1. Lecture: Lecture: ULCERAL DISEASE

2. Gastric antral and body mucous helikobakterial contamination degree determination  a) smears stained by the method of Romanovsky - Giemsa and study of spiral or S - like bacteria in the microscope field of view with increasing 360. They diagnose with three degrees of contamination.  - Up to 20 germs in sight - a faint degree (+)  - 20 to 50 - the average degree (+ +)  - 50> - high (+ + +)

3. Diagnosis of HP  a) diagnosis contamination of HP can be performed with SLO - test (firm Delta), which is a special plate with the reagent in the center, one of which fits biopsy and to change the color of the central ring of biopsies judged on the availability of HP. b) for the same purpose the de-nol-tests (by "Yamanouchi"). c) urea breath test, based on the reception in the middle of urea labeled carbon (C13, C14).

4. Diagnosis of HP 

5. Histological examination They are: -severity of inflammation, - activeness of the process - atrophy (decrease in the number of glands) - intestinal metaplasia - degree of mucous HP insemination. They are: -severity of inflammation, - activeness of the process - atrophy (decrease in the number of glands) - intestinal metaplasia - degree of mucous HP insemination.

6. Histological examination determine the type of intestinal metaplasia. There are 3 types of intestinal metaplasia. Type I - enteric Type II - incomplete colon Type III - colon with secretion sulfomutsyniv.

7. Intragastric pH - metry allows you to set the concentration of free hydrogen ions on the surface of the body and pyloric stomach  pH in the range 0.1 -1.3 indicates hiperacidity,  1,3-2,0 of normo-,  1,7-3,0 - hipoacidity,  and pH 3.0 and more about anacidity.

8. Chronic gastritis Atrophic gastritis Intestinal metaplasia Dysplasia Gastric adenocarcinoma Normal stomach shell mucose † ~ 30 лет

9. Peptic ulcer.  Definitions. Peptic ulcer - a common chronic relapsing disease with a tendency to progression of polycyclic course, theme of which is seasonal exacerbation, accompanied by the appearance of the ulcer in the lining of the stomach or duodenum, and the development of complications that threaten the life of the patient. (I.I. Degtyarev, N.V. Kharchenko, 1996).

10. Epidemiology.  Being a fairly common disease, peptic ulcer disease leads to 20% of all cases of organic nature dyspepsia. In the European population incidence of peptic ulcer is 10% among men and 5% among the female population.  In Ukraine ulcer disease affected about 5 million people. A characteristic feature of our time is sexual dyzmorfizm. In recent years there has been increasing incidence among women 2-3. The male / female is 1 to 2.3 for duodenal ulcer and 1 to 4.8 for gastric ulcer. The incidence of stomach ulcers are almost identical among the elderly.

11. Etiology:  Pylori contamination of the gastric mucosa;  Features gastric acid production (decrease the pH of gastric contents, decreased activity of alpha 1- antitrypsin) deficiency mukohlikoproteinis gastric mucus, excessive postprandial release hastrin;  Hereditary factor (the presence of blood group I (0), HLA B5 antigen);  Stressful factors;  Dyzbalans hormones (sex, thyroid, parathyroid glands);  Tobacco;  Reception "ulcerogenic" of drugs (especially NSAIDs

12. pathogenesis  The predominance of "aggression factors" (hyperatsidity, increase pepsyc component of gastric contents, dysmoty, microcirculation disturbances) over "protection factor" (the formation of mucus and bicarbonate, prostaglandin, regenerative processes in the stomach mucosa) ("weight Sheya").

13. classification Localization of the ulcer: Gastric ulcers: -cardia -body-stomach, small and large curvature (mediogastral) -antral -pyloric channel -antral -pyloric channel Duodenal ulcer (DU): -bulbar -bulbar -postbulbarni -postbulbarni Multiple ulcers (stomach or duodenum) Combined ulcers  course: first detected recurrent course  Phase: -active phase (exacerbation) nonaktyv-phase (remission: clinical, endoscopic, eradication of Hp)  Gravity flow: -Light-sharpening every 1-2 years; -Mild-2 times a year; -Severe-more than 3 times or difficult. -Light-sharpening every 1-2 years; -Mild-2 times a year; -Severe-more than 3 times or difficult.

14. classification The presence of H. pylori contamination of the gastric mucosa: - HP - associated - HpP- not associated Condition atsydnosti gastric contents: - Status normaciditas - Status hyperaciditas - Status hypoaciditas - Status anaciditas Presence of complications: -bleeding (in terms of the source of bleeding and severity of clinical and endoscopic (by J. Forest) features) -perforation - Penetration (in terms of the object / body penetration) -pyloric stenosis (in terms of the degree for radiographic features) -malignancy (for stomach ulcers) Peptic ulcer is always accompanied by gastritis, duodenitis

15. Diagnosis of peptic ulcer provides next volume clinical examination: Anamnestic examination (identification of etiologic factors, comorbidities, genetic predisposition to debutants, determine the number and rate of relapse, the effectiveness of antiulcer therapy and metafilaktyky). Physical examination (local palpation pain in the area of ​​ the projection of the ulcer, positive symptom of Mendel at peryviscerytis), presence of pylori-bulbar shaft. Endoscopic examination, diagnostic accuracy which reaches 95%, has advantages over X-ray only when localising duodenal ulcer. The optimal method of monitoring the effectiveness of antiulcer therapy (duodenal ulcer uncomplicated, if full clinical remission endoscopic control is optional).

16. HP and duodenal ulcer 

17. X-ray examination  is superior to endoscopic where gastric ulcer localization, because it allows to assess the state of gastric motility, convergence of folds of mucous membrane, which is valuable in the differentiation of ulcer- cancer. In addition, X-ray method is leading in the assessment of cardiac and pyloric sphincter and to establish the extent of their dysfunction

18. Interpretation of pH data (V.M.Chernobrovyy, 1998): pH Acidic condition 7,0 – 7,5 3,6 – 6,9 2,3 – 3,5 1,6 – 2,2 1,3 – 1,5 0,9 – 1,2 anacidity expressed hypoacidity moderate hypoacidity normacidity moderate hyperacidity expressed hyperacidity

19. Treatment. At the present stage ulcer requires the use of combinations of the means that can affect the basic pathogenetic links ulceration. Featured Maastricht 2- 2000 consensus, 2003-2005. modern concept of treatment of infections associated with H. Pylory, provide mandatory Helicobacter therapy in cases of duodenal ulcer and gastric ulcer (active or inactive, complicated or uncomplicated). Two component circuits are inefficient (low percentage of eradication). Optimum is currently schema triple and quadro therapy based on proton pump inhibitor

20. at Maastricht 2003-2005 expanded indications for eradication of H. pylori by ekstragastric diseases Now recommends eradication of H. Pylori  with coronary artery disease (level of scientific evidence B)  immune thrombocytopenia (level B)  unexplained iron deficiency anemia (level B).  In addition, the Maastricht 2003- 2005 necessarily recommended (level A) to eradicate H. Pylori in dyspepsia, and in all cases apply the strategy «Test and treat

21. Treatment III line -for patients with newly diagnosed ulcer -the absence of anamnestic instructions on receiving macrolides, including erythromycin II line - If first-line therapy did not lead to eradication H.pylory - In relapse - In the long history of ulcerative  Proton pump blockers (only the means with proven high antisecretory activity: Loseke, Ultop, Pariet, Oprazol, Kontralok, Esomeprazole) - Omeprazole 20 mg twice a day to 3 weeks - Clarithromycin (klatsyd) 500 mg twice a day - Amoxicillin (Flemoksyn, Osmamoks) 1000 mg twice a day The duration of treatment 7 days  Proton pump blockers (only the means with proven high antisecretory activity: Loseke, Ultop, Pariet, Oprazol, Kontralok, Esomeprazole) - Omeprazole 20 mg twice a day to 3 weeks - Bismuth subcitrate * (de-nol) or subsalitsylat - Metronidazole 500 mg three times a day - Tetracycline 500 mg 4 times a day The duration of treatment 7 days * minimum inhubuyucha bismuth subcitrate concentration is 4 times higher than in subsalits илату

22. THANKS FOR ATTENTION!!!