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To a question on a pathogeny of a peptic ulcer

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   To a question on a pathogeny of a peptic ulcer.
   The new approach to treatment of symptomatic gastrodudenal ulcers.
   L.I. Timen, A.I. Cherepanin, S.V. Stonogin.
   ( Urban hospital N20, Moscow, Russia).
  
   On the establishment of results of successful complex treatment 56 patients with symptomatic ulcers of a stomach (34) and duodenum (22) with use of a capillary gastrointestinal (nosoejunal) probe and medical endoscopy the authors came to a conclusion about absence of basic(principal) differences in a pathogeny of peptic and symptomatic ulcers. The pathogenetic therapy, in opinion of the authors, should be directed first of all on liquidation of a pain set of symptoms, motor-evacuational infringements, stimulation of protective mechanisms and reparative functions of the substrate. With this purpose the authors apply statement of a gastrointestinal probe and medical endoscopy.
   The treatment on the offered combined procedure has allowed to achieve a cicatrisation of ulcers of a stomach in 32 observations in 3-4 weeks, and duodenal ulcers at 22 patients - after 2-3 weeks.
   2 observations of treatment of huge ulcers of a stomach are given(reduced).
  
   The unpersuasive results of treatment of a peptic ulcer of a stomach and duodenum testify that the pathogeny of this disease completely is not investigated, and the numerous concepts explaining with different and in own way of the logical points of view a parentage, flow(streaming) and treatment of a peptic ulcer, remind branches, growing in the different side,(party,) of one arbor.
   To so-called symptomatic or secondary ulcers of a stomach and the duodenums carry defects of a mucosa, submucosal and muscle layer more often arising on a background of such diseases, as an atherosclerosis, idiopathic hypertensia, sugar Diabetum, pancreatitis, chronic nonspecific diseases mild, tumoral lesions and being one of signs of these illnesses. In separate bunches, with the count of the special specificity, also excrete(secrete) stressful, endocrine, medicamental, hepatogenic and senile ulcers (5,6,13,14). From the point of view of a pathogeny, the appearance of peptic and symptomatic ulcers is preceded by(with) general pathological processes: deterioration of microcirculation a hypoxia
   Infringement of respiratory function of cells outlier(release) of lyzosomal enzymes from perishing cells inflammatory - destructive changes. It is necessary to note, that the most part of the listed diseases, including in elderly and senile age, is not accompanied by damages of a mucosa of a stomach and duodenum. Besides there is no authentic difference in clinic, character of not symptomatic and symptomatic ulcerous defects, secretory activity of a stomach at these lesions, and the role of the acid factor, as predominant in a pathogeny of a peptic ulcer, at many clinicians invokes(produces) doubt (2,11). Therefore, despite of a various etiology, the differentiation of ulcers on usual and symptomatic wears faster theoretical and conditional character. The exception is represented by(with) acute gastrodudenal ulcers at a hemorrhagic gastritis formed owing to penetrating diffuse distresses of microcirculation at a final stage of aboriginal exhibiting of a ДВС-SET of SYMPTOMS.
   Having studied results of complex treatment 56 patients with symptomatic ulcers of a stomach (34) and duodenum (22) with use of a capillary gastrointestinal (nosoejunal) probe as basic method of pathogenetic therapy, we have received the conclusions similar made us earlier at treatment, of the made by us to an earlier, peptic ulcer, namely:
   1. A transabdominal pain set of symptoms and the motor-evacuational infringements forming vicious circle, compound(make) a key part of a pathogeny of a peptic ulcer.
   2. The acid factor does not play a leading role in a ulcer genesis.
   3. The application of a capillary gastrointestinal probe for liquidation of a pain set of symptoms and regeneration of adequate evacuation is the basic variant of pathogenetic therapy at cankers of a stomach and duodenum.
   We hold the opinion of the clinicians and morphologists (4 etc.), counting, that the originating of a ulcer depends not so much on the factor of aggression, how many from a state of the substrate and in this connection in complex therapy of a peptic ulcer, including at symptomatic ulcers, we use a medical endoscopy directed on reception of long receptor blockage of a pain field and a stimulation of reparative processes in region(zone) of a ulcer: for an injectional infiltration of a submucosal layer(stratum) of edges(territories) of a ulcer of a stomach and pylorobulbar department at duodenal ulcers we use 0,3-0,5 % water solution of methylene blue and 5 % solution of vitamin C with subsequent a cool influence by Aether chloratus on range of ulcerous defect and perifocal region(zone).
   The stopping of bleedings from symptomatic ulcers is not a theme of the present report. However it is necessary to note, that a medical endoscopy in a combination to tube methods, at presence of the individual indications, we successfully conducted and at ulcerous bleedings 1 and 2 bunches on classification J. Forrest, erosion-ulcerous hemorrhagic gastritis, set of symptoms the Melory-Veis by formation(education) of large infiltrational pillow(pad) for region(zone) of defect of a mucosa with the help of solutions of vitamin C and Novocain (Lidocainum, Xylocainum) in an admixture with an epinephrine and processing by Aether chloratus of all mucosal surface of an environment of the struck(knocked) member.
   For a substantiation of pathogenetic therapy of a peptic ulcer is considered(counted) expedient to acuminate attention of the clinicians on value of motor-evacuational distresses and pain factor in a pathogeny of a peptic ulcer. The features a vascular architectonics of a mucosa of a stomach consist that at an empty(blank) stomach shallow arterias, arteriole and the capillars look like krausen, spirals and glomuluses invoking(producing) resistance a blood flow. During an alimentary phase the stomach extends, the arterial pots are straightened also blood pervasion of a mucosa grows. The study of a motility of a gastrointestinal path has allowed to establish, that interalimentiry, the reductions, migrating in a caudal direction, considerably surpass reductions during digestion and to secure(discharge) 4 phases of interalimentiry activity of a stomach and duodenum: I - rest, II - irregular reductions, III - strong reductions and IV - irregular reductions previous to a resting phase (10). At a peptic ulcer the resting phase is absent, and desynchronized chaotic peristalsis and the reductions empty(blank) (hungry) stomach considerably worsen an aboriginal circulation, including in region(zone) of a ulcer. As a result of a motor dyskinesia, continuous reductions of an own muscle layer(stratum) and muscle plate of a mucosa there is a constant(stationary) distention of edges(territories) of ulcerous defect, that invokes(produces) a pain, deterioration of microcirculation and interrupting for reparative neogenesis (1). On our observations a pain and motor dyskinesia initiate a so strong and nonperishable spastic stricture of a sleek musculation of a stomach, that frequently there are infringements of evacuation and segmental stasis of stomachal contents in departments, contiguous to a ulcer. The tightened(delayed) pain attack can result in appearance of a ДВС-SET of SYMPTOMS (7) and, hence, be by one of the causes of ulcerous bleedings. It is represented logical, that a pain set of symptoms, the motor-evacuational infringements and vascular factor by a rule of relative(mutual) burdening sustain and aggravate development of destructive changes. As the distresses of an aboriginal circulation are observed at a significant part of a population not suffering peptic ulcer, it is necessary to assume existence while unknown mediate factor (or factors) at a stage of formation of a ulcer and then becomes apparent, that the pathological processes at a peptic ulcer can interreact under the following schema(circuit):
  
  
  
   Fig. 1 the Schema of interaction of pathological processes at a peptic ulcer.
  
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 UD PS MEI
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 MF DM
  
   DM - distress of microcirculation
   MF - mediate factor
   UD - ulcerous defect
   PS - pain set of symptoms
   MEI - motor-evacuational infringements
  
   Pain - constant(stationary) companion of many diseases. But more often obstinate, excruciating and alternating, connected(linked) with meal and time of day of a pain will manifestate a peptic ulcer. It is known, that the pain is not pathological, but defense reaction of an organism on action of the aggressive factor, exhibiting on H. Selye of an adaptation syndrome on an alarm. In a phase a transferring in the chronic form of process, when the protective mechanisms are exhausted, the pains become less intensive and strengthen again at penetration of a ulcer. The presence of the awake pain answer testifies to mobilization of the factors of protection and potential opportunity of an adhesion, and also about necessity of rendering of the emergency help on an interval of time, when an organism in a state to stand up to(counter, resist) to influence of disturbing factors. Therefore therapy of a peptic ulcer first of all should be directed on a cupping of a pain attack within several day after his(its) originating. Unfortunately these favorable terms are conditional because of a selftreatment, delayed reversion of the patient to the doctor, serotinal(late) diagnostics of a peptic ulcer and delayed hospitalization. In the previous reports (3,8) we have presented the concept of pathogenetic therapy of a peptic ulcer based on the neuroreflex mechanism of a cupping be sick, liquidation of motor-evacuational infringements and deblocking thus of reparative processes with the help of a capillary gastrointestinal (nosoejunal) probe stacked as loops on reflexogenic regions(zones), responsible(crucial) for motor activity of a gastrointestinal path, i.e. there, where the pacemakers and intraparietal nervous plexuses (12 etc.) are posed: in subcardial-fundal and antropyloric departments of a stomach, in range the Fateri of a papilla and ligaments a Treitz (fig. 2).
   Rice 2. The schema of a locating of a gastrointestinal probe.
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   The clinical and endoscopical study of a peptic ulcer with application of tube procedures in composition of the standard therapy or as a unique(sole) agent of antiulcerous treatment has shown, that process of a cicatrisation of ulcers, including symptomatic, begins only after nonperishable decrease or cupping be sick and proceeds(runs) with conservation of a duodenogastral reflux (probe, less wide-spread after statement,) and initial(starting) level of a stomachal secretion: hyperacidities (less often), and also hypo- and achlorhydria at ulcers of a stomach and hyperacidity at duodenal ulcers. The presence of a probe in a lumen of a stomach and duodenal, certainly, could not terminate such popular initiators a ulcer genesis, as a revertive diffusion of hydrions and Helicobacter pylori. Apparently, all made mention factors carry out secondary or supporting role in a pathogeny of a peptic ulcer and should not be a subject(item) of prime attention at purpose(assignment) of treatment.
   The experience of conservative therapy and preparations of the patients with gastrodudenal ulcers to operative treatment has allowed us to secure(discharge) some positions connected(linked) to application of tube procedures:
   1. The parameters of stabilization of destructive process and cicatrizations of ulcers are higher at the patients with more expressed pain set of symptoms and depend on speed of his(its) cupping,
   2. Hyperacid variant of a secretion - favorable prognostic attribute at ulcers of a stomach,
   3. The absence of anaesthetic effect from statement of a probe is an oblique attribute of penetration of a ulcer and by the paste for penetration .
  
   At decor of a stuff of clause we pursued(chased, ran) an overall objective - to formulate principles of treatment of a peptic ulcer according to features of a pathogeny and consequently consciously have lowered(omitted) details at a statement of a clinical stuff, having stopped on the description of the most interesting cases. As a result of the combined treatment 56 patients with symptomatic gastrodudenal ulcers, which basis have made the tube methods and medical endoscopy, the cicatrization of ulcers of a stomach in 32 of 34 observations has taken place within 3-4 weeks, and terms of a cicatrization of duodenal ulcers at all 22 patients have not exceeded 2-3 weeks. At 3 patients with a cancerous lesion mild, the bronchial asthma and atherosclerosis finds huge ulcers of a stomach. After carrying out of treatment on well-tried procedure it was possible to achieve an adhesion of large ulcerous defects. The diagnostic and medical endoscopy, statement of a gastrodudenal probe was carried out by devices К2, Д4 and 1Т of firm Olympus (Japan). The study of a stomachal secretion was carried out(spent) with the help of a рH-chromoscopy on a method of L.I. Timen with etc. (9). We result(bring) observations:
   The patient Ф. 57 years, is hospitalized with the diagnosis: an obliterating atherosclerosis of pots of the inferior extremities, set of symptoms the Lerish, state after high ablation of the left femur, chronic peptic ulcer of a stomach in a phase of an exacerbation, lingering flow(streaming). Since 1986 suffers by an obliterating atherosclerosis of pots of the inferior extremities. In 1989 the set of symptoms the Lerish, 2 months back - high ablation of the left femur concerning wet gangrenes is revealed. In 1990 the peptic ulcer of a stomach fixed, in batches passes stationary treatment. The complaints to a hypersalivation, strong nagging pain in epigastric range decreasing after a vomiting recently by eaten nutrition, dark chair. The deterioration is marked in last 3 weeks. From out-patient three-week treatment of effect has not come(stepped). For 1 month has grown thin on 9 kg. Dermal integuments and seen mucosas acyanotic. The muscle strain in epigastric range and in the left hypochondrium is defined(determined). A sign the Schetkin negative. Arising 3-4 times per day the strong pains were stoped by introduction iv. of a cocktail:
   Sol. Atropine sulf. 0,1 % - 1,0
   Sol. Novamini 50 % - 5,0
   Sol. Nospani 2 % - 2,0
   Sol. Dimedroli 1 % - 1,0
   Sol. Relaniumi 0,5 % - 2,0
   At endoscopical research in range of an angle of a stomach the penetrating ulcer of dimension 5,0 on 4,0 sm. with a detritis, scurf of a fibrin, hematin at the center of a crater and large perifocal inflammatory shaft is found. At a biopsy the chronic ulcer, рH-chromoscopy fixed: less than 1,5 (hyperacidities). Is examined by the surgeon. The operative treatment is offered, which the patient categorically has refused, then the endoscopical variants of antiulcerous treatment are recommended. Because of abandoning the patient of statement of a gastrointestinal probe is nominated and the course of a medical endoscopy is lead(carried out, spent): a submucosal infiltration of edges(territories) of a ulcer and perifocal range by Aether chloratus. After 2 sessions of treatment of a pain of steel by less intensive, and after 4-th - have abated. In 3 weeks the ulcerous defect has decreased up to 1,0 sm. the raised floor of a ulcer had whitish colouring and the detritis did not keep. A control biopsy - formation of cicatrix. In 45 days the patient is written out from a hospital. Is examined in 6 months: The complaints are not present, cicatrical changes of an angle of a stomach, hyperacidity.
   The patient Е. 65 years is directed to a hospital concerning an exacerbation of a bronchial asthma and carcinoma of the stomach. Within 5 years suffers by the инфекционно-allergic hormone dependent form of a bronchial asthma. In an anamnesis: a peptic ulcer of a stomach and duodenum. Last 4 years of exacerbations of a peptic ulcer were not, the preventive treatment was not carried out(spent). Two weeks back in a state of the asthmatic status is hospitalized in regional hospital. After a cupping of an attack the strong abdominal pains, vomiting with clots, melena have appeared. At endoscopical research the carcinoma of the stomach is diagnosed. A consulted oncologist. The repeated endoscopy is executed, the oncologic diagnosis is confirmed and the anaesthetics are nominated. Results of a biopsy the patient does not know. The complaints to a dyspnea, sensation of shortage of air, dry tussis, constant(stationary) nagging pains in epigastric range, absence of appetite, nausea. The low spirits of the patient caused by knowledge of a tumor of a stomach pays attention. Is effected EGDS with a pH-chromoscopy and the superficial huge ulcer propagated from a cardia up to an angle of a stomach is revealed the oval up to 5,0 sm. is linear - овальной the forms with width; hyperacid variant of a secretion (pH < 1,5). A biopsy: a detritis, granulation tissue, attributes of a tubular adenoma and moderate dysplasia. The doubt in correctness of the oncologic diagnosis is stated, the conservative treatment of a peptic ulcer is offered and the statement of a gastrointestinal probe is effected(generated). The diet as a table 1 is nominated as a unique(sole) component of antiulcerous therapy. In 3 day the transabdominal pains were completely stopped(terminated, discontinued), has appeared of appetite, the general(common) state of health was improved. After 3 weeks at a control endoscopy are ascertained formation of the large after ulcerous not rasping cicatrix. A biopsy: fields of a cicatrization in a chronic ulcer; pH < 1,5 (hyperacidities). The medical probe is removed and in 27 days after entering the patient was written out with the reference of carrying out of the endoscopical control in 1 month and continuations of treatment of bronchopulmonal disease.
   Thus, the successful results of treatment of gastrodudenal ulcers on uniform procedure testify to absence of basic(principal) differences in a pathogeny of peptic and symptomatic ulcers and confirm opinion of the explorers attaching in a pathogeny a peptic ulcers of a stomach and a duodenum a leading role to a pain set of symptoms, motor-evacuational infringements, and also state of substrate.
  

The literature:

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      -- Горшков В.А. Патогенетическое и диагностическое значение гиперсекреции кислоты в желудке при язвенной болезни. Терапевтический Архив 1980, N7, р. 65-69.
      -- Ерамишанцев А.К., Тимен Л.Я., Шерцингер А.Г., Киценко Е.А., Жигалова С.Б. Применение гастроинтестинального зонда в лечении язвенной болезни желудка и двенадцатиперстной кишки. Клиническая Медицина, 1994, N2, р. 36-38.
      -- Давыдовский И.В. Патогенез язвенной болезни. In the book Патологическая анатомия и патогенез болезней человека. 1958, т.2, р. 248.
      -- Калинин А.В. Симптоматические гастродуоденальные язвы. The dissertation of the doctor of medical sciences, 1987.
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      -- Петрищев Н.Н. Патофизиологические аспекты боли. In the book Болевой синдром. Moscow, 1980, р. 145.
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The data on authors:

   1) Timen Leonid Jakovlevich - the lieutenant colonel of medical service, a member of the American academy of medical sciences, a member of the American academy of sciences, the doctor of the supreme category of city clinical hospital N20
   Of Moscow the slave. Phone 471-33-62.
   129327 Moscow, street Lenskaja 15, 3 case, branch Endoscopies.
   2) Cherepanin Andrey Igorevich - the candidate of medical sciences, the senior lecturer of stand of surgical illnesses N2 of the Moscow medical academy of a name I.M. Sechenov
   Office number 471-11-35.
   The address: 129327 Moscow, Street Lenskaja 15, 5-th body, 2 surgical separation.
   3) Stonogin Sergey Vasil'evich - the surgeon of zymotic body of Tooshino children's municipal hospital of Moscow, the candidate of medical sciences.
   143400 city Krasnogorsk, street Zheleznodorozhnaja, the house 28А, flat 24, Russia.
   Http://stonogin.narod.ru/sergeyvs.html
   E-mail: [email protected]
  
  
  
  
  
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