Peptic ulcer

Introduction Gastric ulcers and duodenal ulcers are generally referred to as peptic ulcers, sometimes referred to as ulcers. The stomach acid (hydrochloric acid) and pepsin (a kind of enzyme) that originally digested food digested the stomach wall and the duodenal wall, thereby damaging the mucosal tissue, which is the main cause of peptic ulcer. Stomach ulcers occur in middle-aged and elderly people, and duodenal ulcers are mainly young and middle-aged. Men have a higher proportion of peptic ulcers than women. In recent years, with the development of drugs such as H2 receptor blockers and gastric mucosal protective agents that strongly inhibit gastric acid secretion, the mortality rate of peptic ulcer has been reduced year by year. Compared with gastric ulcers, there are more people with duodenal ulcers, about three times that of gastric ulcers. In recent years, the number of people suffering from duodenal ulcers in cities has increased. Compared with sugar-containing substances such as edible grains, gastric acid secretion increases when meat is eaten. When the state of hyperacidity persists for a long time and accumulates in the duodenal bulb (the entrance to the duodenum), it is easy to damage the mucosa and cause duodenal ulcer. The part of the stomach that is prone to ulceration can be divided into two parts: the corpus (2/3) and the pylorus (the lower 1/3). Most of the gastric ulcers occur near the pyloric sinus stomach. As you age, the area prone to ulceration will gradually move closer to the esophagus in the upper part of the stomach. Most of the duodenal ulcers occur in the duodenal bulb near the stomach.

Cause

Recent experimental and clinical studies have shown that factors such as excessive gastric acid secretion, Helicobacter pylori infection and weakened gastric mucosal protection are the main causes of peptic ulcer. Gastric emptying delay and bile reflux, the role of gastrointestinal peptides, genetic factors, drug factors, environmental factors and mental factors are all related to the occurrence of peptic ulcer.

1, excessive gastric acid secretion

Hydrochloric acid is the main component of gastric juice, secreted by parietal cells, regulated by nerves and body fluids. It is known that parietal cells contain three receptors, namely hirstamine receptors, cholinergic receptors and gastrin receptors, which receive histamine, acetylcholine and gastric secretion, respectively. Activation of the prime. When the surface cell surface receptor is bound by the corresponding substance, the second messenger in the cell is activated, thereby affecting gastric acid secretion.

In the pathogenesis of duodenal ulcer, excessive gastric acid secretion plays an important role. The amount of gastric acid basal secretion (BAO) and maximum secretion (MAO) in patients with duodenal ulcer were significantly higher than those in normal people; duodenal ulcers never occurred in people with little gastric acid secretion or secretion. After the chyme enters the duodenum from the stomach, under the stimulation of gastric acid and chyme, the pancreas secretes a large amount of pancreatic secretion, trypsin, and cholecystokinin. In addition to secretory mucus, the intestinal mucosa also releases hormones such as intestinal high. Glucagon, gut peptide (GIP), vasoactive intestinal peptide (VIP), which inhibits gastric acid secretion and stimulates secretion of gastrin, so when the function of releasing these hormones in the duodenal mucosa is reduced, It can cause gastrin and gastric acid secretion to increase, which contributes to the formation of duodenal ulcer.

The long-term and repetitive nature of gastric ulcer, the nature of complications, and the tendency of ulcers to heal under conditions of reduced gastric acid suggest that the pathogenesis is similar to that of duodenal ulcer. However, BAO and MAO in patients with gastric ulcer are similar to normal people, even lower than normal; some gastric mucosal protective drugs (non-antacids) can promote the healing of ulcers without reducing the effect of gastric acid; some damage to the gastric mucosa Drugs such as aspirin can cause gastric ulcers, and the fact that experimental animals continue to suck mucus from the stomach cavity can cause gastric ulcers, etc., all suggest that the occurrence of gastric ulcers is caused by the local part of the gastric mucosa. Due to the destruction of the gastric mucosal protective barrier, it is not effective against the erosion and digestion of gastric acid and pepsin, and ulceration occurs.

2, Helicobacter pylori infection

HP infection is the main cause of chronic gastritis and an important cause of peptic ulcer. In the HP-adhered epithelial cells, microvilli were reduced, cell-to-cell connections were lost, cells were swollen, the surface was irregular, the intracellular mucus particles were depleted, vacuolated, and the adhesion between the bacteria and the cells formed a sticky pedicle and a shallow cup-like structure.

3, gastric mucosal protection

Under normal circumstances, the physical and chemical factors of various foods and the digestion of acidic gastric juice can not damage the gastric mucosa and cause ulcer formation, because the normal gastric mucosa has protective functions, including mucus secretion, gastric mucosal barrier integrity, and abundant mucosal blood. Flow and regeneration of epithelial cells, etc.

Neither mucus nor bicarbonate can prevent the gastric epithelium from being damaged by gastric acid and pepsin alone, and the combination of the two forms an effective barrier. The formation of this gradient depends on the rate of alkali secretion and its thickness through the mucus layer, which in turn depends on the rate at which mucus is reborn and lost from the epithelial cell surface into the stomach cavity. If any one or more of the above factors are disturbed, the pH gradient will be reduced and the protective barrier will be destroyed.

4, gastric emptying delay and bile reflux

This degenerative change of the gastric antrum and pyloric region during gastric ulcer can invalidate the contraction of the antrum and affect the advancement of the chyme. Delayed gastric emptying may be a factor in the pathogenesis of gastric ulcer disease.

Certain components of the duodenal contents, such as bile acids and lysolecithin, can damage the gastric epithelium. The duodenal contents can flow back into the stomach and cause chronic inflammation of the gastric mucosa. The damaged gastric mucosa is more susceptible to damage by acid and pepsin. In gastric ulcer, the concentration of bile acid conjugate in fasting gastric juice is significantly higher than that in normal controls, suggesting that bile reflux into the stomach may play an important role in the pathogenesis of gastric ulcer.

5, the role of gastrointestinal peptides

Many gastrointestinal peptides are known to affect gastric acid secretion, but only studies on the relationship between gastrin and peptic ulcer are more common. The role of gastrin in the pathogenesis of peptic ulcers is unclear.

6, genetic factors

It has been agreed that the occurrence of peptic ulcer is genetically pleasing, and that gastric ulcer and duodenal ulcer disease are genetically independent and irrelevant. In the family of patients with gastric ulcer, the incidence of gastric ulcer is three times higher than that of normal people; in the family of patients with duodenal ulcer, duodenal ulcer is more common than gastric ulcer.

7, drug factors

Some antipyretic analgesics, anticancer drugs, etc., such as indomethacin, phenylbutazone, aspirin, adrenocortical hormone, fluorouracil, methotrexate, etc. have been classified as ulcerative factors. Non-steroidal anti-inflammatory drugs, such as indomethacin, phenylbutazone, ibuprofen, naproxen, etc., can also inhibit the synthesis of prostaglandins to varying degrees, which in theory can produce clinical effects similar to aspirin. Lixue et al. have a histamine-like effect, which can increase gastric acid secretion, so it has the potential to cause ulceration.

8. Environmental factors

Smoking can stimulate the increase of gastric acid secretion. Long-term smoking is not conducive to the healing of ulcers, and can also cause recurrence. Food can cause physicochemical properties damage to the gastric mucosa. Overeating or irregular eating may disrupt the rhythm of gastric secretion. According to clinical observations, coffee, tea, spirits, spicy spices, kimchi and other foods, as well as partial eating, too fast, too hot, too cold, overeating and other bad eating habits, may be related to the occurrence of this disease.

9, mental factors

According to the modern psycho-social-biomedical model, peptic ulcer is one of the typical psychosomatic diseases. Psychological factors can affect the secretion of gastric juice.

an examination

Related inspection

Helicobacter pylori serological test direct screening of Helicobacter pylori painless endoscopy microscopic examination of drug vagus nerve block test

Endoscopy

Whether using a fiberscope or an electronic gastroscope, it is the main method for the diagnosis of peptic ulcer. Under endoscopic direct vision, peptic ulcer usually has a round, elliptical or linear shape, sharp edges, basically smooth, covered with gray-white or gray-yellow coating, and the surrounding mucosa is congested, edematous, and slightly elevated.

2. X-ray barium meal inspection

The main X-ray of the peptic ulcer is the sputum or shadow, which is caused by the sputum suspension filling the depressed part of the ulcer. In front view, the shadow is round or oval and the edges are neat. A circular translucent area is formed due to inflammatory edema around the ulcer.

3. Detection of HP infection

The detection methods of HP infection are roughly divided into four categories: (1) direct examination of HP from gastric mucosa, including bacterial culture, tissue smear or section staining microscopic bacteria; 2 urease test, breath test, gastric juice urea nitrogen test, etc. Determination of urease activity in the stomach; 3 serological examination of anti-HP antibodies; 4 determination of HP-DNA using polymerase chain reaction (PCR) technology. Bacterial culture is the most reliable method for diagnosing HP infection.

4. Gastric juice analysis

The average basal acid excretion (BAO) of normal males and females was 2.5 and 1.3 mmol/h, respectively (0-6 mmol/h), and the average BAO of male and female duodenal ulcer patients was 5.0 and 3.0 mmol/h, respectively. . When BAO>10mmol/h, the possibility of gastrinoma is often suggested. After the injection of pentagastrin gas at 6 g/kg, the maximum acid output (MAO), duodenal ulcer often exceeds 40 mmol/h. Due to the gastric juice analysis results of various stomach diseases, the gastric acid amplitude overlaps with normal people, and the diagnosis of ulcer disease is only for reference.

Differential diagnosis

Gastric cancer

The identification of benign gastric ulcers and malignant ulcers is very important, and the identification of the two is sometimes difficult. The following situations should be given special attention: 1 middle-aged and elderly people have mid-upper abdominal pain, hemorrhage or anemia in the near future; 2 clinical manifestations of gastric ulcer patients have obvious changes or anti-ulcer drug treatment is ineffective; 3 gastric ulcer biopsy pathology has intestinal metaplasia or atypical Hyperplasia. Clinically, patients with gastric ulcer should be treated with internal medicine for regular follow-up after endoscopic examination, and close observation until ulcer healing.

2. Chronic gastritis

The disease also has chronic upper abdominal discomfort or pain, and its symptoms can be similar to peptic ulcer, but the periodicity and rhythm of the attack are generally not typical. Gastroscopy is the main method of identification.

3. Gastric neurosis

The disease may have upper abdominal discomfort, nausea and vomiting, or resemble peptic ulcer, but often accompanied by obvious systemic neurological symptoms, mood swings are closely related to the onset. No obvious abnormalities were found in endoscopy and X-ray examination.

4. Cholecystitis cholelithiasis

More common in middle-aged women, often interstitial, paroxysmal right upper abdominal pain, often radiated to the right scapular area, may have biliary colic, fever, jaundice, Murphy sign. Eating greasy food can often be induced. B-ultrasound can make a diagnosis.

5. Gastrinoma

This disease is also known as Zollinger-Ellison syndrome. It has refractory multiple ulcers or atopic ulcers. It is easy to relapse after subtotal gastrectomy, and is often accompanied by diarrhea and obvious weight loss. The patient's pancreas has non--cell tumor or gastric antral G cell hyperplasia, serum gastrin levels are increased, gastric juice and gastric acid secretion are significantly increased.

6. Functional dyspepsia

Ulcer-like symptoms in functional dyspepsia resemble peptic ulcers, and their identification depends on endoscopy or X-ray examination.

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