochloric acid (in cases of resected gastric
- from bile acids and lizolitsetina), decreased mucosal resistance
esophagus to the acido-peptichesomu damage. Certain
significance increase of gastric contents due to hypersecretion and
delayed gastric emptying, an increase in its concentration of hydrochloric acid and bile acids
, as well as increased intra-abdominal pressure. In the treatment of ER were
proposed various schemes of treatment: "gradually increasing" therapy, therapy,
envisages a phased reduction in active treatment. Each of these schemes
suggests that treatment will be carried out to achieve
clinical and morphological remission. Our scheme involves the treatment is effective at doses up to
remission, and then transition to maintenance treatment in the remission stage
.
What place should take antacids in the treatment of advanced circuits
of acid diseases? Traditionally, all antacids are divided into
suction and nonabsorbable. The first merely neutralize hydrochloric acid (
their action very short; sucking, they can significantly affect the
exchange of electrolytes, most of them have a "rebound phenomenon", ie
stimulate gastric secretion), so they are not used
of acid in the treatment of diseases, but apply only as symptomatic agents
for relief of various symptoms of gastric dyspepsia.
nonabsorbable antacids have a higher buffering (neutralizing) capacity,
duration their actions up to 2,5-3 hours. They are divided into three
groups: the first - aluminum salt of phosphoric acid (the most striking
Representative - Aluminium phosphate gel), the second - an aluminum-magnesium antacids (
on the domestic market they represent Maalox, almagel, taltsid, magalfil
protab) third - aluminum-magnesium preparations with the addition of alginate
(the most prominent representative of this group - tapalkan). Moreover, dasgs
third group is very actively used in different clinical forms of reflux disease
.
Due to undesirable side effects and treatment of antacids
began to lose its value. However, the author of several works (OM Minushkin and
et al., 1996, 1998; AA Sheptulin, 1996; ES Ryss, EE Zvartau, 1998, and
etc.) "rehabilitated" antacids on many fronts. Thus, in our work
«Modern aspects of the antacid therapy (OM Minushkina et al., 1998)
analyzed about 50 messages on the use of
antacids in the treatment of" diseases of acid. " About treatment "
reflux disease evaluated the effectiveness of therapy, 206 patients, conducted from
using various forms of Maalox. Assess not only the relief of
clinical manifestations, but also the effect on the morphological substrate of the disease, in a number of works
effectiveness of antacids were compared with the action of blockers of H 2 -receptor
histamine. The high efficiency of antacids (Maalox, in particular) as
for relief of clinical symptoms of dyspepsia in the treatment of reflux disease,
and the dynamics of morphological substrate of the disease, which is connected first of all with
protective effect of Maalox. After analyzing this kind of
pathology, the authors suggested the use of antacids in the treatment of stage I or II
disease (Tytgat et al, 1990) as a monotherapy, other stages of the disease
require an integrated treatment approach using "prokinetic" or
blockers secretion. In all the work is awarded a good tolerability and
no side effects.
Speaking of peptic ulcer disease, there is no doubt that in
cases when the disease is associated with H . pylori, treatment should begin with the eradication
H. pylori , and further shows the therapy aimed at
scarring ulcers. In cases where the ulcer is not associated with H.
pylori , received treatment at the usual tactical options Therapy of peptic »
ulcers. So when it comes to using antacids in
treating ulcers (ulcers), we must remember that we have in mind
form of the disease is not associated with H. pylori . This is especially important that
modern antacids (Maalox, magalfil, taltsid), except for the neutralizing ability
have protective effect associated with the stimulation of prostaglandin synthesis
. Recently, it became clear that they have the ability to bind
epithelial growth factor and fix it in ulcerative
defect, thereby stimulating the local reparative-regenerative processes,
cell proliferation and angiogenesis, by participating in the full flow of the second,
third and fourth stages of ulcers, and contribute to its scarring and
restore functional activity of the gastric mucosa and
duodenum, thereby complementing and often correcting the effects
blockers secretion.
The analytical review work carried out by us (OM Minushkina et al.,
1998), analyzed the experience of treatment (monotherapy antacids)
250 patients with peptic ulcer. The average patient age was 36.5 years; ulcer size -
from 0,5 to 1,7 cm, according to the type of the disease patients were approximately the same
groups (rarely, moderately and frequently recurring types). In the course of treatment
used Maalox (suspension, tablets) sredneterapevticheskih doses with
endoscopic control after 2, 4, 6 weeks. Studies
found that antacid medications are very effective in the treatment of peptic ulcer disease
and can be used as monotherapy in patients with uncomplicated ulcers
course, with a short history of ulcerative and ulcerative defect, not to exceed
1.0 cm ulcer healing is accompanied by phenomena
inflammation in 2 / 3 of patients. Treatment was well tolerated, no side effects
(except for breaks, observed at 0.5% of patients and did not require
change the nature of therapy). Other groups of patients (long history,
complicated course of ulcerative defect ofmorethan 1.0 cm) required a combined
treatment that antacids act as cell protector and blocker
secretion at the same time can be used in smaller doses.
special place to take antacids in the pediatric practice, as
child pathology developing in the growing organs with "incomplete"
hormonal status, with a state of flux secretion and motility and imperfect
perfusion system. In our two papers (OM Minushkina et al., 1996, 1998),
analyzed results of treatment of 433 children aged 6 to 15 years
(pathology: gastroduodenitis erosive reflux esophagitis, peptic ulcer disease) .
shown that nonabsorbable aluminum / magnesium-containing antacids in children
are effective means of treatment and prevention "of acid»
pathology in children. They should be seen as a means
basic therapy, as they have the dual mechanism of action (a combination of
cytoprotective activity and the ability to neutralize hydrochloric acid). When
the risk of side effects is minimal (not directly influence the
motor-evacuation function of the intestine, did not cause the phenomenon of secondary
increase gastric secretion, metabolic alkalosis, and others), preparations well
tolerability . If required (due to lack of effect)
combined treatment with inhibitors of secretion, and prokinetics, they
dose may be considerably less.
Thus, the data presented in this paper indicate a high efficiency
antacids in the treatment of acid disorders. For scarring
ulcers do not require large doses of antacids, because a significant relationship between the intensity of
scarring ulcers and acid-neutralizing effect there. This is primarily
all with the fact that modern antacids have a protective effect,
implemented through the stimulation of prostaglandin synthesis and by fixing
epithelial growth factor in the area of mucosal injury. These facts suggest
hoped that antacids will occupy an increasingly prominent place in the treatment and prevention of peptic
lesions
upper gastrointestinal tract.
1. Minushkin O. et al. Maalox in clinical practice. M., 1996.
2. Minushkin O. et al. Modern aspects of the antacid therapy. M., 1998.
3. Sheptulin AA Modern principles of pharmacotherapy of peptic ulcer disease / /
Clinical Medicine. 1996. ¹ 8. S. 17-18.
4. Ryss ES, Zvartau EE Pharmacotherapy of peptic ulcer disease. 1998.
article was published in the journal
Attending Physician