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Peptic ulcer

Peptic ulcer disease (synonym: peptic ulcer of the stomach and duodenum, round ulcer, Cruviellie disease) is a common chronic recurrent disease with a characteristic clinical picture and local anatomical changes in the stomach and duodenum. Peptic ulcer usually occurs between the ages of 25 to 50 years, significantly more often in men.

Etiology and pathogenesis . The main factors in the development of peptic ulcer are disorders of the neurohumoral mechanisms that regulate the functions of the digestive system , disorders of local digestive mechanisms and changes in the structure of the mucous membrane of the stomach and duodenum; predisposing - heredity and environmental conditions, among which the leading place is occupied by food. An important place in the etiology and pathogenesis of peptic ulcer belongs to impaired function of the nervous system, arising under the influence of negative emotions , overstrain in mental and physical work. Nutrition plays a significant role in the etiology and pathogenesis of peptic ulcer disease. Excessive intake is difficult and long digestible in the stomach of food, the predominance in the diet of carbohydrates , free from protein, causes hypersecretion, and over time and in the presence of other factors - ulceration. Irregular food intake can contribute to the occurrence of the disease, as this results in one of the most important factors regulating the secretory process - the buffering effect of food acting in a neutralizing manner on the acidic environment in the stomach.

Large doses of nicotine cause ischemia of the gastric mucosa, which in some cases can create a prerequisite for ulcer formation. The negative effect of alcohol on the gastric secretion of the mucous membrane makes it possible to attribute it to the category of factors predisposing to the development of peptic ulcer. Thus, the causes of peptic ulcer disease are diverse, and the pathogenesis is complex and in many respects remains unclear.

Peptic ulcer disease [synonym: peptic ulcer and duodenal ulcer (ulcus pepticum ventriculi et duodeni), round ulcer (ulcus rotundum), disease Cruveilhier] - common chronic relapsing disease characterized by seasonal exacerbations with the emergence of ulcers of the stomach wall or duodenum.

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The frequency of peptic ulcer disease in all countries of Europe and the United States is steadily increasing. The increase in the number of cases of peptic ulcer disease is associated with an increase in urbanization, wars and changes in the dietary pattern of the population (the prevalence in the diet of refined carbohydrates, which increase the secretory activity of the glandular apparatus of the stomach). In children (under the age of 14 years), peptic ulcer disease is rare.

Most often, peptic ulcer disease occurs in people aged 25 to 50 years, and in men 3-10 times more often than women. The lower incidence of peptic ulcer disease among women is due to the biological properties of the female sex hormones ( estrogens reduce the secretory activity of the gastric glands).

Profession does not affect the occurrence of peptic ulcer disease. Among the rural population, the disease is less common than in urban areas. Uncomplicated peptic ulcer disease is not a direct cause of death. Mortality in peptic ulcer disease is caused by joining complications (perforation, bleeding, malignancy).

Etiology and pathogenesis
Despite numerous clinical and experimental studies, the etiology and pathogenesis of peptic ulcer disease is still unclear.

The main manifestation of peptic ulcer - ulcerative defect of the wall of the stomach or duodenum - according to most authors, occurs as a result of the digestive effect of gastric juice on limited areas of the mucous membrane, and then on the deeper layers of the gastrointestinal wall. However, under normal conditions, the mucous membrane of the stomach and duodenum is resistant to the digestive effect of gastric juice due to the presence of a number of complex protective mechanisms. In order for self-digestion to occur, some factors must be influenced, as a result of which the resistance of the mucous membrane to the digestive effect of gastric juice is reduced, or its digestive properties are enhanced, or, finally, both of these conditions occur. Numerous theories have been proposed: alimentary, mechanical, traumatic, intoxication, neuroreflex, spasmogenic, or neurovegetative, cortico-visceral, hormonal, but none of them fully explains the causes of peptic ulcer.

At the present level of knowledge is extremely difficult to separate the etiology and pathogenesis of peptic ulcer disease, which are inextricably linked. For example, it has been established that the nervous factor plays an etiological and pathogenetic role in peptic ulcer disease.

Currently identified the main and predisposing factors in the etiology and pathogenesis of peptic ulcer. The main factors in the development of peptic ulcer are considered disorders of the neurohormonal mechanisms that regulate digestion, disorders of local digestive mechanisms and changes in the structure of the mucous membrane of the stomach and duodenum; predisposing - heredity and environmental conditions, especially food.

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Central to the etiology and pathogenesis of peptic ulcer belongs to disorders of the nervous system, which can occur in its central and autonomic divisions, under the influence of various influences (negative emotions, overstrain in mental and physical work, viscero-visceral reflexes, etc.).

The assumption about the importance of disorders of the nervous system in ulceration was expressed long ago and was confirmed in the first half of the 20th century by clinical and pathological-anatomical experimental studies of mainly domestic scientists (M. P. Konchalovsky, N. D. Strazhesko, N. N. Burdenko, B. N. Mogilnitsky, S. S. Weil, Yu. M. Lazovsky, and others.).

As a result of the work of IP Pavlov’s school, ideas arose about the role of the nervous system and its highest section — the cerebral cortex — in regulating all vital functions of the body, including the gastrointestinal tract.

Developing these ideas of I. P. Pavlov, K. M. Bykov and I. T. Kurtsin on the basis of extensive experimental material! showed normal interrelations of the cortex and subcortical centers and their change in cases of overstrain and depletion of the cellular elements of the cortex. In the latter case, the “subcortex” becomes autonomous, freeing itself from the regulatory influence of the cortex. As a result, in the hypothalamus *, a congestive focus of excitation arises, causing a violation of the basic functions of the gastro-duodenal system and other internal organs, as well as the endocrine glands.

The cortico-visceral theory created by these authors explains the development of a peptic ulcer by a violation of the dynamic interaction between the organism and the external environment, as well as between the nervous system and the internal environment. Negative environmental factors in the form of various stressors (extreme irritants) affect the neuro-regulatory mechanisms of the gastro-duodenal system. Pathological irritation spreads from the cerebral cortex to the interstitial brain, then to the centers of the vagus nerve and through it to the stomach. As a result of the arrival of pathological impulses from the cortex through an interoreceptor, an ulcer forms in the stomach. In turn, from the stomach, nerve impulses are sent to the cortex, intensifying the process of pathological arousal, eventually leading to the depletion of the functional activity of the cortex.

In recent years, the importance of the hypothalamus as one of the central regulators of gastric secretion has been shown. It affects the structure of the mucous membrane, the function and blood circulation of the stomach. At various effects on the hypothalamus, the development of ulcers in the stomach was observed with a simultaneous quantitative change in the active substances in the gastric mucosa (serotonin, histamine, etc.). It is significant that bilateral pharmacological sympathectomy dramatically slowed the formation of ulcers in the stomach.

Wagner and Fodor (S. Wagner, O. Fodor) attach great importance in the pathogenesis of peptic ulcer to improving the tone of the vagus nerve. The consequence of this are increased secretion of active gastric juice on an empty stomach and into 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 an increase in the tone of the vagus nerve, the secretion of gastrin in both phases of secretion increases.

The vagus nerve exerts its effect on the stomach through acetylcholine. Clinical data confirm the presence of hypertonus of the vagus nerve in patients with peptic ulcer disease (hypotension, bradycardia, increased salivation, rapidly advancing red dermographism).

Thus, under the influence of environmental factors, a disorder occurs in the coordination of the activity of the cerebral cortex and subcortical structures. The greatest increase in the tone of the diencephalic region and hypothalamus. This leads to pathological arousal of the centers and the vagus nerve itself. Overexcitation of the latter causes hypersecretion of hydrochloric acid and enzymes. So there is one of the causes of peptic ulcer.

Numerous experimental and clinical observations confirm the existence of a close connection between the adrenal cortex and the stomach. Impaired function of the hypothalamus caused by stress affects the anterior pituitary through the hypothetical hormone, causing the release of ACTH. ACTH stimulates increased secretion of glucocorticoids, under the influence of which there is a significant increase in gastric secretion, release of hydrochloric acid and enzymes, a decrease in the level of potassium and sodium in the gastric juice, a decrease in its viscosity and the amount of mucus. The latter indicates a decrease in the protective function of the gastric mucosa, which may contribute to the formation of an ulcer. Vagotomy and antrectomy did not eliminate the effects of the hormone. S. M. Ryss believes that, of all the endocrine glands, only disorders of the pituitary-adrenal system play a certain role in the development of peptic ulcer. Sex hormones have a certain value. Participation in ulceration of the thyroid and parathyroid glands has not been proven.

Thus, both the nervous and hormonal pathways of pathological irritation to the stomach pass through the same centers of the cortex, interstitial brain, hypothalamus, pituitary gland, which gives grounds to combine them into a single mechanism of neurohormonal dysregulation of digestive functions. The relationship between these factors is determined by the response of the stomach to both stimuli. With the synergistic action of both factors increases the possibility of the formation of peptic ulcer.

The impairment of the neurohormonal regulation of the gastro-duodenal system functions is a violation of their local mechanisms (acid-peptic factor, digestive hormones, mucous barrier, regeneration of the mucous membrane, motor function, state of blood circulation in the wall of the stomach and duodenum, morphological mutation of the mucosa, local mechanisms of gastro - duodenal system, suppressing the secretory function).

P. V. Vlasov, V. N. Tugolukov, and others established an increase in the mass of parietal cells and gastric secretion with the localization of an ulcer in the duodenum. With the localization of ulcers in the stomach, their number is reduced.

Increased activity of the acid-peptic factor can contribute to ulceration only in combination with other pathogenetic mechanisms. It should be emphasized that the increased activity of the acid-peptic factor persists during the remission of peptic ulcer.

The question of the role of the main food hormones (gastrin, histamine and serotonin) in the formation of peptic ulcer has not been studied enough. Apparently, the secretion of gastrin and histamine in peptic ulcer disease increases, which, along with an increase in the number of parietal cells, may increase the activity of the acid-peptic factor.

In recent years, ideas about the chemical composition of gastric mucus and its role in protecting the gastric mucosa from various injuries have significantly expanded. It is proved that mucoid substances of mucus resist the active action of acid-peptic factor.

The complex chemical composition of mucus can qualitatively change under the influence of various influences. As a result, the protective properties of mucus can be reduced, which, in combination with increased activity of acid-peptic factor, can increase the possibility of ulceration. Circulatory disorders in the wall of the stomach and duodenum are given importance in the pathogenesis of peptic ulcer. Modern methods of research established the presence of arteriovenous shunts located near the actual muscle layer of the mucous membrane. These shunts are responsible for the focal nature of ischemia or plethora of the choroid of the stomach and duodenum in normal and pathological conditions. In peptic ulcer disease (mainly duodenal ulcer), as a result of hyperreactivity of the adrenal cortex and hypertonus of the vagus nerve, disorders in the shunt circulatory system can occur: congestive plethora or local ischemia, causing hypoxia of the mucous membrane, its increased visibility. With other violations of local mechanisms that regulate the functions of the gastro-duodenal system, there is a prerequisite for the formation of peptic ulcer.

Structural changes in the gastric and duodenal mucosa depend on the localization of the ulcerative process. So, with the localization of ulcers in the duodenum, the number of main, foliated and mucoid cells increases, which is accompanied by a significant hypersecretion of hydrochloric acid, pepsin and mucoproteins. At the same time, the changes are not inflammatory.

With the localization of ulcers in the duodenum, duodenitis was observed, which lowers the resistance of the mucous membrane to the acid-peptic factor and violates the physiological mechanism of inhibition of gastric secretion emanating from the duodenum (Ts. G. Masevich and others).

With the localization of ulcers in the stomach, there are changes in the mucous membrane, typical for various forms of chronic gastritis, the development of intestinal metaplasia of the surface epithelium and impaired regeneration processes. All these changes contribute to a significant reduction in the resistance of the mucous membrane to the action of acid-peptic factor.

M. P. Konchalovsky, R. A. Luria, I. M. Flekel, I. F. Lorie, V. I. Smotrov, and others believe that there is a hereditary predisposition to a peptic ulcer. Clinical observations have established that peptic ulcer is more common in families with a “ulcer history” than in families where it has not been seen before. However, another group of researchers explains the emergence of the disease among members of the same family by the community of nutrition and nutritional skills. The study of genetic features in patients with peptic ulcer modern methods of research (determination of blood group, determination of the mass of occipital cells) does not yet allow us to conclude that the hereditary factor is involved in the etiology and pathogenesis of peptic ulcer.

Of environmental factors, nutrition plays a role in the etiology and pathogenesis of peptic ulcer disease. Excessive intake is difficult and long-digestible food in the stomach, the prevalence of refined carbohydrates, completely free of protein, in the diet causes hypersecretion, and over time, and in the presence of other factors, ulceration. Irregular food intake can also contribute to the occurrence of the disease, since it causes one of the most important factors in the self-regulation of the digestive system of the gastro-duodenal system - the buffering effect of food. The most distinct buffer property, limiting the activity of acid-peptic factor, have proteins.

Data on the effect of smoking on the functional state of the stomach are contradictory. Proven effects of nicotine on the shunt system of the blood circulation of the stomach. It causes increased blood circulation, alternating with ischemia of the gastric mucosa. With the introduction of large doses of nicotine is only observed ischemia. The effect of nicotine on the blood circulation of the stomach and its main functions can, in some cases, create a prerequisite for ulceration.

The negative effect of alcohol on gastric secretion and the 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 ulcer are diverse, and the pathogenesis is complex and in many respects remains unclear. The modern idea of ​​a peptic ulcer as a disease of the whole organism remains unshakable. Apparently, a number of pathogenetic factors may cause the occurrence of peptic ulcer. In some cases, peptic ulcer has a nervous genesis, in others - hormonal, thirdly - neurohormonal, fourthly - violations of local mechanisms of gastric digestion come to the fore.