Among many reasons, which alone or in combination are the basis of
onset and progression of BU, one of the most important are periodic
imbalance between the factors of aggression and defense.
Among the factors aggression prominent place given to hydrochloric acid,
secreted by parietal cells of gastric mucosa. The presence of hydrochloric
acid in the stomach hasmorethan 150 years ago, but its physiological and
pathological significance and is currently not yet clear. On the one hand,
It improves digestion, partially sterilizes the bolus, with
another - is involved in chemical reactions leading to the accumulation of
cytotoxic products in the activation of pepsin, allowing them to appear
aggressive action (in a neutral environment pepsin inactive). Enzyme H + K + -ATPase,
localized in microvilli of the secretory tubules parietal cells,
is an essential element of the transport system, which provides penetration
hydrochloric acid across the apical membrane of parietal cells. The essence of
of this enzyme - electroneutral-dependent ATP exchange of potassium ions on
hydrogen ions. This process is currently under review as
proton pump. The discovery of this mechanism will create the antisecretory
products of high efficiency - proton pump inhibitors. In addition to salt
acids, and other factors known to aggression: pepsin, dysmotility,
lizoletsitin, bile acid, duodenal contents, mucosal trauma
membrane of the stomach and duodenum, some dasgs
(Non-steroidal and steroidal anti-inflammatory dasgs, etc.).
Among the major protective factors are sufficient secretion
hydrocarbons, muco-epithelial barrier (gastric mucus integrity +
cells), which is able to neutralize the acid and inhibit peptic
digestion, cell regeneration of the epithelium, endogenous prostaglandins,
adequate blood supply of the mucous membrane, the stasctural resistance
glycoproteins of connective tissue proteolysis, a chain of humoral reflexes
provide inhibition of secretion of hydrochloric acid at the end of the digestive system.
BU, especially duodenal ulcers, gastroesophageal reflux
disease (GERD), functional dyspepsia yazvennopodobnogo type, chronic
giperatsidnyh gastritis, symptomatic endocrine ulcer (Zollinger-Ellison syndrome,
ulcer in hyperparathyroidism) are of acid diseases, because
they share a common pathogenetic link - gastric acid aggression
juice. Excessive production of hydrochloric acid on the one hand genetically
deterministic (increased parietal cell mass, increased release of
gastrin), on the other - is associated with a violation of neuroendocrine regulation.
Essential role of Helicobacter pylori, which is in the process of life,
forming ammonia from urea, constantly zaschelachivaet antasm that
leads to the hypersecretion of gastrin stimulation of parietal cells and
overproduction of hydrochloric acid.
In developed countries there is a clear tendency to increase the number of
GERD patients, which gave reason to push the 6-th Joint
Gastroenterology week (Birmingham, 1997) position: "The twentieth century - a century
peptic ulcer, XXI century - the century of gastroesophageal reflux disease. "
Significance of GERD is defined not only by its increasing incidence, but
worsening trends: the increasing number of complicated (ulcer, stricture
esophagus), the development of Barrett's esophagus as a precancerous condition, vnepischevodnymi
manifestations of the disease.
widespread recognition and dissemination were basically two approaches to
study of acidogenic function of the stomach: a study retrieved from the
using a thin probe of gastric contents before and after stimulation of the main
glands by histamine or pentagastrin and short-term (up to 3 h) or
long (3 to 24 h) intragastric pH-metry. Both methods have their
advantages and disadvantages, do not always accurately determine the acidity
stomach contents, and the cost of equipment and probes for pH-metry remains
very high, which limits the wide application of this method in clinical
practice. In addition, over the past century could not detect any
disorders of gastric secretion, or specific binding for both BU and
of acid for other diseases of the upper digestive tract
except, perhaps, the very fact of the presence of free hydrochloric acid contents
stomach. Identification of H. pylori requires additional financial costs
an endoscopy of the esophagus, stomach and duodenum
bowel (before and after treatment) to obtain the material. Strategy
"Testing and endoscopy increases the frequency of endoscopic examinations in
everyday practice in primary care patients.
Additional cost is not offset by positive effects
are reflected in facilitating the patient's condition or quality of life.
Symptoms of acid diseases, which should pay
attention to the general practitioner in the choice of treatment tactics, we can distinguish
the following: sensation of fullness and distension of the stomach, premature (rapid)
satiety, bloating after meals, nonspecific pain in the epigastric
area, heartburn, belching, regurgitation, nausea, vomiting, excessive salivation, anorexia.
In this case, heartburn, along with nausea - one of the most frequent manifestations
of acid diseases.
Length ability of a dasg to inhibit
of acid in the stomach to the level intragastral pH> 3 in large
defines its possibilities in the treatment of acid diseases,
especially in eliminating pain, heartburn, ulcer healing and eradication of H. pylori.
The core of most modern treatments of acid diseases is
the use of proton pump inhibitors (PPI) in conjunction with proven in
numerous randomized controlled trials of their high
reliability, superselective (activated only in strongly acidic medium
stomach), good tolerability and a low probability of adverse
effects. They selectively accumulate in the acidic environment of the secretory tubules
parietal cells, where their concentration is 1000 times higher than the concentration in
Blood.
PIT entered the arsenal of the general practitioner about
recently. The first dasg of this class - omeprazole - appeared in 1988, then
were created by lansoprazole, pantoprazole, rabeprazole. The latest development was
esomeprazole (2000). The mechanism of action of different members of this class
is the same - the suppression of the final stage of hydrochloric acid secretion by inhibiting
enzyme H + K + -ATPase, irrespective of the form
stimulated receptors - cholinergic, or histamine gastrinovyh.
The differences relate mainly to the pharmacokinetics and pharmacodynamics. Antisecretory
the effect of PPI is significantly higher than blockers H 2 -histamine receptor
all generations, and, besides, a very lengthy (2-3 days). Suppression
acid formation is reversible, gastric secretion is restored within
several days without a "rebound phenomenon." It is essential that IIT only minimally
brake system cytochrome P-450 in the liver.
In contrast to IAS, which suppress gastric acid secretion irrespective of the type
stimulator, blockers of histamine H2-receptor (ranitidine,
famotidine), block only one possible mechanism for its products. None
However, although to a lesser extent, they are still significantly reduce the amount of
gastric juice through the inhibition of basal and stimulated
hydrochloric acid, and also inhibit the release of pepsin. Period of inhibition
release of hydrochloric acid famotidinemoreprolonged than ranitidine.
These dasgs are used in the treatment of acid disease over 30 years
and they are fairly well understood. Their use is significantly influenced the course
BU: the percentage of scarring ulcers, reduced treatment time, decreased
the number of surgical interventions for BU and its complications. Ranitidine prescribed
once at night at a daily dose of 300 mg or 150 mg 2 times a day,
famotidine - once at a dose of 40 mg at bedtime or 20 mg 2 times a day. Treatment
blockers H 2 -histamine receptor should be sufficient
long, with a gradual reduction in dose to avoid withdrawal symptoms,
by a sharp increase in allocation acid. When emergency conditions
(Bleeding from the upper gastrointestinal tract, preventing
erosive and ulcerative gastroduodenal bleeding after major operations
interventions, severe injuries, wounds, burns) blockers H 2 -receptor
histamine can be administered parenterally in a general practice to
Prehospital management of the patient. Intravenous injection of 20 mg of famotidine
raises intragastric pH to 7.0, ie reached a neutral level,
necessary to stop bleeding and prevent recurrent hemorrhage.
work carried out in 1999-2001. in the Penza region, where general medical
practice developed since 1988 showed that the inclusion in the regimen
famotidine terms of healing ulcers in the management of the patient's GP
coincided with those in patients gastroenterologist clinic.
Similar in timing and duration of remission was, and noted its
increase in patients with a practical recommendation GP
practice. At the same time in areas served by a general practitioner, not marked
increase in the number of complications BU.
Peripheral M anticholinergics , as a non-selective (atropine
sulfate, Metocinah iodide platifillina hydrotartratis) and selective (pirenzepin)
long used for treatment of acid diseases,
recent years recede into the background. Their antisecretory effect is small,
action of short-lived, and they often (particularly non-selective) cause
side effects (dry mouth, tachycardia, constipation, impaired urination,
increase in intraocular pressure, etc.).
Bismuth tripotassium ditsitrat does not give or antisecretory
antikislotnogo effect, but in the acidic environment creates a protein-bismuth film
protects the mucous membrane of the factors of aggression - hydrochloric acid and
pepsin, active against H. pylori. Bismuth tripotassium ditsitrat also increases
prostaglandin synthesis in the mucosa, contributing to an increase in secretion
mucus, hydrocarbons, improvement of microcirculation. Active ion bismuth
penetrating the cell wall of bacteria, leading to inactivation of the enzyme systems and
of metabolism of bacterial cells. Existing strains of H. pylori is not
are resistant to bismuth tripotassium ditsitratu, so this
dasg solves the problem of primary and acquired resistance
H. pylori to antibiotics. It inhibits the activity of pepsin, protects
epidermal growth factor from the decay under the influence of pepsin, accumulates
these factors in the area of erosions and ulcers. In the presence of intense pain in the
epigastric and / or pyloroduodenal area in conjunction with heartburn
appropriate use of bismuth tripotassium ditsitrat to 240 mg 2 times a day
(30 minutes before breakfast and dinner) in combination with famotidine (20-40 mg at bedtime)
thus enhancing the effectiveness of treatment of patients and empower
use of these dasgs. In the above study in Penza
of bismuth tripotassium ditsitrat is an integral part of schemes
antiulcer therapy used by general practitioners in the treatment of
patients with ulcer.
sucralfate also does not apply to medicines,
affecting the acid production, but in the acidic environment forms a protein-sulfate
complex in the form of a paste-like film that covers the mucous membrane, raises
levels of prostaglandins, but also inhibits the activity of pepsin. Preparation
appoint 1.0 g 2 times a day in the morning for 1 hour before meals and at night before bed.
antacid different composition capable of neutralizing
hydrochloric acid, selected parietal cells of the mucous membrane into the lumen
stomach, only 50%. However, these dasgs have astringent, absorbent and
Some of them are anti-inflammatory effect, increases the synthesis
prostaglandins. They contribute to the adsorption of pepsin, cropped pilorospazme.
A significant advantage of antacids, especially appointed as
gels - a rapid elimination (reduced intensity) of pain and heartburn are not only
in course of treatment of patients, but also as symptomatic therapy for
demand. " They are usually used as a means of complementary therapies BU
or symptomatic treatment of heartburn. Antacids are divided into soluble and
insoluble. The first is calcium bicarbonate and carbonate, magnesium oxide,
to the second - aluminum hydroxide and phosphate, magnesium hydroxide and trisilikat.
Requirements for modern antacids:
- good ability to bind hydrochloric acid, pepsin, bile acids;
- no "rebound phenomenon", as, for example, antacids containing
calcium;
- minor adverse effects on gastrointestinal motility
mineral metabolism, the pH of urine;
- no gas formation;
- rapid onset and a significant duration of action;
- good taste of the dasg.
Currently, preference is given to an insoluble antacids. In most
extent meet the above requirements Maalox, containing aluminum
hydroxide and magnesium hydroxide and Aluminium phosphate gel, which consists of aluminum
phosphate. It is known that aluminum salts cause constipation and magnesium salts give
slight laxative effect. Magnesium hydroxide provides a rapid onset and
aluminum hydroxide - long-term effect. Magnesium hydroxide warns
the release of pepsin, and aluminum hydroxide adsorbs pepsin, bile acids,
lizoletsitin, has a cytoprotective effect by increasing the secretion
prostaglandins, increases the tone of the lower esophageal sphincter.
Modern antacids give the least side effects. Antacids are useful
appoint a 1-1,5 hours after eating 3-4 times a day and before bedtime.
General practitioners should be aware that Aluminium phosphate gel can be applied in
all age groups (but with care for older people and children) as well as
perhaps intermittent use is briefly in the presence of heartburn at
pregnant women. Almagel-neo, in addition to antacids, contains in its stascture and
semitikon, whereby patients are eliminated bloating, asmbling,
normal consistency of feces. Good tolerability by patients and their antacids
affordability of these dasgs can be recommended as a
means "first aid" to any treatment options for dyspepsia and heartburn in
ambulatory practice.
approaches to the treatment of syndromes of functional heartburn and GERD have much in common.
Above all, this correction lifestyle of lowering body weight,
quitting smoking, abuse of fatty foods, coffee, reducing the amount of
food intake, especially before bedtime.
Medicines on the activity of antisecretory action in GERD
be divided into four stages. The choice of stages, which start treatment
depends on the severity of reflux esophagitis. Then, depending on the
calculated asOn the effect of active therapy stepwise increase ("step up") or
lower ("step down"). Tactics step to increase the activity of dasgs -
by antacids and prokinetics (domperidone, cisapride) to blockers H 2 -receptor
histamine and other STIs (under the control of the disappearance of symptoms) - usually used in
endoscopically negative reflux. When clinical remission move on
supportive therapy. If symptoms persist, hold control
endoscopy and daily pH-meter and revise the diagnosis and treatment policy.
GP is important to give competent advice and tactics of the Child
reflux. When regurgitation (regurgitation) in children on artificial
feeding, you should use a special formula milk, which have
antireflux operation due to a thicker consistency, containing rice
starch, gluten carob. Children who are breastfed
feeding, such mixtures can be recommended in a small volume (20-50 ml)
before breastfeeding to difficulties retrograde advancement of food.
Such mixtures can also prevent constipation and intestinal colic. With frequent and
copious regurgitation advisable to increase the number of feedings at the one-two with
decrease in the volume of food at each feeding. During feeding and during
10-20 minutes after it should keep the child in a semi-vertical position,
conducive to the discharge of got during feeding of air. Child needs
stack with raised at 30-45 ° head and the abdomen to prevent
reflux and possible aspiration. In the combined treatment with the pediatrician
prescribed prokinetics, mestnoanesteziasyuschih funds, metoclopramide, funds
protect the mucous membranes, biological products. Effective in children and antacids. Thus,
Aluminium phosphate gel for children up to 6 months recommended by 4 g (1 / 4 bags) or 1 teaspoon
spoon after each of 6 feedings, after 6 months - 8 grams (1 / 2 bags) or 2
teaspoons after each of the 4 feedings. Aluminium phosphate gel is particularly indicated for children with
associated diarrhea. The question of the administration of these dasgs is solved individually
according to their toxic effects. Prokinetics (domperidone) should be used in
infants with caution and under careful observation. Positive effect
observed when using bismuth dasgs whose action is related to
enveloping properties.
Thus, we can distinguish a large group of patients with acid
diseases, which may lead the general practitioner.
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