Diagnosis and differential diagnosis of stomach ulcers

Recognition of uncomplicated form of peptic ulcer disease in typical cases, there is no great difficulty with careful analysis of historical data, as well as a detailed physical and laboratory and instrumental examination of the patient.
Among the complaints leading importance pain syndrome with a distinctive rhythm and frequency of pain associated with eating. With a stomach ulcer more vividly presented diarrhoeal disorders (nausea and vomiting). Signs, obtained by means of physical methods of investigations, most diagnostic significance should be attached percussion pain (positive symptom Mendel), always have a place in the period of exacerbation. High rates of gastric secretion as mezhpischevaritelny phase and after the introduction of the stimulus are very characteristic of duodenal ulcers. At the same time, a stomach ulcer accompanied low functional activity of the main gastric glands.
In cases with persistent pain syndrome in combination with high performance night and basal gastric secretion, painful vomiting rich acidic content and sometimes diarrhea with steatorrhea need to think about the syndrome Zollinger-Ellison and to carry out additional targeted studies.
Additional helper methods takes the leading position of the x-ray method, has a definite value gastroscopy, especially using a fiberscope and gastrocamera. Aspiration biopsy of the mucous membrane of stomach and duodenal ulcers allows to determine the morphological the background for developing ulcers in the gastro-duodenal system.
Laboratory and instrumental methods for helping to diagnose when atypical clinical picture, or in cases of "silent ulcers". When atypical pain syndrome should differential diagnosis with lesions of the biliary tract and pancreas. Both of these infections can occur in waves, with occasional outbreaks. But with cholecystitis attacks of pain are shorter, shall be calculated in days, not weeks, as ulcers, exacerbations not typical seasonality. Such patients pain depend more on the nature, and not from food, there intolerance fats, eggs, mushrooms, onions and other Pathology gallbladder more common in women over 35 years. At exacerbation of chronic pancreatitis pain are paroxysmal character, usually last for a few hours, they are more acute than in ulcerative disease, accompanied by flatulence and nausea. Pain often localized in the upper left quadrant of the abdomen, meet and surrounds the pain.
At pathology biliary pain more often than ulcers, iradionet shoulders and under the shoulder blade. Objective examination are appropriate pain points and zones, there is no symptom Mendel.
Among young people often have functional disorders of the secretory function of the stomach, and sometimes motor of its activities, which should be differentiated from peptic ulcer disease. In these cases, the clinical manifestations, as a rule, are not of a periodical nature, devoid of seasonal factors, there are diarrhoeal disorders (often heartburn, acid burp), and pain may be absent. Rates of gastric secretion are sharply increased. Crucial diagnostic value in these cases has a dynamic x-ray examination. In some patients, these functional disorders may precede the development of peptic ulcers.
Chronic duodenitis characterized by pain in epigastralna area is very reminiscent of a duodenal ulcer. They are located to the right of the centre line and often iradionet in the area right costal arch. Pain may be accompanied by nausea, dizziness (C. N. Shmakov, 1965). In order differential diagnosis it is necessary to resort to the x-ray study and duodenalis.
The most relevant in differential diagnosis is the question of the relationship ulcers and stomach cancer.
At the beginning of the current century among clinicians was a shared view that in 50% of cases of stomach cancer develops sores, so the majority of patients with this localization ulcers underwent resection of the stomach. However, it was discovered that the direct malignancy ulcers observed only in 1 - 1,5% of cases. Stomach cancer can develop not only in the stomach with existing ulcer, but also outside of it, i.e., two of the pathological process can co-exist in one body. Stomach cancer at certain stages of development, when the saved of gastric secretion may ulcerate. This form is called ulcerative inflammatory cancer. In 10-15% of cases, there is so-called primary and ulcerative form of cancer that is clinically not always an easy way of distinguishing from ulcers with localization ulcers in the stomach (C. H. and M. Vasilenko Umalatova, 1964;M Umalatova, 1966, and others).
At the bedside, the Clinician should solve vital for the patient question whether benign or malignant ulcer. This refers to General patterns of the disease, inherent in or ulcer or gastric cancer. The greatest risk of malignancy is characteristic of ulcers horizontal part of the stomach (between the small curvature and angle) compared with ulcers located in the vertical part - between angle and kardia (Gutman, 1960; Jones, 1961). The size of ulcer not play a significant role.
The most important for differential diagnosis of benign and malignant ulcer is the analysis of the main clinical symptoms of the disease.
1. Age and sex are not important, given the significant rejuvenation of cancer now.
2. Long duration of the disease indicates benign peptic ulcer disease, and changes symptoms, especially rhythm and character of pain (the onset of a dull, constant pain), the emergence of persistent nausea and decrease appetite cause to suspect malignant course. When pyloro-antral the location of the tumor pain can save rhythmic in nature. Usually they are accompanied by vomiting.
3. Normal or reduced rates of gastric secretion can even sharper declines, and in some cases, developing a true achlorhydria. However, normal or even high secretory indicators do not exclude the diagnosis of gastric cancer. A value is a progressive decrease in the content of pepsinogen in urine (uropathogen).
4. Available positive symptom Mendel may become less pronounced in the cases of cancer in the background of ulcers.
5. Serious attention should be firmly positive reaction of yens Gregersen collection.
6. Gradual or rapid emergence of anaemia is of some importance in the interpretation of the case. As much an indication of the patient to fast weight loss in compliance with the usual diet.
7. Play an important role timely x-ray examination and gastroscopy using fiberscope and gastrocamera. If fibroscopy possible to produce targeted biopsy of suspicious areas in the sides or bottom of ulcer.
8. The complex of auxiliary diagnostic laboratory studies specific place is occupied by exfoliative Cytology and tetracycline test (yellow luminescence in ultraviolet light sediment gastric juice after pretreatment patient tetracycline). There is an opinion about the low diagnostic value tetracycline test (Frend and others, 1965). The old principle of diagnosis ex juvantibus remains in force: the effects of the ongoing anti-ulcer therapy confirms the benign nature of gastric lesions. According to the data by Sakita and others (1966), the complete healing of ulcers by visual inspection should occur in 2-3 months from the beginning of treatment.