Peptic ulcer disease (synonym: peptic ulcer of stomach and duodenal ulcers, round-the plague, the disease Cryole) is a common chronic relapsing disease with a characteristic clinical picture and local anatomical changes in the stomach and duodenum. Ulcers disease occurs normally in the age of from 25 till 50 years, significantly more often in men.
The etiology and pathogenesis. The main factors in the development of peptic ulcer disease are disorders of neurohumoral mechanisms regulating the functions of the digestive system, disorders of local mechanisms of digestion and changes in the structure of the mucous membrane of stomach and duodenal ulcers; predisposing - heredity and environment, among which occupies the leading place nutrition. An important place in the etiology and pathogenesis of peptic ulcer disease belongs to violations functions of the nervous system that occur under the influence of negative emotions, overvoltage in mental and physical work. A significant role in the etiology and pathogenesis of peptic ulcer disease plays food. Excessive consumption difficult and long perevarivaetsya in the stomach food, predominance in the diet of carbohydrates, free from protein, causing hypersecretion, and over time, and when other factors - ulceration. Irregular meal may contribute to the occurrence of the disease, as this falls one of the most important factors of regulation of secretory process a buffering effect of food affecting neutralizing on acidic environment of the stomach.
Large doses of nicotine cause ischemia of the mucous membrane of the stomach, which in some cases may to create a precondition for the formation. The negative impact of alcohol on the secretion of gastric mucosa allows it to be included in the category of factors predisposing to the development of peptic ulcer. Thus, the causes of peptic ulcers diverse and pathogenesis complicated and largely remains unclear.
Ulcers disease [synonym: peptic ulcer of stomach and duodenal ulcers (ulcus pepticum ventriculi et duodeni), round ulcer (ulcus rotundum), a disease Krouvila] - common chronic relapsing disease, characterized by seasonal exacerbations with the appearance of sores wall of the stomach or duodenum.
The frequency of ulcer disease in all countries of Europe and in the US is steadily growing. The increase in the number of cases of peptic ulcer associated with increasing urbanization, war and change in the character of nutrition of the population (prevalence in dietary intake of refined carbohydrates, reinforcing the secretory activity of the glandular apparatus of the stomach). Children (under 14 years) peptic ulcer disease is rare.
More often peptic ulcer disease is common in people aged 25 to 50 years, with men 3-10 times more often than women. Lower incidence of peptic ulcer disease among women is caused by biological properties of female sex hormones (estrogens reduce the secretory activity of the gastric glands).
The profession has no effect on the occurrence of peptic ulcer disease. Among the rural population, the disease is less common compared with the city. Uncomplicated peptic ulcer disease is not the immediate cause of death. Mortality ulcers caused joined complications (perforation, haemorrhage, malignancy).
The etiology and pathogenesis
Despite numerous clinical and experimental research, etiology and pathogenesis of peptic ulcer disease to date is unclear.
The main manifestation of ulcer disease or ulcerative defect in the wall of the stomach or duodenum,in the opinion of the majority of authors occurs in the digestive influence of gastric juice on the limited areas of the mucous membrane, and then on the deeper layers of the gastro-intestinal wall. However, in normal conditions, the mucous membrane of stomach and duodenal ulcer resistant to digestive action of gastric juice because of the presence of a number of complex mechanisms of protection. For that to happen self-digestion requires the influence of any factors, resulting in either lowered resistance mucous membrane to digestive action of gastric juice, or increase its digestive properties, or, finally, are both listed conditions. Numerous theories have been proposed: alimentary, mechanical, traumatic, intoxication, serverelement, spasmogenic, or neuro, kortiko-visceral, hormonal, but none of them fully explains the causes of peptic ulcer.
At the modern level of knowledge is extremely difficult to separate the etiology and pathogenesis of peptic ulcers, which are inextricably linked. For example, it is established that the nervous factor plays with ulcers and etiological and pathogenetic role.
Currently defined basic and predisposing factors in etiology and pathogenesis of peptic ulcer disease. The main factors in the development of peptic ulcer believe disorders neurohormonal mechanisms regulating digestion disorders local mechanisms of digestion and changes in the structure of the mucous membrane of stomach and duodenal ulcers; predisposing - heredity and environment, first of all meals.
The Central place in the etiology and pathogenesis of peptic ulcer disease belongs to disorders of the nervous system that may occur in the Central and autonomic departments, under the influence of different impacts (negative emotions, stress in mental and physical work, viscero-visceral reflexes and others).
The assumption about the value of disorders of the nervous system in the formation spoke for a long time and was confirmed in the first half of the 20th century clinical and postmortem experimental studies mainly domestic scientists (M. P. Konchalovsky, N. D. Strazhesko, N. N. Burdenko, B. N. Mogilnitsky, S. S. Weill, Yu. M. Lazovsky and others).
In result of studies of the school of I. P. Pavlov originated the idea of the role of the nervous system and its highest division of the cerebral cortex in the regulation of all life: the functions of the body, including the gastrointestinal tract.
Developing these ideas I. P. Pavlov, K. M. Bykov and I. So Curtin based on extensive experimental material! showed normal relations cortex and subcortical centers and their change in cases of stress and depletion of cellular elements of the cortex. In the latter case the "child" is Autonomous, free from regulatory impact crust. As a result, in the hypothalamus* occurs congestive center of excitement, contributing to the violation of the basic functions of the gastro-duodenal system and other internal organs and glands of internal secretion.
Created by these authors kortiko-visceral theory explains the development of peptic ulcer violation of dynamic interaction between the organism and the environment, as well as between the nervous system and internal environment. Negative factors of external environment in the form of various stressors (emergency stimuli) affect serverhellodone mechanisms gastro-duodenal system. Pathological annoyance extends from the cortex to the interstitial mind, next to the wandering nerve and through him to the stomach. As a result of arrival of pathological activity of bark through interoreceptors in the stomach ulcer is formed. In turn from the stomach nerve impulses are sent to the bark, amplifying the pathological process of excitation, eventually leading to the depletion of the functional activity of the cortex.
In recent years demonstrates the value of the hypothalamus as one of the main regulators of gastric secretion. It will influence the structure of the mucous membrane, function and circulation of the stomach. Under different effects on the hypothalamus watched the development of ulcers in the stomach with simultaneous quantitative changes of active substances in the gastric mucosa (serotonin, gistamina and other). It is essential that bilateral pharmacological sympathectomy is sharply inhibited the formation of ulcers in the stomach.
Wagner and Fodor (S. Wagner, O. Fodor) attach a great importance in the pathogenesis of peptic ulcer disease increases tone wandering nerve. The result is enhanced active secretion of gastric juice on an empty stomach and in the nervous phase of secretion and hypoxia caused by spasm of the muscles of the stomach. Hypoxia in turn contributes to the vulnerability of the gastric mucosa. In addition, with increased vagal tone is increased gastrina in both phase of secretion.
The vagus nerve has an effect on the stomach through the acetylcholine. Clinical data confirm the presence of hypertonicity of the vagus nerve in the patients with ulcer (hypotension, bradycardia, increased salivation, quickly advancing red dermographism).
Thus, under the influence of external factors comes disorder in coordination of activity of the cerebral cortex of the brain and subcortical formations. To the greatest extent increases the tone of the area of diencephalic and hypothalamus. This leads to pathological excitation centres and the vagus nerve. Over the past determines the Hyper hydrochloric acid and enzymes. So there is one of the causes of peptic ulcer.
Numerous experimental and clinical studies confirm the existence of close ties between the adrenal cortex and stomach. Violation function of the hypothalamus, caused by stress, has an impact on the anterior pituitary gland through a hypothetical hormone, causing the release of ACTH. ACTH stimulates increased secretion of glucocorticoids, under influence of which is a significant increase gastric secretion, the allocation of hydrochloric acid and enzymes, reduction in the level of potassium and sodium in the gastric juice, reducing its viscosity and quantity of mucus. The latter indicates a decrease in the protective function of the stomach mucosa that may contribute to the formation of ulcers. Vagotomy and antrectomy not eliminated the effects of the hormone. S. M. RISS believes that of all the glands of internal secretion, only violations of the hypophysial-adrenal system play a notable role in the development of peptic ulcers. Some importance sex hormones. Participation in the formation of the thyroid and parathyroid glands is not proven.
Thus, as the nervous and hormonal pathways pathological irritation to the stomach go through the same centers of bark, interstitial the brain, the hypothalamus, pituitary, which allows to combine them into a single mechanism neurohormonal violations of regulation digestive functions. The relationship between these factors is determined and the response of the stomach to both stimulants. When the synergistic action of both factors increase the possibility of the formation of ulcers.
The result of violation of neurohormonal regulation of functions of the gastro-duodenal system is a violation of their local mechanisms (acid-peptic factor, digestive hormones, mucus barrier, regeneration of the mucous membrane, motor function, condition of blood circulation in the wall of the stomach and duodenal ulcers, morphological reconstruction of the mucous membrane, local mechanisms gastro-duodenal system, depressing secretory function).
P. C. Vlasov, V. N. Tugolukov and others established the increase of mass obkladochnykh cells and gastric secretion in the localization of ulcers in the duodenum. The localization of ulcers in the stomach their number reduced.
The increased activity of acid-peptic factors may contribute to the formation only in combination with other pathogenetic mechanisms. It should be emphasized that the increased activity of acid-peptic factor was maintained in the period of remission of ulcerative disease.
The question of the role of the main food hormones (gastrin, histamine and serotonin) in the formation of peptic ulcer has been studied insufficiently. Apparently, the secretion of gastrin and histamine ulcers increases that along with the increase in the number obkladochnykh cells may contribute to the increased activity of acid-peptic factor.
In recent years, much broader thinking about the chemical composition of the gastric mucus and its role in the protection of gastric mucosa from those or other damage. It is proved that mukodni substances mucus resist active action of the acid-peptic factor.
Complex chemical composition of mucus can qualitatively change under the influence of different impacts. Consequently, the protective properties of mucus may be reduced, which, combined with increased activity of acid-peptic factor may increase the chance of the ulcer formation. Disorders of blood circulation in the wall of the stomach and duodenum attach importance in the pathogenesis of peptic ulcer disease. Modern methods of examination revealed the presence of arteriovenous shunts, located near the actual muscle layer of mucous membranes. These tubes cause a focal nature of ischemia or plethora of vascular membrane of stomach and duodenal ulcer in norm and pathology. When ulcers (mainly duodenal ulcer) as a result hyperresponsiveness adrenal cortex and Hyper vagus nerve can cause disorders in shunt the circulatory system: congestive plethora or local ischemia, causing hypoxia mucosa, it increased vulnerability. Other violations of local mechanisms regulating the functions of the gastro-duodenal system, there is a prerequisite to the formation of ulcers.
Structural changes of the mucous membrane of stomach and duodenal ulcers depend on localization of ulcers. So, the localization of ulcers in the duodenum increases the number of major, tuck and mukodni cells, which is accompanied by considerable hypersecretion of hydrochloric acid, pepsina and mukoproteidov. The changes are not inflammatory nature.
The localization of ulcers in the duodenum of the discovered phenomenon duodenitis, which lowers resistance mucous membrane to acid-peptic factor and violates the physiological mechanism of inhibition of gastric secretion, outgoing from the duodenum (the Church, Masevich and others).
The localization of ulcers in the stomach there are changes in the mucous membrane, typical for different forms of chronic gastritis, development of intestinal metaplasia surface epithelium and violation of the regeneration processes. All these changes contribute to significant reduction of resistance mucous membrane to the action of the acid-peptic factor.
M. P. Konchalovsky, R. A. Luria, I. M. Flegel, the Imperial family Lorie, V. I. Parades and others believe that there is a genetic predisposition to peptic ulcer. Clinical observations have shown that peptic ulcer disease is more common in families with peptic ulcer anamnesis"than in families where it was not previously met. However, another group of researchers explain the appearance of disease among members of the same family, community nutrition and food skills. The study of the genetic characteristics in patients with peptic ulcer modern research methods (determination of blood, determination of mass obkladochnykh cells) does not allow even at the present time to draw a conclusion about the participation of hereditary factors in etiology and pathogenesis of peptic ulcer disease.
Of environmental factors a role in the etiology and pathogenesis of peptic ulcer disease plays food. Excessive consumption difficult and long perevarivaetsya in the stomach food, the predominance of the intake of refined carbohydrates, completely free from protein, causing hypersecretion, and over time, and when other factors - ulceration. Irregular eating can also contribute to the emergence of the disease, as this falls one of the most important factors of self-regulation of digestion gastro-duodenal
system buffering effect of food. The most distinct buffer property that restricts the activity of acid-peptic factor, are proteins.
Data on the effect of Smoking on the functional state of the stomach contradictory. Proven effects of nicotine on shunt the circulatory system of the stomach. It causes increased blood circulation, changing ischemia of the gastric mucosa. When large doses of nicotine observed only ischemia. Effects of nicotine on the circulation of the stomach and its main functions can create in some cases a prerequisite to the formation.
The negative impact of alcohol on gastric secretion and morphological state of the mucous membrane allows it to be included in the category of factors contributing to the development of peptic ulcer.
Thus, the causes of peptic ulcers diverse and complicated pathogenesis and remains largely unclear. Steadfast is modern idea of ulcer disease as a disease of the entire organism. Apparently, a number of pathogenic factors can lead to ulcers. In some cases, peptic ulcer disease has a nervous Genesis, in other hormonal, third - neurohormonal, fourth - come to the fore violation of local mechanisms gastric digestion.