Gastric ulcer

Introduction to gastric ulcer Ulcer disease or peptic ulcer is a common digestive tract disease that can occur in the esophagus, stomach or duodenum. It can also occur in the stomach-jejunum anastomosis or in the Meckel room containing the gastric mucosa because of gastric ulcer and Duodenal ulcers are the most common, so the so-called peptic ulcers generally refer to gastric ulcers and duodenal ulcers. It is called peptic ulcer because it was previously thought that gastric ulcer and duodenal ulcer were formed by gastric acid and pepsin digestion of the mucous membrane itself. In fact, gastric acid and pepsin are only one of the main causes of ulcer formation. There are other reasons for peptic ulcers. Because of the many similarities between the etiology and clinical symptoms of gastric ulcer and duodenal ulcer, it is sometimes difficult to distinguish between gastric ulcer and duodenal ulcer, so it is often diagnosed as a peptic ulcer, or a stomach or duodenal ulcer. If the ulcer is clear in the stomach or duodenum, it can be directly diagnosed as a gastric ulcer or duodenal ulcer. basic knowledge The proportion of illness: 0.02% Susceptible people: no special people Mode of infection: non-infectious Complications: upper gastrointestinal bleeding, pyloric obstruction, gastric ulcer perforation, pyloric obstruction

Cause of gastric ulcer

Infection factors:

The role of Helicobacter pylori (HP) in the development of gastric ulcer is still difficult to explain, because only a small number of HP infected people have gastric ulcer, but almost all patients with gastric ulcer combined with chronic active gastritis, HP is the main cause of gastritis The cause, HP is cleared, gastritis disappears, quantitative studies of HP infection show that gastric ulcers, especially in the upper part of the stomach, often combined with severe HP infection.

envirnmental factor:

The incidence of this disease varies from country to country and from region to region. The incidence rate varies from season to season, indicating that the geographical environment and climate are also important factors. In addition, the disease can be caused by other primary diseases such as burns, severe brain injury, and stomach. Onset of oncology, hyperparathyroidism, emphysema, cirrhosis, and renal failure, the so-called "secondary ulcer", which may be associated with gastrin, hypercalcemia, and vagus nerve hyperactivity related.

genetic factors:

Gastric ulcers sometimes have a family history, especially those with a family history of children with ulcers can account for 25% to 60%, and people with type A blood are more susceptible to this disease than others with other blood types.

Chemical factors:

Long-term consumption of alcohol or long-term use of aspirin, corticosteroids and other drugs may cause this disease, in addition to long-term smoking and drinking tea seems to have a certain relationship.

Life factor:

Patients with ulcer disease seem to be more common in some occupations such as drivers and doctors, and may be related to the law of diet deficiencies. Work too much can also induce the disease.

Pathogenesis:

1, pathological typing

Gastric ulcer is a chronic disease, which is divided into four types according to the location of the ulcer:

Type I: small curved ulcer, located near the small curved side of the gastric incision, especially found in the junction of gastric antrum mucosa and gastric mucosa, often low gastric acid secretion, accounting for 80% of gastric ulcer;

Type II: compound duodenal ulcer, often first duodenal ulcer, secondary gastric ulcer, high gastric acid secretion, easy to merge with bleeding, stubborn condition, accounting for 5% to 10%;

Type III: pre-pyloric and pyloric tube ulcers, usually high gastric acid secretion, medical treatment is easy to relapse;

Type IV: high gastric ulcer, located in the upper third of the stomach, within 4cm from the junction of the esophagus and stomach, within 2cm, called "near cardia ulcer", low gastric acid secretion, easy to send blood and perforation.

It can be seen that gastric ulcers are most common with small curved ulcers, especially small antrums. Some large ulcers can occur in the upper part of the small bend and even in the Tuen Mun area. It is rare in the fundus and large curved side.

2, pathological morphology

Ulcers are usually single-shot, round or elliptical, 0.5 to 2 cm in diameter, rarely more than 3 cm, the edges of the ulcers are neat, like a knife cut, the bottom usually passes through the submucosa, deep into the muscle layer or even the muscle layer, submucosa The muscle layer is completely destroyed by erosion and replaced by granulation tissue and scar tissue. During the active period, the bottom of the ulcer can be divided into 4 layers from the surface layer to the deep part: 1 exudation layer; 2 necrotic layer; 3 granulation tissue layer; 4 scar tissue Floor. A gastric ulcer can occur in 2% to 5% of the ulcer.

Gastric ulcer prevention

1. Quit smoking

Smokers have a 2-fold higher incidence of ulcer disease than non-smokers. Smoking affects ulcer healing and promotes ulcer recurrence. Possible mechanisms:

(1) Smoking can promote the secretion of gastric acid and pepsinogen.

(2) Smoking may inhibit the secretion of HCO3-salt from the pancreas, thereby weakening the ability to neutralize acidic fluids in the ball.

(3) Smoking can affect the pyloric sphincter closure function and lead to bile reflux, destroying the gastric mucosal barrier; smoking can delay gastric emptying and affect the gastric and duodenal motor function.

(4) Smoking can affect prostaglandin synthesis in the gastric duodenal mucosa, reduce mucus volume and mucosal blood flow, thereby reducing the defense function of the mucosa.

2, diet

Drinks such as alcohol, coffee, strong tea, and Coca-Cola can stimulate the increase of gastric acid secretion and easily induce ulcer disease. Those who eat refined low-fiber foods have higher incidence of ulcers than those who eat high-fiber. Some people think that multi-slag food may promote epidermal growth factor. Or the role of increased prostaglandin release.

3. Mental factors

People with long-term mental stress, anxiety or mood swings are prone to ulcers. When people are under stress, they may promote gastric secretion and motor function, increase gastric acid secretion and accelerate gastric emptying. At the same time, due to sympathetic excitation, stomach twelve Intestinal vasoconstriction, decreased blood flow to the mucosa, weakening the mucosal defense function.

4, drugs

About 10% to 25% of patients with long-term oral non-steroidal anti-inflammatory drugs develop ulcer disease, of which gastric ulcer is more common, except for drugs that directly stimulate the gastric mucosa mucosa, mainly due to such drugs. Inhibition of cyclooxygenase activity in the body reduces the synthesis of prostaglandins in the mucosa and weakens the protective effect on the mucosa. The original aspirin is fat-soluble and can penetrate the epithelial cell membrane to destroy the mucosal barrier.

Gastric ulcer complications Complications upper gastrointestinal bleeding pyloric obstruction gastric ulcer perforation pyloric obstruction

1, upper gastrointestinal bleeding: upper gastrointestinal bleeding is the most common complication of ulcer disease, about 20% to 30% of patients with ulcers have a history of bleeding, duodenal ulcer bleeding more than gastric ulcer, according to statistics Among the various causes of upper gastrointestinal bleeding, ulcers account for about 50%, ranking first, and most of the peptic ulcers and bleeding (about 80%) can stop by themselves. About 30% of the first bleeding can recur, 80%. ~90% of rebleeding occurred within 48 hours after the initial bleeding, gastric ulcer (32% to 48%) more than duodenal ulcer, bleeding easily occurs within 1 to 2 years after the appearance of ulcer disease, about 10% ~15% of ulcer patients with bleeding as the first performance.

2, ulcer perforation: peptic ulcer perforation can be divided into acute, subacute and chronic three, the incidence rate is 5% to 10%, the incidence of duodenal ulcer is higher than gastric ulcer.

3, pyloric obstruction: about 10% of patients with ulcer disease may be complicated by pyloric obstruction, 80% of which occur in duodenal ulcer, followed by pyloric or pyloric ulcer, ulcer disease complicated by pyloric obstruction is more common in the elderly, mainly male In recent years, due to the wide application of various effective anti-ulcer drugs, such complications have been significantly reduced. There are two types of pyloric obstruction: organic and functional. The former is caused by chronic ulcers causing submucosal fibrosis, resulting in scarring stenosis. Ineffective treatment, often requires surgical treatment, the latter due to inflammation around the ulcer caused by congestion and edema and pyloric reflex sputum, medical treatment is effective.

4, cancer: whether chronic gastric ulcer will be cancerous, there is still controversy, most scholars believe that gastric ulcer cancer is present, its cancer rate is estimated to be 1% to 7%, gastric ulcer cancer often occurs at the edge of the ulcer, cancer cells can be infiltrated Duodenal ulcers generally do not develop cancer between ulcerated scar tissue.

Symptoms of gastric ulcer Common symptoms Postprandial episodes of abdominal pain, ulcers, bloating, abdominal distension, gastroscope, wideness of the stomach... Stomach, bad breath, burning pain, nausea, stomach cramps, abdominal pain

The clinical manifestations of gastric ulcers are somewhat similar to those of duodenal ulcers, but they have their own specificities.

1. Clinical features

The clinical manifestations of gastric ulcer have three characteristics: 1 chronic process: as few as several years, more than 10 years or longer; 2 periodicity: often occur in the course of the attack and remission in the course of the disease; 3 rhythm: pain manifested as meal After the pain, the pain starts half an hour after the meal, and disappears until the next meal. The symptoms of gastric ulcer are mainly abdominal pain, with or without vomiting, nausea, acid reflux, belching and other symptoms, but there are many patients with stomach. Various complications of ulcers such as perforation, hemorrhage, and pyloric obstruction are the first symptoms.

2, clinical symptoms and signs

(1) Pain in the upper abdomen: The pain of gastric ulcer is a kind of visceral pain. The surface location is not accurate. At the same time, the pain is not severe, and it can be tolerated. It is characterized by burning pain, dull discomfort, etc. It is characterized by postprandial pain. With the development of pathology, it has periodic and seasonal characteristics. The ulcer near the cardia can also be expressed as a burning sensation in the back of the chest and pain in the left chest. When the ulcer penetrates, the pain is aggravated. Back radiation or back pain, as well as nighttime pain, etc., when the nature of pain and rhythm changes, you should also be alert to the possibility of malignant transformation.

(2) nausea and vomiting: vomiting without pyloric obstruction indicates that the ulcer is in active phase, vomiting is intermittent, and frequent vomiting indicates pyloric obstruction.

(3) acid reflux, hernia, diarrhea: acid reflux also suggests that the ulcer may be in active phase.

(4) Bleeding, perforation: bleeding occurs, and it has its special clinical manifestations after perforation.

(5) Signs: There is generally no positive signs during the remission period. The active period is only mild tenderness in the upper abdomen, but attention should be paid to anal examination and examination of lymph nodes for differentiation to distinguish them from gastric cancer.

Gastric ulcer examination

1, gastric juice analysis and gastric acid determination

Gastric juice analysis and gastric acid determination are helpful for the diagnosis and treatment of gastroduodenal ulcer. Basal acid output (BAO)>5mmol/h may be duodenal ulcer, BAO>7.5mmol /h should be treated surgically, BAO > 20mmol / h maximum acid secretion (MAO) greater than 60mmol / h, or BAO / MAO > 0.6 may be gastrinoma, further gastrin determination.

2, serum gastrin and serum calcium determination

Determination of serum gastrin can help to rule out or diagnose gastrinoma, serum gastrin > 20pg / ml is considered gastrinoma; when gastrin > 100pg / ml can be confirmed as gastrinoma, Patients with parathyroidism are prone to peptic ulcer, so the determination of serum calcium is also helpful.

3, fecal occult blood test

Gastric ulcers with combined hemorrhage may be positive, but if the fecal occult blood test continues to be positive, gastric malignant lesions should be considered.

4, related examination with gastric ulcer combined with bleeding

These include hemoglobin, hematocrit, reticulocyte count, hemorrhage and clotting time.

5. Schilling test

A Schilling test for the determination of vitamin B12 is performed in patients with extensive atrophic gastritis.

6, Helicobacter pylori examination

Although this test is not the basis for the diagnosis of ulcer disease, it is closely related to the recurrence of ulcer disease, so it is of great significance in treatment. Those who are positive for this disease should be eradicated with effective drugs.

7, gastroscope plus biopsy

Accuracy and sensitivity are better, the diagnosis rate is high, electronic fiber endoscopy can accurately understand the size and location of gastric ulcer, whether there is bleeding, penetration, active period or stationary phase, according to the pathological morphology of the ulcer can be roughly understood to be benign and malignant In addition, pathological biopsy can clearly know whether it is benign or malignant. At the same time, the gastroscope can also be combined with the detection of Helicobacter pylori to understand the presence or absence of Helicobacter pylori infection. The gastroscope can perform some treatments, such as local hemostasis under the microscope.

8, barium meal inspection

It is simple and easy to perform, and it has less pain. It can understand the peristalsis of the stomach and the stomach of the bag according to the general shape of the stomach. At the same time, benign or malignant can be identified according to the changes of the shadow and mucous membrane. The benign ulcer is mostly located outside the stomach wall, and the surrounding mucosa is radially concentrated. It is also possible to understand that the duodenum and pylorus have deformation, stenosis, and obstruction, but there is a certain false negative in barium meal.

9, CT examination

It is not the first choice and routine examination of this disease, but it still has certain significance in the diagnosis and differential diagnosis of ulcerative diseases. The CT manifestations of gastric ulcer are a combination of ulcer, gastric wall edema and scarring changes.

Diagnosis and identification of gastric ulcer

Diagnostic criteria

1. Clinical features

There was a deep upper abdominal pain 2 hours after the meal, usually without abnormal signs.

2, auxiliary inspection

The diagnosis of gastric ulcer mainly depends on the symptoms of medical history, gastroscopy plus biopsy, barium meal examination, other gastric acid determination, serum gastrin determination, serum calcium determination also have certain diagnostic and differential diagnosis significance. In recent years, with the application of electronic gastroscope, the diagnosis of gastric ulcer The compliance rate is extremely high.

Differential diagnosis

1, functional dyspepsia

Usually there are dyspepsia syndromes, such as acid reflux, belching, nausea, upper abdominal fullness discomfort, but no positive findings in gastroscopy and barium meal examination, is functional.

2, chronic stomach, duodenitis

There is chronic irregular upper abdominal pain, gastroscopy can identify, more than chronic antral sinusitis and duodenal inflammation but no ulcers.

3, gastrinoma

Also known as Zhuo-Ai syndrome, it is caused by the secretion of a large amount of gastrin from pancreatic delta cells. The main points of diagnosis are:

(1) BAO>15mmol/h, BAO/MAO>0.6;

(2) X-ray examination shows atypical ulcers, especially multiple ulcers;

(3) refractory ulcer, easy to relapse; 4 with diarrhea; 5 serum gastrin increased > 200pg / ml (usually > 500pg / ml).

4, gastric ulcer malignant or gastric cancer

The most important differential diagnosis method is gastroscope plus biopsy and barium meal examination. Biopsy is needed during gastroscopy to identify benign and malignant. For gastric ulcer, gastroscopy plus biopsy should be continuously followed up.

5, gastric mucosal prolapse

Intermittent upper abdominal pain, antacid can not be relieved, and changing position such as left lateral position may be relieved, gastroscope, barium meal can be identified, X-ray barium meal examination can show duodenal bulbs have "fragrant" or "parachute" "Damage shadow.

6, other

In addition, complicated hemorrhage should be differentiated from esophagogastric rupture caused by portal hypertension, and should be differentiated from various common acute abdomen, such as pancreatitis, appendicitis, biliary tract disease, intestinal obstruction, etc. Wait.

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