Treatment of uncomplicated gastric and duodenal ulcers. Peripheral M-anticholinergics in the treatment of peptic ulcer

Peptic ulcer- a chronic recurrent disease of the gastroduodenal region, in which relapses of stomach or duodenal ulcers occur.

In the treatment of patients with peptic ulcer there are two main period(two tasks):

Treatment of the active phase of the disease (newly diagnosed peptic ulcer or its exacerbation);

Prevention of relapse (preventative treatment).

Treatment in the active phase of the disease (i.e. during the exacerbation period) includes the following main directions:

1. Etiological treatment.

2. Treatment regimen.

3. Medical nutrition.

4. Drug treatment.

5. "Herbal medicine.

6. Use of mineral waters.

7. Physiotherapeutic treatment.

8. Local treatment long-lasting ulcers.

Etiological treatment is an important section in the complex therapy of peptic ulcer and includes:

Elimination of chronic duodenal disorders that exist in some cases
dental patency;

stopping smoking and alcohol abuse;

elimination of factors damaging the mucous membrane of the stomach and duodenum (medicines - acetylsalicylic acid and other non-steroidal anti-inflammatory drugs, reserpine, glucocorticoids, occupational hazards, etc.).

The first stage of active antiulcer treatment (especially for newly diagnosed ulcers) is most appropriate to carry out in a hospital. During the period of exacerbation of the disease, the patient must be provided with mental and physical rest. It is advisable to recommend relaxed bed rest for 7-10 days, followed by replacing it with free rest. Bed rest has a beneficial effect on intra-abdominal pressure and blood circulation in the gastrointestinal tract, promotes rapid healing of ulcers. However, prolonged rest negatively affects the functional state of the body. Therefore, after eliminating acute manifestations diseases, it is necessary to gradually introduce patients to exercise therapy. With mild exacerbation of peptic ulcer disease, small size of the ulcer, outpatient treatment of patients is possible.

The criteria for discharge of a patient from the hospital are the disappearance of symptoms of exacerbation, healing of ulcers and erosion, reduction in the severity and prevalence of the inflammatory process in the esophagogastro-duodenal mucosa. Extending the duration of hospital treatment until the onset of complete endoscopic remission is not justified, since limited gastroduodenitis, and sometimes distal esophagitis with moderate degree inflammation can persist for three or more months. After discharge from the hospital, treatment is continued on an outpatient basis without release from work.

2.1. Estimated duration of inpatient treatment, outpatient treatment and temporary disability due to peptic ulcer disease

2.1.1. peptic ulcer of the stomach and duodenum,
first identified

Inpatient treatment - 29-25 days.

Outpatient treatment after inpatient treatment - 3-5 days.

The total period of temporary disability is 23-30 days.

2.1.2. Mediogastric ulcer

Inpatient treatment - 45-50 days.

Outpatient treatment after inpatient treatment - 4-10 days.

The general period of temporary disability is 50-60 days.

2.1.3. Peptic ulcer of the stomach and duodenum
(chronic flow)

Mild exacerbation

Outpatient treatment - 20-25 days

or hospital treatment- 18-20 days.

The general period of temporary disability is 18-25 days.

Moderate exacerbation

Inpatient treatment - 30-35 days.

The general period of temporary disability is 30-35 days.

Severe exacerbation

Inpatient treatment 40-45 days.

The general period of temporary disability is 40-45 days.

2.2. Working capacity of patients with peptic ulcer

Stomach and duodenal ulcers (newly identified): exemption from heavy physical labor for 2 weeks.

Mediogastric ulcer:

exemption from heavy physical labor for 3 months.

Peptic ulcer of the stomach and duodenum (chronic course).

Mild exacerbation:

liberation from hard physical labor. Exacerbation medium degree severity and severe course:

liberation from hard physical labor. For very frequent exacerbations:

release from work of moderate intensity.

Clinical studies in recent years indicate that mechanically and chemically gentle anti-ulcer diets No. 1a and No. 16 (in the chapter "Treatment" chronic gastritis") are indicated only for severe symptoms of exacerbation, they are prescribed only for 2-3 days, and then patients are transferred to diet No. 1. This diet stimulates the repair processes of the affected mucous membrane, prevents the development of constipation, restores appetite and has positive influence on the general well-being of the patient. Food is given boiled, but not mashed.

The diet includes white stale bread, soups from cereals, vegetables, well-cooked porridges, mashed potatoes, lean varieties of meat, poultry, fish (boiled, in pieces), ripe fruits, baked or boiled berries, berry and fruit juices, cottage cheese, milk, omelettes, puddings and cottage cheese pancakes.

You need to eat 5-6 times a day. Diet No. 1 contains proteins - 110-120 g, fats - 110-120 g, carbohydrates - 400-450 g. It is not recommended to eat spicy foods, pickled and smoked foods.

During the period of remission, there are no major dietary restrictions, but frequent meals are recommended, which have a buffering effect and prevent duodenogastric reflux. In the scarring phase of the ulcer, patients can be transferred to a general diet.

In recent years, the need to prescribe special therapeutic nutrition for patients with peptic ulcer disease has been questioned, since the effect of diet therapy on the healing time of ulcers has not been proven. In addition, modern pharmacotherapeutic agents allow sufficiently block acid formation stimulated by food intake.

In the diet of patients with peptic ulcers, it is necessary to provide an optimal amount of protein (120-125 g) in order to meet the requirements

nosgey of the body in plastic material and strengthening of regeneration processes. In addition, complete protein supplied to sufficient quantity with food, reduces the excitability of glandular cells, reduces the production of hydrochloric acid and pepsin, has a neutralizing effect on acidic contents (binds hydrochloric acid), which creates peace for the stomach and leads to the disappearance of pain. X. X. Mansurov (1988) proposed adding soy flour to the diet of patients 5 g 3 times a day 30 minutes before meals for 4-6 weeks as vegetable fiber, which reduces the production of hydrochloric acid and pepsin, normalizes the motor function of the gastrointestinal tract.

Drug therapy for patients with peptic ulcer disease (PU) is one of the most important components of conservative treatment.

Main groups of drugs for the treatment of ulcers

I. Drugs that suppress Helicobacter pylori infection (de-nol, trichopolum, furazolidone, oxacillin, ampiox and other antibiotics).

II. Antisecretory agents (suppressing the secretion of hydrochloric acid, pepsin and increasing intragastric pH or neutralizing and adsorbing hydrochloric acid and pepsin).

1. M-anticholinergics:

Non-selective (atropine, platyphylline, metacin);

Selective (gastrocepin, pirenzepin).

2. H2-histamine receptor blockers:

Tsimetvdin (histodil, tagamet);

Ranitvdin (ranisan, acelok E, zantac, pentoran);

Famotidine (ulfamide);

Nizatidine (Axid);

Roxatidine.

3. H + K + -ATPase (proton pump) blockers - omeprazole (omez, losec, timoprazole).

4. Gastrin receptor antagonists (proglumide, milid).

5. Antacids (sodium bicarbonate, magnesium oxide, calcium carbonate, almagel, phosphalugel, maalox, gaviscon, bismuth).

III. Gastrocytoprojectors (increasing the resistance of the mucous membrane of the stomach and duodenum).

1. Cytoprotective agents that stimulate mucus formation:

Carbenoxolone;

Synthetic prostaglandins - enprostil, cytotec.

2. Cytoprotectors that form a protective film:

Sucralfate;

Colloidal bismug - de-nol;

3. Enveloping and astringent agents:

Bismuth preparations - Vikalin, Vikair.

IV. Drugs that normalize the motor function of the stomach and duodenum (cerucal, raglan, metoclopramide, eglonil, sulpiride), antispasmodics (no-spa, papaverine).

V. Reparants (solcoseryl, obleggikh oil, anabolics, acemin, gastrofarm).

VI. Facilities central action(dalargin, eglonil, sedatives, tranquilizers).

4.1. Agents that suppress Helicobacter pylori infection

Currently Helicobacter pylori(HP) is recognized as the leading etiological factor in gastric and duodenal ulcers. HP is found in the mucous membrane of ulcers in almost 100% of cases; its role in the development of inflammation, the formation of erosions and ulcers in the mucous membrane of the stomach and duodenum has been proven. Exacerbation of Helicobacter pylori infection is also the most common cause of exacerbation of ulcerative disease.

In this regard, the main modern principle of treatment of ulcer and the accompanying chronic active gastroduodenitis associated with HP is the destruction of bacteria infecting the gastric mucosa and duodenum.

For this purpose, drugs are used that suppress the activity of HP, which contributes to the rapid onset of remission and the prevention of relapses.

De-nol(colloidal bismuth subcitrate), available in tablets of 0.12 g. When taken orally, the drug gradually forms a colloidal mass distributed over the surface of the mucous membrane of the stomach and duodenum. The ulcer becomes covered with a foamy white coating, which persists for several hours and is easily detected endoscopically.

In a de-nol solution, the pH is approximately 10.0. Lowering the pH to 4.0 or lower by exposure to hydrochloric acid causes precipitation of insoluble bismuth oxychloride and citrate. When exposed to gastric juice, a precipitate forms at pH 3.5.

Maximum precipitation occurs at pH values ​​ranging from 2.5 to 3.5. The pH of gastric acidity is usually below this limit, which, however, is achieved by combining hydrogen ions with amino acids at the ulcer site.

The drug causes the formation of chelate compounds of bismuth and proteins of ulcerative exudate, which protect ulcers and erosions from the further destructive effects of gastric juice. De-nol forms a complex with gastric mucus, which is more effective against hydrogen ions than normal gastric mucus.

In addition, de-nol reduces the activity of pepsin and has a gastrocytoprotective effect (increases the quantity and quality of gastric

mucus, increases the production of gastric mucin). De-nol destroys HP infection in the stomach and duodenum.

De-nol take 1 tablet half an hour before breakfast, lunch and dinner and before bed for 4-6 weeks. The drug should not be taken with milk; half an hour before taking it and for half an hour after it, you should refrain from drinking drinks, solid food and antacids (so as not to increase the pH of gastric juice and reduce the activity of the drug).

There is another method of treatment with de-nol: 2 tablets half an hour before breakfast and 2 hours after dinner, washed down with water.

The drug has virtually no side effects or contraindications; nausea occurs occasionally. De-nol causes darkening of stool.

During a course of treatment with de-nol in the form of monotherapy (4-8 weeks), an average of up to 50% of HP is destroyed. De-nol has direct cytotoxicity and destroys both dividing and dormant bacteria, preventing the formation of strains resistant to therapy. To increase the effectiveness of treatment, de-nol must be combined with other antibacterial agents(metronidazole, ampicillin, clarithrimycin, amoxicillin, tetracyclines) and omeprazole(Ch. "Treatment of chronic gastritis").

Optimal combinations for course therapy of peptic ulcer disease associated with HP (P. Ya. Grigoriev, A. V. Yakovenko, 1997).

1. De-nol 0.12 g 4 times a day for 14 days + metronidazole(Trichopolum) 0.25 g 4 times a day for 14 days + gastrocepin 0.05 g 2 times a day for 8 weeks for duodenal ulcer and 12 weeks for gastric ulcer.

2. Gastrostatpo 1 tablet 5 times a day for 10 days + omeprazole(Losec) 20 mg 2 times a day for 10 days and 20 mg 1 time a day for 4 weeks for duodenal ulcer and 6 weeks for gastric ulcer.

Gastrostat is a combined preparation containing 108 mg of colloidal bismuth subcitrate, 200 mg metronidazole, 250 mg tetracycline.

3. Omeprazole (Losec) 20 mg 2 times a day for 7 days and 20 mg 1 time a day for 4 weeks for duodenal ulcer and 6 weeks for gastric ulcer +metronidazole amoxicillin 500 mg 4 times a day for 7 days or clarithrimycin

4. Ranitidine 150 mg 2 times a day for 7 days and 300 mg 1 time a day for 8 weeks for duodenal ulcer and 16 weeks for gastric ulcer + metronidazole 250 mg 4 times a day 7 days + amoxicillin 500 mg 4 times a day or clarithrimycin 250 mg 2 times a day for 7 days.

5. Ftotidt(kvamatel, ulfamid) 20 mg 2 times a day for 7 days and 40 mg 1 time a day for 8 weeks for duodenal ulcer and 16 weeks for gastric ulcer + metronidazole 250 mg 4 times a day 7 days + amoxicillin 0.5 g 4 times a day or clarithrimycin 250 mg 2 times a day for 7 days.

With the first combination of agents, HP infection is eliminated in 80% of cases, with the 2nd, 3rd, 4th, 5th combinations - in 90% of cases or more.

Of interest are the data from Khulusi et al. (1995) that bile acids inhibit HP growth by damaging bacterial walls. The same authors established a reliable inhibitory effect of linoleic acid

you on the growth of Helicobacter, which is associated with its active incorporation and accumulation in them. It has been shown that the incidence of duodenal ulcer inversely correlates with the consumption of unsaturated fatty acids.

The number of relapses in patients with peptic ulcer after combination anti-Helicobacter pylori therapy is less than with de-nol monotherapy.

To consolidate remission, it is advisable to carry out repeated courses of antibacterial therapy de-nol, oxacimin, trichopolom with possible replacement of the last two drugs furazhodon, tetracycline, amoxicimine or erythromycin.

N. E. Fedorov (1991) showed high efficiency in HP tari vida(ofloxacin) at a dose of 0.2 g 2 times a day after meals for 10-14 days, as well as cephalexin in capsules of 0.25-0.5 g 4 times a day for 7-14 days, regardless of food intake.

4.2. Antisecretory agents

Antisecretory agents have a different mechanism of action: they suppress the secretion of hydrochloric acid and pepsin, or neutralize or adsorb them.

One of the most important factors of ulcer formation is acid-pegging. The production of hydrochloric acid is controlled by three types of receptors located on the basement membrane of parietal cells - Ngistamine, gastrin and M-cholinergic receptors.

Inside the cell, the effect of stimulation of H 2 -Histamine receptors is realized through the activation of adenylate cyclase and an increase in the level of cAMP, and gastrin and M-cholinergic receptors - through an increase in the level of free Ca ++.

The final stage of intracellular reactions is the activation of H + K + -ATPase, leading to an increase in the secretion of hydrogen ions into the lumen of the stomach.

Thus, the production of hydrochloric acid can be reduced with the help of Ngistamine and M-cholinergic receptor blockers, as well as H + K + -ATPase inhibitors (6)

Somatosgatin and prostaglandin E 2 have an antisecretory effect by inhibiting adenozyme enzyme.

4.2.1. M-anticholinergics

M-anticholinergics have the ability to block M-cholinergic receptors; they become insensitive to acetylcholine formed in the area of ​​the endings of postganglionic parasympathetic (cholinergic) nerves. There are two subtypes of M-cholinergic receptors (M and M2), which differ in density in different organs.

Non-selective M-anticholinergics block M and Mg cholinergic receptors and reduce the secretion of hydrochloric acid, bronchial, sweat glands, pancreas, cause tachycardia, and reduce the tone of the GLAD-muscular organs.

Selective M, -CholInalithias1 selectively block M, -CHOLIN receptors of the stomach and reduce its secretory and motor activity, with virtually no effect on M-cholinergic receptors of other organs (heart, bronchi, etc.).

Non-selective M^ and M 2 -anticholinergics

Atropine - used in VVD 0.1% solution orally 5-10 drops or subcutaneously 0.5-1 ml 30 minutes before meals and at night.

Metacin - taken orally in tablets of 0.002 g 3 times a day 30 minutes before meals and 0.004 g before bedtime or 1-2 ml of a 0.1% solution subcutaneously 1-3 times a day.

Platifillin - applied orally 0.003-0.005 g 3 times a day before meals and at night or 1-2 ml of a 0.2% solution subcutaneously 2-3 times a day.

Platiphylline and metacin, unlike atropine, are better tolerated by patients and cause dry mouth to a lesser extent.

Belladonna extract - taken orally 0.015 g 3 times a day before meals and at night. Belladonna is also included in the composition of the tablets becarbon, by-lastezin, belmeti etc. .

Non-selective M-cholinolytics cause the following side effects: dry mouth, decreased visual acuity, increased intraocular pressure, tachycardia, urinary retention, atonic constipation, often bile stasis, sometimes mental agitation, hallucinations, euphoria, dizziness occur.

Contraindications: glaucoma, prostate adenoma, bladder atony, constipation, hypokinetic dyskinesia biliary tract, reflux esophagitis, esophageal achalasia.

Non-selective M-holinolytics give a short antisecretory effect. It is advisable to combine them with antacids (this potentiates their effect); this combination quickly eliminates hyperkinetic disorders of motility of the stomach and intestines, and quickly relieves pain and dyspeptic disorders.

Non-selective M-anticholinergics are usually prescribed 30-40 minutes before meals (or 1.5 hours before the onset of pain) and before bedtime. For severe pain in the first 5-7 days, it is advisable to administer the drugs parenterally. The course of treatment lasts 2-3 weeks, if necessary it is increased to 4-6 weeks, taking a break of 2-3 days every 10 days to avoid overdose.

Non-selective M-cholinolytics are more indicated for pilorhoduodenal ulcer. The possibility of using drugs of this group for monotherapy has not been proven. They are used mainly during exacerbation.

Selective M-anticholinergics

Gastrocepin (pireiaapt)- tablets of 0.025 and 0.05 g, ampoules of 2 ml (10 ml of dry preparation) with the addition of a solvent. Selectively blocks Mg cholinergic receptors of the stomach, significantly suppresses the secretion of pepsin and hydrochloric acid, quickly reduces pain, dyspeptic symptoms, and shortens the healing time of ulcers.

The drug is well tolerated, has virtually no side effects (only dry mouth is possible), and can be prescribed in cases where non-selective M-anticholinergics are contraindicated. The drug penetrates the blood-brain barrier poorly and does not affect the central nervous system.

Gastrocepin is used to treat duodenal and gastric ulcers (with preserved secretion). Prescribed orally 25-50 mg in the morning before breakfast and 50 mg in the evening before bed; for duodenal ulcer, the daily dose can be 125 mg (50 mg before breakfast and 100 mg before bed). Can be used intramuscularly at 10 mg 2-3 times a day.

Healing of duodenal ulcers is usually observed at 3-4 weeks, gastric ulcers - at 4-6 weeks. With long-term use at night at a dose of 50 mg, a decrease in the frequency of relapses was noted, less pronounced than with the use of H2-histamine receptor blockers.

At a dose of 100-150 mg/day, Gastrocepin caused ulcer healing in 60-90% of patients.

Telenzepin - a new analogue of gastrocepin, but 10-25 times more active than it, it binds more selectively to M.-cholinergic receptors.

Among anticholinergics, telenzepine is the most potent inhibitor of hydrochloric acid secretion. The drug is administered intravenously for 15-20 days; 3-5 mg can be taken orally before breakfast and in the evening before bed.

Selective Mr. Anticholinergic blockers can be recommended for monotherapy of patients with peptic ulcer of the stomach and duodenum, but, according to Yu. B. Belousov, only in cases of mild disease. In cases of mild to moderate peptic ulcer disease and the absence of pronounced hypersecretion of hydrochloric acid, selective M,-CHOLINOLYTICS can be considered as an alternative to H2-histamine receptor blockers; in particular, Gastrocepin can be used if the latter are ineffective.

4.2.2. Blockers of Shch-histamine receptors

The stimulating effect of histamine on gastric secretion is carried out through the Hg receptors of the parietal cells of the stomach. By blocking these receptors, H2-histamine receptor blocking drugs have a pronounced antisecretory effect. In the therapeutic doses used, they reduce the basal secretion of hydrochloric acid by 80-90%, inhibit the production of pepsin, and reduce nighttime gastric acid secretion (by 70-90%).

Blockers of H 2 -histamine receptors were created in the mid-70s. This major achievement in medicine of the 20th century was awarded the Nobel Prize in 1988.

Hg histamine receptor blockers are the most effective and frequently used antiulcer drugs - the “gold standard” of antiulcer therapy.

Drugs in this group also affect the motility of the gastrointestinal tract and regulate the function of the gastric and esophageal sphincters. There are 5 generations of H2-histamine receptor blockers.

Hg blockers of histamine receptors of the 1st generation

Cimetidine(histodil, belomet, tagamet, acylok) is available in tablets of 0.2 g, ampoules of 2 ml of 10% solution.

During an exacerbation of peptic ulcer, cimetidine is prescribed 200 mg 3 times immediately after meals or during meals and 400 mg at night or 400 mg after breakfast and before bed for 4-8 weeks or more, and then 400 mg before bed for a long time (from 6 to 12 months). This distribution of the drug during the day is due to the fact that from 11 pm to 7 am, 60% of hydrochloric acid is released, and from 8 am to 10 pm - only 40% of hydrochloric acid.

Cimetidine can also be used intramuscularly or intravenously at 200 mg every 4-6 hours.

In recent years, cimetidine has been prescribed once at night in a dose of 800 mg (this method of administration gives the same antacid effect as twice the use of the drug 400 mg).

Cimetidine has a healing effect on duodenal ulcers and gastric ulcers with high acidity. At the same time, the drug is not very effective for stomach ulcers with low secretion of hydrochloric acid and does not prevent its recurrence. But, according to some data, cimetidine is effective for mediogastric localization of ulcers due to the ability to reduce dysrhythmia in the activity of the neuromuscular apparatus of the antrum of the stomach and normalize the reparative processes of the mucous membrane of the gastroduodenal zone.

Cimetidine causes the following side effects:

Hyperprolacganemia, which causes persistent galactorrhea syndrome in women and gynecomastia in men;

Antiandrogenic effect (loss of libido, impotence), to a certain extent associated with hyperprolainemia;

Impaired liver and kidney function, and in case of severe renal and hepatic failure and large doses of the drug - side effects from the central nervous system: drowsiness, depression, headache, agitation, periods of apnea;

“rebound syndrome” is the possibility of a rapid relapse of peptic ulcer disease, often with complications in the form of gastroduodenal bleeding when the drug is abruptly discontinued, which is associated with hyperplasia of gastrin-producing cells and the preservation of their activity while taking cimetidine. To avoid this syndrome, it is necessary to reduce the dose of the drug very gradually and combine for

1.5-2 months of therapy with cimetidine with anticholinergics or antacids. It is recommended to take β-blockers for a long time, which prevent degranulation of mast cells, inhibit the activity of endocrine cells and the release of gastrin;

Cardiac arrhythmias, lowering blood pressure (when administered intravenously); neutropenia, thrombocytopenia;

Formation of antibodies to cimetidine long-term treatment;

Skin rashes, itching.

Cimetidine is a powerful inhibitor of microsomal oxidation due to inhibition of the activity of cytochrome P 45 o enzymes and increases the concentration of many drugs in the blood - theophylline, oral anticoagulants, diazepam, lidocaine, propranolol and metoprolol.

Cimetidine also increases the absorption of ethanol and inhibits its breakdown, which is due to inhibition of microsomal oxidation of ethanol.

According to Yu. B. Belousov (1993), during treatment with cimetidine compared to placebo, duodenal ulcers are scarred in the majority of patients: in 82.6% during treatment with cimetidine compared to 48% during placebo.

In approximately half of the patients, the duodenal ulcer heals in the first 2 weeks, in 67% - after 3 weeks, in 89% - after 4 weeks. Gastric ulcers heal in 57-64% of patients after 4 weeks, in 91% - after 8 weeks.

It should be noted that 10-25% of ulcers are resistant to treatment with cimetidine, even if it is used in a daily dose of 1-1.2 g.

If after 4-6 weeks of treatment with cimetidine in an adequate dose the ulcer has not healed, you can proceed as follows (P. Ya. Grigoriev):

1. add gastrozepin to the therapy with cimetidine at a dose of 50-75 MG at night;

2. replace cimetidine with more powerful ranitidine or famotidine;

3. switch to treatment with other drugs (omeprazole, De-nol, sucral-fat).

Resistance of ulcers to treatment with cimetidine may be due to the formation of antibodies to it during long-term use and, to a certain extent, continued smoking during treatment with cimetidine.

Cimetidine extended release neutronorm-retard Available in tablets of 0.35 g, take 1 tablet with each meal, for maintenance therapy - 1 tablet at night.

II generation histamine receptor blockers

Ranitidine Available in tablets of 0.15 g. Synonyms: ranisan, acylok E, zantac, ranigast.

Compared with cimetidine, ranitidine has a 4-5 (according to some data, 19) times more pronounced antisecretory effect and lasts longer (10-12 hours), while the drug causes almost no side effects (rarely headache, constipation , nausea).

In the mechanism of action of ranitiDIN, in addition to the blockade of H2-histamine receptors, its ability to enhance the inactivation of hisgamine, which is associated with an increase in the activity of taegamin methyltransferase, is also important.

Pharmacokinetic studies have shown that ranitidine is sufficient to prescribe at a dose of 150 mg 2 times a day or 300 mg once a day.

night, i.e. its effective dose is 3-4 times less than that of cimetidine. The effectiveness of two-time use of ranitidine and a single dose at night is almost the same, but a single dose of the drug at night is more convenient in outpatient practice.

According to P. Ya. Grigoriev, after 4 weeks of treatment with ranitvdin, gastric ulcers scar in 80-85% of patients, duodenal ulcers - in 90%, with 6-week treatment, scarring of gastric ulcers is observed in 95% of patients, duodenal ulcers - almost in 100% of patients.

Ranitidine does not have the side effects of cimetidine, does not affect the metabolism of other drugs, since it does not inhibit the activity of liver monooxygenase enzymes. Treatment with ranitidine can be continued for several months or even years. Long-term (for 3-4 years for duodenal ulcers and 2-3 years for mediogastric ulcers) maintenance, continuous or intermittent therapy with ranitidine at a dose of 150 mg at night reduces the frequency of relapses of peptic ulcer disease.

Ranitidine bismuth citrate(pylorid) - complex drug, combining in its structure the H2-histamine receptor blocker ranitidine and bismuth citrate. The drug inhibits gastric secretion, has anti-Helicobacter and gastrocytoprotective effects. Available in 400 mg tablets.

Treatment regimen for duodenal ulcers with HP infection: for the first 2 weeks, ranitidine-bismuth citrate is taken 400 mg 2 times a day in combination with clarithromyctomus at a dose of 250 mg 4 times a day or 500 mg 3 times a day or amoxicymin at a dose of 500 mg 4 times a day. After 2 weeks, antibiotics are stopped, and treatment with ranitidine-bismuth citrate is continued for another 2 weeks. For duodenal ulcers without HP infection, take ranitidine bismuth citrate 400 mg 2 times a day for 4 weeks. For stomach ulcers, the drug is used in the same dose, but for 8 weeks.

III generation Hg histamine receptor blockers

Famotidine(ulfamide, pepcid) is available in tablets of 0.02 and 0.04 g and ampoules (1 ampoule contains 20 mg of the drug) and wafers containing 20 or 40 mg of the drug. The antisecretory effect is 9 times greater than ranitidine and 32 times greater than cimetidine.

In case of exacerbation of peptic ulcer, famotidine is prescribed 20 mg in the morning and 20-40 mg in the evening before bedtime or 40 mg before bedtime for 4-6 weeks; to prevent relapse, the drug is prescribed 20 mg once at night for 6 months or more.

The drug is well tolerated and causes almost no side effects.

IV generation Ngistamine receptor blockers

Nizatidine(axid) is available in tablets of 0.15 g. Prescribed 0.15 g 2 times a day or 0.3 g at night for a long time for the treatment of ulcers and 0.15 g at night to prevent exacerbation of ulcers. In 4-6 weeks, gastroduodenal ulcers heal in more than 90% of patients.

V generation ff2-histamine receptor blockers

Roxacidin - Available in tablets of 0.075 g, prescribed 150 mg per day in 2 or 1 dose (in the evening before bedtime). It is believed that drugs of the IV and V generations are practically free of side effects.

H2-histamine receptor blockers are the most active antisecretory agents; in addition, they also stimulate the production of protective mucus (i.e., they also have a gastroprotective effect).

eat), normalize motor function gastroduodenal zone, effective for duodenal and gastric ulcers with high acidity, both to relieve exacerbations and to prevent relapses of peptic ulcer disease. At the same time, there is an opinion that H2-histamine inhibitors receptors for symptomatic ulcers are ineffective, in this situation it is more advisable to use antacids, as a prophylactic, or de-nol, as well as synthetic analogues pro-staglandins (Cytotec and etc.).

4.2.3. Blockers H + K + -ATPase (proton pumps)

Enzymes H+K+-ATPases participate in the functioning "proton pump" of secretory tubules lining stomach cells, which provides the synthesis of hydrochloric acid.

Omeprazole(losec, timoprazole, omez) - available in tablets of 0.02 g, is a derivative benzimidazole and blocks the enzyme N + K + - ATPase, involved in the final stage of the synthesis and excretion of hydrochloric acid.

Omeprazole suppresses both basal, and stimulated secretion of hydrochloric acid, since it acts on the intracellular enzyme, and not on receptor device and, in addition, does not cause side effects, since it exists in active form only in the parietal cell.

After 7 days of treatment omeprazole at a dose of 30 mg per day basal and stimulated secretion is blocked 100% (London, 1983).

A single dose of 80 mg of omeprazole leads to complete inhibition of secretion for 24 hours. By changing the dose and time of administration of this drug, you can set the desired pH value in the gastric lumen.

Omeprazole is the most powerful antisecretory drug; with a monthly course, it promotes scarring of duodenal ulcers in almost 100% of cases. It caused scarring of stomach and duodenal ulcers when ranitidine-resistant ulcers in 94.4% of patients.

After discontinuation of omeprazole, there is no “rebound” increase in gastric secretion. Omeprazole is the only drug that is superior in effectiveness H2-histamine blockers receptors in patients with peptic ulcer disease.

When treated with omeprazole, persistent achlorhydria leads to increased production gastrin and hyperplasia enterochromaffin cells (ECL) of the stomach (in 10-20% of patients), but not to dysplasia or neoplasia. In connection with this effect, treatment with omeprazole is recommended to be prescribed only for exacerbation of peptic ulcer for 4-8 weeks, mainly for severe cases. leptic ulcers that cannot be treated with other antiulcer drugs (H 2 -gastamine blockers).

The drug is prescribed orally. The usual doses for peptic ulcer of the duodenum and stomach are 20-40 mg 1 time per day before breakfast (20 mg 2 times a day is possible), for the syndrome Zollinger-Ellison the daily dose can be increased to 60-80 mg per day (in 2 divided doses). There is also a method of using omeprazole 30 mg orally in the evening (after dinner), the dose can be increased to 60 mg after dinner.

4.2.4. Antagonists gastrin receptors

This group of antiulcer drugs blocks gastrinaceae receptors, reduces the secretion of hydrochloric acid and increases resistance gastric mucosa.

Proglumide(mtsh)- tablets of 0.2 and 0.4 g, glutamic acid derivative. Used orally in a daily dose of 1.2 g in 4-5 doses. The duration of treatment is 4 weeks.

In terms of effectiveness, the drug does not differ from Hg histamine receptor blockers, it significantly reduces acid formation, has a local protective effect, strengthening the mucous barrier of the stomach and duodenum. After 4 weeks of treatment, ulcer scarring occurs in 83% of cases; 6 months after treatment, relapses are noted in 8%, after 2 years - in 35% (Bergman, 1980).

4.2.5. Antacids and adsorbents

Antacids and adsorbents neutralize hydrochloric acid in the stomach without affecting its production. By reducing the acidity of gastric juice, these drugs have a beneficial effect on tone (eliminate muscle spasm) and the mountain-evacuation function of the gastroduodenal zone.

Antacids are divided into three groups:

absorbable (easily soluble, short but fast acting);

non-absorbable (insoluble, long-acting);

adsorbent.

Absorbable antacids

Absorbed antacids dissolve in gastric juice (and sodium bicarbonate - in water), have a high acid-binding ability, act quickly, but for a short time (from 5-10 to 30 minutes). In this regard, soluble antacids are used to relieve pain and heartburn; pain and heartburn are most quickly relieved by taking sodium bicarbonate.

Sodium bicarbonate(soda) - used in a dose of 0.5-1 g 1 and 3 hours after meals and at night. In case of prolonged use, it may cause alkalosis. When taken orally, carbon dioxide molecules are formed in the gastric cavity when hydrochloric acid is neutralized and this leads to secondary hypersecretion of gastric juice (however, this effect is low). 1 g of sodium bicarbonate neutralizes 11.9 mmol of hydrochloric acid.

Magnesium oxide(burnt magnesia) - prescribed in a dose of 0.5-1 g 1 and 3 hours after meals and at night. Neutralizes hydrochloric acid of gastric juice, without the release of carbon dioxide and therefore the antacid effect is not accompanied by secondary hypersecretion of gastric juice. Passing into the intestines, the drug causes a laxative effect. 1 g of magnesium oxide neutralizes 49.6 mmol of hydrochloric acid.

Magnesium carbonate basic(magnesii subcarbonas) is prescribed 0.5-1.0 g 1 and 3 hours after meals and at night. Has a slight laxative effect. It is also included in the Vikalin and Vikair tablets.

Calcium carbonate(precipitated chalk) - has a pronounced antacid activity, acts quickly, but after the cessation of the buffering effect it increases the secretion of gastric juice. Has a pronounced antidiarrheal effect. Prescribed orally 0.5-1 g 1 and 3 hours after meals and at night. 1 g of calcium carbonate neutralizes 20 mmol of hydrochloric acid.

Gafter mixture: calcium carbonate, bismuth subnitrate, magnesium hydro-CSID in a ratio of 4:1:1. Prescribed 1 teaspoon per ½ glass of water 1.5-2 hours after meals.

Rent - antacid preparation containing 680 mg of calcium carbonate and 80 mg of magnesium carbonate. Take 1-2 tablets 4 times a day (1 hour after meals and at night), if necessary, you can increase the daily dose to 16 tablets. The drug has a pronounced neutralizing effect on the hydrochloric acid of gastric juice (the pH of gastric juice increases to 4.3-5.7), quickly relieves heartburn. Rennie is well tolerated. The use of the drug is contraindicated in case of renal failure and hyperkalydemia. The onset of action of reHNi is 5 minutes after administration, the duration of action is 60-90 minutes.

Non-absorbable antacids

Non-absorbable antacids have slow neutralizing properties, adsorb hydrochloric acid and form buffer compounds with it. The drugs of this group are not absorbed and do not change the acid-base balance.

Aluminum hydroxide(alumina) - has antacid, adsorbing and enveloping properties. The drug neutralizes hydrochloric acid (1 g of the drug neutralizes about 250 ml of 0.1 N solution of hydrochloric acid) with the formation of aluminum chloride and water; The pH of gastric juice gradually increases to 3.5-4.5 and remains at this level for several hours. At this pH value, the peptic activity of gastric juice is also inhibited. In the alkaline contents of the intestine, aluminum chloride forms insoluble and non-absorbable aluminum compounds. Available in powder form, used orally as a 4% suspension in water, 1-2 teaspoons 4-6 times a day 30 minutes before meals or 1 hour after meals and at night.

It is advisable to combine aluminum hydroxide with magnesium oxide (burnt magnesia). Magnesium oxide reacts with hydrochloric acid to form magnesium chloride, which has laxative properties. In order to prolong the angacid effect of magnesium oxide, it is used in a dose of 0.5-1 g 1-3 hours after meals. Magnesium oxide is included in many other antacid medications.

Protab contains aluminum hydroxide, magnesium hydroxide, methylpolyxylosane (absorbs gas bubbles and eliminates symptoms of flatulence).

Alfogy - aluminum phosphate gel, envelops the mucous membrane. Prescribed 1-2 packets of 16 g 3 times a day in 1/2 glass of water before meals or 2 hours after meals.

Almagel - bottles of 170 ml. A combined preparation, every 5 ml of which (1 dosage spoon) contains 4.75 ml of aluminum hydroxide gel and 0.1 g of magnesium oxide with the addition of D-sorbitol. It has antacid, enveloping, and adsorbing properties. D-sorbitol has a laxative and choleretic effect. The dosage form (gel) creates conditions for uniform distribution of the drug throughout the gastric mucosa and a longer lasting effect.

Almagel A - bottles of 170 ml. This is an almagel containing an additional 0.1 g of anesthesin for every 5 ml of gel. Almagel A is used if a hyperacid state is accompanied by pain, nausea, and vomiting.

Almagel and Almagel A are prescribed orally 1-2 teaspoons (dosage) 4 times a day (morning, afternoon, evening 30 minutes before

meals or 1-1.5 hours after meals) and before bedtime. To avoid dilution of the drug, do not take liquid in the first half hour after taking it. After taking the drug, it is recommended to lie down and turn from side to side several times every 2 minutes (to improve the distribution of the drug on the gastric mucosa). The duration of treatment is 3-4 weeks. With long-term treatment, hypophosphatemia and constipation may develop.

Phosphalugel - available in sachets of 16 g. The drug contains aluminum phosphate (23%) in the form of a colloidal gel, as well as pectin and agar-agar. The drug has an antacid and enveloping effect, protects the gastric mucosa from the effects of aggressive factors.

It is taken orally undiluted (1-2 sachets) with a small amount of water or diluted Chg a glass of water (you can add sugar) 30 minutes before a meal or 1.5-2 hours after a meal and at night.

Lini - tablets containing 0.45 g of aluminum hydroxide in combination with magnesium carbonate and magnesium oxide (0.3 g). The drug has a high antacid effect. Take 1-2 tablets 1 hour after meals 4-6 times a day.

Compensated - 1 tablet contains 0.5 g of aluminum silicate and 0.3 g of sodium bicarbonate. Take 1 tablet 1-1.5 hours after meals 3 times a day and at night.

Alugastrj - sodium salt of dischdroxyaluminum carbonate, has an antacid, astringent, enveloping effect. Produced in bottles of 250 ml and sachets of 5 and 10 ml. It is taken orally 0.5-1 hour before or 1 hour after meals and at night, 1-2 teaspoons of the suspension or the contents of 1-2 sachets (5 or 10 ml) with a small amount of warm boiled water or without it.

Maadox (maalokat) - is issued in the form of suspension in bags on 10 and 15 ml, in tablets, bottles on 100 ml. It is a well-balanced combination of aluminum hydroxide and magnesium hydroxide, which provides a high neutralizing ability and a gastrocytoprotective effect.

10 ml of suspension contains 230 mg of aluminum hydroxide, 400 mg of magnesium hydroxide, as well as sorbitol and mannitol. 15 ml of suspension neutralizes 40.5 meq HC1, one tablet - 18.5 meq. The gastroprotective effect of the drug is due to the stimulation of mucus formation and the synthesis of PgE 2 .

The drug is prescribed 1 hour after eating and immediately before bedtime 1-2 sachets or 1-2 tablets.

Shalox-70 tablets, sachets of 15 ml, vials of 100 ml of suspension. Is different increased content active ingredients, which provides acid-neutralizing activity up to 70 meq. One tablet contains 400 mg aluminum hydroxide and 400 mg magnesium hydroxide. 15 ml suspension in a sachet contains 523.5 mg of aluminum hydroxide and 598.5 mg of magnesium hydroxide. The drug is used 1 hour after meals and immediately before bedtime 1-2 sachets or 1-2 tablets.

Magnesium tishkat - antacid, adsorbent and enveloping agent, 1 g of magnesium tilicate binds 155 ml of 0.1 N. hydrochloric acid solution. The drug is a slow-acting antacid. The colloid formed as a result of the interaction of magnesium tilicate and hydrochloric acid has a high adsorption capacity and protects the gastric mucosa from the aggressive effects of hydrochloric acid and pepsin. Magnesium tilicate is taken orally 0.5-1.0 g 3-4 times a day 1-3 hours after meals.

Gaviscon - combined antacid and an enveloping agent. Available in packages, containing 0.3 g sodium bicarbonate, 0.2 g aluminum hydroxide, 0.05 g magnesium tilicata and 1 g of basic magnesium carbonate. The contents of the package are dissolved in 80-100 ml of water and taken 4-6 times a day during the inter-digestive period (1 and 3 hours after meals and at night).

Telusil-varnish - a combination drug, available in tablets. One tablet contains 0.5 g of aluminum silicate, 0.5 g of magnesium silicate and 0.3 g of skimmed milk powder. Is non-absorbable antacid long-acting. Prescribed 1 tablet 1.5-2 hours after meals and at night.

Pee-hoo (Finland) - a combined preparation consisting of aluminum hydroxide, magnesium carbonate, calcium carbonate, burnt magnesia. Available in tablets of 0.8 g and bottles of 500 ml. It is prescribed 2 tablets or 10 ml 4 times a day (1.5 hours after meals and at night). The course of treatment is 20-30 days. The drug has a pleasant taste.

clay white(bolus alba) - aluminum silicate with a small admixture of calcium and magnesium silicates. Available in powder form. Possesses antacid, enveloping and adsorbing effect. Applicable inside 30 each G V 1/2 a glass of warm water 1.5 hours after eating. Currently, it is rarely used to treat peptic ulcers.

Side effects with long-term use of antacids containing aluminum

Aluminum-containing antacids form insoluble aluminum phosphate salts in the small intestine, disrupting the absorption of phosphates. Hypophos- fatemia manifests itself as malaise, muscle weakness, and with a significant deficiency of phosphates, osteoporosis and osteomalacia, brain damage, nephropathy.

With long-term use aluminum-containing antacids develops "Newcastle bone disease" - aluminum directly affects bone tissue, disrupts mineralization, toxic effect on osteoblasts, disrupts the function parathyroid glands, inhibits the synthesis of the active metabolite of the vitamin D3- 1,25-dihydroxycholecalciferol.

to the occurrence of aluminum intoxication appears when its concentration in the blood is more than 100 µg/ml, and clear signs of aluminum intoxication develop when its concentration in the blood is more than 200 µg/ml. The maximum permissible daily dose of aluminum is 800-1000 mg.

Severe side effects from the use of aluminum-containing antacids are often irreversible, especially in children and the elderly. That's why you should use the recommended doses of these drugs and do not use them for a very long time. IN THE USA aluminum-containing Antacids are not recommended for use for more than 2 weeks.

Adsorbent antacids

To adsorbent angacids relate bismuth nitrate basic(Bismuth!subnitras) and combination preparations containing it. The name of this subgroup (adsorbent antacids) is to some extent conditional, since the action of bismuth goes beyond only the adsorbing effect, in addition, non-absorbable antacids also have adsorbing properties to a certain extent.

Bismuth nitrate basic(Bismuthi subnkras) - the drug has an astringent, partially antiseptic effect, in addition, it is an adsorbent, enhances the separation of mucus, forms a protective layer over the gastric mucosa; The neutralizing (antacid) ability of bismuth is low. Available in powders and tablets of 0.25 and 0.5 T. It can be used for gastric and duodenal ulcers, regardless of the state of acidity of gastric juice, 0.25-0.5 g 2 times a day after meals.

Bismuth is a component of vikhalin and vikair.

Vikalin - Available in tablets. One tablet contains 0.3 g of bismuth subnitrate, 0.4 g of basic magnesium carbonate, 0.2 g of sodium bicarbonate, 0.025 g of calamus rhizome and buckthorn bark powder, 0.005 g of rutin and kellin.

Bismuth subnitrate, sodium bicarbonate and magnesium carbonate provide antacid and astringent action, buckthorn bark - laxative effect, rutin - some anti-inflammatory, kellin - antispasmodic effect. Take 1-2 tablets 3 times a day after meals in 2 glasses of water (it is advisable to crush the tablets). The stool turns dark green or black while taking the pills.

Vikair - tablets that have the same effect as vikalin, but unlike it do not contain kellin and rutin, the remaining components are the same as in vikalin. Take 1-2 tablets 3 times a day, 1-1.5 hours after meals, with a small amount of water.

De-nol(Tribimol, Ulceron) - colloidal bismuth subcitrate, has an antacid and enveloping effect. Available in tablets of 0.12 g. When tablets are taken orally, a colloidal mass is formed, which is distributed over the surface of the gastric mucosa and envelops the parietal cells, thus the drug also has a cytoprotective effect. In addition, de-nol has an anti-Helicobacter effect. The drug is taken 1-2 tablets 1 hour before meals 3 times a day and before bedtime. The course of treatment is 4-8 weeks. When treated with de-nol, stool turns black.

Ventol - Available in tablets of 0.12 g, contains bismuth oxide, the mechanism of action is the same as that of do-nol. It also has anti-helicobacter activity and is also used as de-nol.

IN medical practice Combinations of various antacids are widely used:

Bourget's mixture: sodium bicarbonate - 4 g, sodium phosphate - 2 g, sodium sulfate - 1 g; take 1/2 teaspoon per 2 glasses of water 1 and 3 hours after meals;

Magnesium oxide (burnt magnesia) and sodium bicarbonate - 15 g each, bismuth subnitrate - 6 g; take 2 teaspoons 1 and 3 hours after meals;

Sodium bicarbonate - 0.2 g, magnesium carbonate - 0.06 g, calcium carbonate - 0.1 g, magnesium tilicate - 0.15 g; take 1 powder 1 and 3 hours after meals;

Calcium carbonate and bismuth subnitrate - 0.5 g each; take 1 powder 3 times a day 1 hour after meals;

"calcium carbonate, bismuth subnitrate, magnesium oxide 0.5 g each;

take 1 powder 3 times a day 1 hour after meals.

Thus, antacids reduce the activity of hydrochloric acid and pepsin, normalize the motor function of the stomach and duodenum due to faster opening of the pylorus and expulsion of gastric contents into the cavity of the duodenum, which reduces intragastric and intraduodenal pressure, and eliminates pathological reflexes. The same mechanism explains the analgesic effect. Along with this, antacids also have gasgrocytoprotective properties due to stimulation of the production of protective prostaglandins, astringent and enveloping effects (magnesium tilicate, bismuth preparations), and binding of bile acids (aluminum compounds).

The anti-relapse activity of antacids in patients with peptic ulcer disease when taken long-term has not been proven in randomized controlled trials. In addition, there are reports that long-term administration of antacids can lead to an increase in gastric acid formation (acid rebound), which in turn is caused by the resulting hypersecretion of gastrin. Therefore, antacids are used, as a rule, during the period of exacerbation of the ulcer, for 4-6 weeks.

In descending order of antisecretory effect, the drugs can be arranged as follows: omeprazole, ranitidine, cimetidine, phosphalugel and almagel, gastrocepin, peripheral M-anticholinergics. Drugs such as cimetidine, ranitidine, famotidine, gastrocepin, omeprazole can be used for monotherapy of peptic ulcer disease; they not only accelerate the healing of ulcers, but are also used to prevent relapses and complications. Antacids and anticholinergics are used mainly in complex therapy during exacerbations.

4.3. Gastrocytoprotectors

Gastrocytoprotectors have the ability to increase the resistance of the mucous membrane of the stomach and duodenum to aggressive factors of gastric juice.

Misoprostol(Cytotec, Cytotec) - a synthetic analogue of PgE. Available in tablets of 0.2 and 0.4 mg. The drug causes gastrocytoproteority (increased production of bicarbonates and mucus by the gastric mucosa; formation epithelial cells stomach surfactant-like compounds - phospholipids; normalization of blood flow in the microvessels of the gastric mucosa; trophic effect on the mucous membrane of the stomach and duodenum) and antisecretory effects (suppresses the release of hydrochloric acid and pepsin, reduces the reverse diffusion of hydrogen ions through the gastric mucosa).

The cytoprotective effect is manifested in doses lower than those necessary to suppress the secretion of hydrochloric acid and pepsin.

Misoprostol and other prostaglandin derivatives are successfully used to treat gastroduodenal erosions and ulcers, especially in patients who smoke and abuse alcohol, as well as in those who are refractory to treatment with H2-histamine receptor antagonists. In addition, Misoprostol is used to prevent ulcers and erosions in people taking non-steroidal anti-inflammatory drugs.

Misoprostol is prescribed 0.2 mg 4 times a day immediately after meals for 4 to 8 weeks. O. S. Radbil (1991) recommends taking 1 tablet 2 times a day for duodenal ulcers, and 1 tablet 4 times a day for stomach ulcers.

Side effects of the drug: transient diarrhea, mild nausea, headache, abdominal pain. The drug is contraindicated during pregnancy.

Enprostil - synthetic analogue of PgEj. Analogs: arbaprosgil, rio-prosgil, tamoprostil. Available in tablets and capsules of 35 mg. Used in the form of capsules of 35 mg 3 times a day after meals for 4-8 weeks.

The mechanism of action is similar to that of misoprostol. Side effects are mild, usually transient diarrhea.

Sodium carbenoxolone fiotasgro")- obtained from an extract of licorice root, from glycyrrhizic acid, which is part of it. The drug stimulates the secretion of mucus, increases the content of sialic acids in it, increases the lifespan of the integumentary epithelium of the mucous membrane and its regenerative abilities, and prevents the reverse diffusion of hydrogen ions. The positive effect of carbenoxolone on ulcer healing is manifested primarily when it is localized in the stomach; when the ulcer is localized in the duodenum, the effect is less pronounced. Available in tablets of 0.05 and 0.1 g, in capsules of 0.15 g.

The drug is used in a daily dose of 300 mg in the first week of treatment (i.e., 0.1 g 3 times a day before meals), then 150 mg per day (0.05 g 3 times a day) for 5 weeks Since carbenoxolone is quickly absorbed in the stomach, it is advisable to use carbenoxolone in capsules - duogastron - when treating duodenal ulcers.

Side effects of the drug: hypokalemia, sodium and fluid retention, edema, increased blood pressure. These side effects are due to the structural similarity between sodium carbenoxolone and aldosterone and, thus, the manifestation of the mineralocortacoid effect of the drug. When treated with carbenoxolone simultaneous administration antacids and anticholinergics are inappropriate. Contraindications to treatment with sodium carbenoxolone: arterial hypertension, heart and kidney failure, pregnancy, childhood.

Sucralfate(venter) - aluminum salt of sucrose-octahydrogen sulfate. The mechanism of action of the drug is based on the binding of the drug with the proteins of the damaged mucous membrane into complex complexes that form a strong barrier, in the form of a protective film, which has protective properties at the site of localization ulcerative lesion. In addition, sucralfate locally neutralizes gastric juice without affecting the pH of the entire stomach, slows down the action of pepsin, absorbs bile acids (they are thrown into the stomach during duodenogastric reflux), increases the resistance of the gastric mucosa, and inhibits the reverse diffusion of hydrogen ions. At low pH, sucralfate dissociates into aluminum and sucrose sulfate, which are fixed on the surface of the ulcer for 6 hours. The drug does not affect the physiological processes in the stomach and duodenum, is absorbed very poorly (3-5% of the administered dose), does not have a systemic effect, 90% of sucralfate is excreted unchanged in the feces. Increases mucus secretion.

Sucralfate is available in tablets of 1 g or in sachets of 1 g of the drug. Use 1 g 40 minutes before meals 3 times a day and before bed for 4-8 weeks.

The drug can be used in monotherapy, as well as in combination with M-anticholinergics and H2-histamine receptor blockers. It is not recommended to prescribe it together with antacids. If necessary, apply

If antacids are not accepted, they should be prescribed no earlier than behind half an hour before taking sucral-fat.

When treated with sucralfate, side effects are possible: constipation, nausea, gastric discomfort.

Treatment with sucralfate for 4-6 weeks leads to healing of gastric and duodenal ulcers in 76-80% of cases. After a course of treatment, maintenance therapy can be carried out orally at a dose of 0.5-1 g 30 minutes before breakfast and in the evening before bed (P. Ya. Grigoriev).

Gastrocytoprotectors should also include colloidal bismuth subcitrate - de-nol (forms a protective film on the surface of the gastric mucosa), as well as preparations containing bismuth subnitrate - vicalin, vikair (enveloping effect).

Smecta(dioctahedral replace) - medicine natural origin, characterized high level fluidity of its components and thus excellent enveloping ability. It is a mucosal stabilizer, forms a physical barrier that protects the mucosa from the negative effects of ions, toxins, microorganisms and other irritants. Use 1 sachet 3 times a day for 3-4 weeks.

4.4. Drugs that normalize the motor function of the stomach and duodenum

Yaerukal (metoclopramide, Raglan) is a derivative of orthoprocainamide. The mechanism of action of the drug is associated with the blockade of dopamine receptors and suppression of the release of acetylcholine. Cerucal suppresses vomiting reflex, nausea, hiccups, increases the tone of smooth muscles in the lower parts of the esophagus, in the area of ​​\u200b\u200bthe entrance to the stomach, stimulates gastric emptying and petalsis in the upper sections of the small intestine. Does not significantly affect the secretory functions of the digestive organs.

The drug is used in the complex therapy of gastric ulcer and duodenal ulcer, reduces duodenogastric and gastroesophageal reflux, is administered orally at 5-10 mg 4 times a day before meals or intramuscularly at 10 mg 2 times a day. Available in tablets of 1 mg and ampoules of 2 ml (one ampoule contains 5 mg of the drug).

When treated with cerucal, side effects are possible: galactorrhea due to hyperprolactinemia, headache, skin rashes, increased aldosterone in the blood plasma, feeling of weakness. At joint use cerucal and cimetidine may reduce absorption of the latter by 20%.

Domtridon(motilium) - a dopamine antagonist, stimulates and restores normal motor activity of the upper gastrointestinal tract, accelerates gastric emptying, eliminates gastroesophageal and duodenogastric reflux, nausea. Use 0.01 g 3 times a day for 3-4 weeks. Available in 10 mg tablets.

Sul/sh/>CD (eglonil, doshatal) is a central anticholinergic and antipsychotic drug, as well as a selective dopamine receptor antagonist. It has an antiemetic effect, has an inhibitory effect on the hypothalamus, which helps normalize the increased activity of the vagus nerve, inhibits the secretion of hydrochloric acid and gastrin. In addition, sulyshrid has an antidepressant effect and normalizes the motor function of the gastrointestinal tract. The drug is used in the complex therapy of gastric and duodenal ulcers (eliminates spasms of the pylorus, accelerates

prevents evacuation, reduces secretion and acidity), combined with antacids and separators.

In case of peptic ulcer, sulpiric is first applied intramuscularly at a dose of 0.1 g 2-3 times a day, after 7-15 days - in capsules daily inside, 1-2 pieces 3 times a day for 2-7 weeks. Available in capsules of 50 and 100 MG, in tablets of 0.2 g and ampoules of 2 ml of a 5% solution.

Possible side effects: increased blood pressure, galactorrhea, gynecomastia, amenorrhea, sleep disturbance, allergic reactions, dizziness, dry mouth.

Antispasmodics -(no-shpa or papaverine, 2 ml of a 2% solution 1-2 times a day intramuscularly) are used for peptic ulcer of the stomach and duodenum in the presence of spastic phenomena from the stomach (pylorospasm).

4.5. Reparants

Reparants - a group of drugs that can improve the regenerative processes in the mucous membrane of the gastroduodenal zone and thus accelerate the healing of the ulcer.

Solcoseryl - large blood extract cattle(calves), freed from protein, devoid of antigenic properties. 1 ml of solcoseryl contains about 45 mg of dry matter, 70% of which are inorganic and organic compounds, including amino acids, OXIKeto acids, deoxyribonucleotides, purines, polypeptides. Active beginning Solcoseryl has not yet been identified or isolated. The drug improves capillary circulation, oxidative metabolic processes in pathologically altered tissues and the action of tissue enzymes (cytochrome oxidase, succindehydrogenase, etc.), accelerates granulation and epithelialization, increases oxygen uptake in tissues. Between the healthy tissue and the necrotic zone, there is a perinecrotic zone, the metabolic processes in which are reversibly disturbed. Solcoseryl has a positive effect at the level of this zone.

The drug is administered intramuscularly, 2 ml 2-3 times a day until the ulcer heals, and then 2-4 ml 1 time per day for 2-3 weeks. Available in ampoules of 2 ml.

Sea buckthorn oil - has anti-inflammatory and stimulating the healing of tissue defects, including the healing of ulcers. The drug contains an antioxidant tocopherol, which suppresses the processes of lipid peroxidation, which promotes faster healing ulcers It is prescribed orally before meals for "/g tablespoon 3 times a day for 3-4 weeks. Available in 100 ml vials.

Etaden - participates in the metabolism of nucleic acids, stimulates reparative processes in epithelial tissue, which accelerates the healing of ulcerative defects. The drug is administered intramuscularly at a dose of 0.1 g (i.e. 10 ml) once a day for 4-10 days. Available in ampoules of 5 ml of 1% solution.

Caleflon - purified extract from marigold flowers has an anti-inflammatory effect and stimulates reparative processes in the gastroduodenal zone. In recent years, the antacid effect of caleflon has also been established. Take 0.1-0.2 g 3 times a day after meals for 3-4 weeks. Available in tablets of 0.1 g.

Sodium oxyfercorbone complex ferrous salt of gulonic and alloxonic acids. Stimulates repair and healing processes

ulcers, mainly of the stomach, has an anti-inflammatory effect. 30-60 ml is administered intramuscularly daily for 1 month; after a month, the course of treatment can be repeated (for stomach ulcers). For duodenal ulcers, treatment lasts 6-8 weeks, repeated courses of treatment of 10-15 injections are prescribed for 2 years. Available in ampoules of 30 mg of dry substance with the addition of a solvent (3 ml of isotonic sodium chloride solution).

Side effects: skin itching, possible increase in glycemia.

Gastrofarm - contains dried bacterial bodies of lactic acid bulgaric bacillus - the main component of the drug. Stimulates repair processes in the gastroduodenal zone. Prescribed orally 1-2 tablets 3 times a day 30 minutes before meals for 30 days. Available in tablets of 2.5 g.

Anabolic steroid(retabolil - 1 ml 5% solution intramuscularly 1 time per week 2-3 injections or methandrostenolone - 5 mg 2-3 times a day for 3-4 weeks) can be recommended for patients with significant weight loss. Anabolic steroids improve the state of protein metabolism and increase protein synthesis, but do not have a significant healing effect on the ulcer. It should also be taken into account that under their influence it is possible to increase the level of carbonic acid in the gastric contents.

The effectiveness of previously widely used B vitamins, methyluracil, biogenic stimulants(aloe, bioseda, etc.) is currently considered doubtful.

4.6. Central acting agents

Sedatives and tranquilizers(diazepam, elenium, seduxen, relanium in small doses, infusion of valerian, motherwort) may be included in complex therapy peptic ulcer disease, taking into account the role of cortico-visceral disorders in the genesis of this disease, as well as taking into account the fact that in many patients an exacerbation of the disease occurs after exposure to psycho-emotional stress. However, these drugs do not play a significant role in the healing of ulcers.

Dalargin - opioid pjsapeltide, a synthetic analog of enkephalin. The drug has an analgesic effect, inhibits hydrochloric acid (hydrochloric acid production), and has protective effect on the gastric mucosa, promotes the healing of ulcers, improves psycho-emotional status.

The drug is administered intravenously or intramuscularly, 1 mg in 10 ml of isotonic sodium chloride solution 2 times a day. The total dose of the drug for the course of treatment is 30-60 mg. Ulcer healing occurs by the 28th day in 87.5% of patients. In recent YEARS, it has been proven that the drug increases the number of cells producing somatostatin, which inhibits the production of hydrochloric acid. With intravenous administration, a feeling of heat is possible. Produced in ampoules of 1 mg of powder.

4.7. Differentiated prescribing of drugs for peptic ulcer disease

1. For antropyloroduodenal ulcers occurring with gastric hypersecretion, gastroduodenal dyskinesia of the hypermotor type, the following options for the use of drugs are recommended:

a) antisecretory agents (gasgrocepin, metacin, or H2-histamine receptor blockers - cimetidine, famotidine) + antacid (almagel, phosphalugel, maalox, gastal, vikalin);

b) antisecretory agent (gastrocepin, metacin, cimetidine, ranitidine or famotidine) + cytoprotector (sucralfate, sichgek or misoprostol);

c) omeprazole;

d) sucralfate;

d) de-nol.

In table 32 (P. Ya. Grigoriev, A. V. Yakovenko, 1997) provides a comparative assessment of combinations of antiulcer drugs used to treat exacerbation of ulcer disease.

2. With mediogastric ulcers (including ulcers of lesser curvature.
stomach) regardless of the state of gastric secretion, it is advisable
use the following options:

a) antisecretory agent (ranitvdin or famotidine) + eglonil (sulpiride) + gastrocytoprotector (Venter) + reparants (solcoseryl, sea buckthorn oil);

b) eglonil (or sulpiride, or cerucal) + cytoprotector (venter, sucralfate);

c) eglonil (sulpiride or cerucal) + de-nol;

d) sucralfate (Venter);

e) de-nol;

f) eglonil + antacid (vikalin or almagel).

Thus, in traditional therapy for relapse, antisecretory agents are more often used, often in combination with antacids and adsorbents, as well as cytoprotectors and reparatives.

Currently, a point of view has emerged that, due to the availability of modern effective antiulcer drugs (de-nol, omep-razole, famotidine, ranigidine, cytotec, venter, etc.), monotherapy for patients with peptic ulcer disease is advisable. However, when treating a relapse of ulcer in the same patient, it is necessary to change drugs, since antibodies are formed to some drugs (to gastrocepin, cimetidine, etc.) and their effectiveness is significantly reduced.

Combination therapy is indicated for a very persistent course of recurrence of PU.

The main type of anti-relapse drug therapy for ulcerative disease is intermittent (course) drug treatment, usually including the use of a full dose of one antisecretory drug (ranitidine, famotidine, gastrocepin, etc.), often in combination with an antacid (gasgal, almagel, etc.) , and if HP is detected in the inflamed anthropopyroduodenal mucosa, therapy includes at least 3 antibacterial drugs (de-nol, trichopolum, oxaTSSHSHIN or tetracycline, furazolvdon).

Treatment tactics are adjusted depending on the location of the ulcer, the state of the secretory function of the stomach, and the effectiveness of previously administered therapy.

Usually within 3-4 weeks it is possible to achieve jushno-endoscopic remission of the disease (“healing”, “scarring” of the ulcer). If during this period the ulcer does not heal, the attending physician must exclude malignancy of the ulcer, its penetration, periulcerous sclerosing changes (callous ulcer), analyze the rationality, validity of therapy, discipline of the patient, review the treatment regimen with a possible replacement of the drug, physiotherapeutic procedures (if no contraindications).

In case of a long-lasting gastric ulcer, despite intensive treatment, it is advisable to repeat a targeted multiple biopsy and, in the absence of signs of malignancy, continue treatment by replacing drugs. It is better to switch to treatment with omeprazole, sucralfate or de-nol in combination with anti-Helicobacter drugs, if the latter have not been used previously and a connection between ulcerative disease and HP cannot be ruled out.

In addition, for long-term non-healing ulcers, local treatment through an endoscope is added to drug treatment (intragastric laser therapy, sealing the ulcer with special adhesives, injecting the ulcer with reparants, etc.).

Upon the onset of clinical and endoscopic remission of ulcer and negative test in case of HP, it is advisable to stop the course of drug therapy and determine its type to prevent possible exacerbation of the disease and relapse of the ulcer (course of treatment “on demand” or continuous maintenance therapy).

Indications for continuous maintenance drug therapy for ulcerative disease

1. Unsuccessful use of intermittent course treatment, when after its completion there were frequent relapses(three or more times a year).

2. Complicated course of peptic ulcer (history of bleeding or perforation).

3. Concomitant erosive reflux gastritis, reflux esophagitis.

4. The patient’s age is over 50 years.

5. The presence of concomitant diseases requiring constant use of non-steroidal anti-inflammatory drugs and other drugs that damage the gastroduodenal mucosa.

6. The presence of gross cicatricial changes in the walls of the affected organ with symptoms of perivisceritis.

7. Ulcers resistant to treatment with histamine H2 receptor blockers, when in order to achieve an effect it is necessary to lengthen the treatment period and resort to combined treatment.

8. "Heavy smokers."

9. Persons with diseases contributing to the development of peptic ulcers (chronic obstructive pulmonary diseases, liver cirrhosis, rheumatoid arthritis), chronic renal failure.

10. The presence of active gastroduodenitis and Helicobacter bacteria of the mucous membrane.

1. cimetidine - 400 mg or ranitidine - 150 mg or famotidine 20 mg once before bedtime;

2. gastrocepin - 50 mg (2 tablets) after dinner;

3. misoprostol (Cytotec, Cytotec) - 200 mcg after breakfast and dinner;

4. omeprazole -20 mg after dinner;

5. sucralfate (Wenger) - 1 g 30 minutes before breakfast and before bed;

6. peritol - 2-4 mg after dinner in combination with sucralfate (both drugs in the indicated doses simultaneously);

7. metacin - 0.004 g after dinner in combination with sucralfate (two drugs at the same time in the indicated doses);

8. Eglonil or Raglan (cerucal, perinorm, bimaral, etc.) - 1-2 times a day simultaneously with sucralfate or antacids(vikalin, vikair, almagel, phosphalugel, gastal, gelusik-varnish, acidrinmaloxy, etc.).

The duration of the prolonged course varies from 2-3 weeks to several months and even years.

A. A. Krylov, L. F. Gulo, V. A. Marchenko, L. M. Yazovitskaya, S. G. Borovoy (1987) recommend year-round preventive treatment regimens for peptic ulcer disease (Table 33, 34).

The following preventive treatment regimens use the following fees: medicinal plants.

Note. Bourget's mixture: sodium sulfate - 0.1 g, sodium phosphate - 0.1 G, sodium bicarbonate - 4 g dissolved in 250 ml of water. Belpap (composition of 1 powder): papaverine hydrochloride - 0.1 g, belladonna extract - 0.015 g, phenobarbital - 0.015 g, sodium bicarbonate - 0.25 g, burnt magnesia - 0.25 g, basic bismuth nitrate - 0.25 Bish- pan: no-shpa- 0.06 g + anticholinergic isopropamide- 0.005 G(combined tablets).

If you are prone to constipation, you can add rhubarb root or buckthorn bark, dill seeds, joster fruits, 1 weight each, to collection No. 1 Ch., and also reduce the dose of St. John's wort by 2 times, which, due to the presence of tannins, can cause a fixing effect.

Indications for intermittent on-demand treatment:

Newly diagnosed duodenal ulcer;

Uncomplicated course of duodenal ulcer with a short history (no more than 4 years);

The frequency of relapses of duodenal ulcers is no more than 2 per year;

The presence of typical pain and ulcerative defect during the last exacerbation without gross deformation of the wall of the affected organ;

Absence of active gastroduodenitis and Helicobacteria in the mucosa
shell.

Indications for a course of treatment “on demand” are peptic ulcer disease with an uncomplicated course, a short history (no more than 4 years), with a history of no more than 2 relapses per year, with the presence of typical pain and an ulcer defect without gross deformations of the wall at the last exacerbation of the affected organ, as well as rapid attack remission under the influence of course treatment and the patient’s consent to actively follow the doctor’s instructions.

The essence of the course of treatment “on demand” is that when the first subjective manifestations of an exacerbation of the disease appear, the patient immediately independently resumes taking one of the antiulcer drugs in the full daily dose (cimetvdine, ranitvdine, famotidine, omeprazole, gastrocepin, misoprostol, sucralfate) . If subjective symptoms stop completely within 4-6 days, the patient independently switches to maintenance therapy and stops treatment after 2-3 weeks, and if there is no effect in the first days, the patient should consult a doctor.

Patients undergoing a course of treatment “on demand” should be advised to exclude risk factors (smoking, taking non-steroidal anti-inflammatory drugs and other ulcerogenic drugs) and carefully follow the doctor’s instructions.

Treatment "on demand" can be prescribed for up to 2-3 years.

P. Ya. Grigoriev names the following advantages of “treatment on demand”:

The patient is responsible for the effectiveness of treatment and therefore takes it seriously;

This treatment has a positive effect psychological impact on the patient, he does not consider himself doomed, hopeless;

the effectiveness of on-demand therapy is not inferior to the effectiveness of continuous maintenance therapy with H2-histamine blockers, the cost of treatment is lower, and the quality of life of patients is higher.

Regardless of the type of preventive treatment, if a relapse occurs against the background of chronic active gastroduodenitis associated with HP, a 2-week course of anti-Helicobacter therapy is justified (above).

Anti-Helicobacter therapy is also indicated for patients with antropyloroduodenal ulcer, if they have recurred again 2-4 months after the end of the course of treatment of the previous relapse. typical symptoms exacerbations. At the same time, Helicobacter bacteria can always be detected in the gastroduodenal mucosa.

The use of medicinal plants for peptic ulcers is based on the use of anti-inflammatory, enveloping, laxative, astringent, analgesic, carminative, antispasmodic and hemostatic effects. Herbal medicine improves the trophism of the mucous membrane of the gastrointestinal tract and promotes regeneration processes.

In herbal medicine for peptic ulcers, plants with anti-inflammatory properties (oak, St. John's wort, plantain, calendula, elecampane, yarrow), antispasmodic (chamomile, licorice, mint, oregano, dill, fennel), antispastic (calendula, St. John's wort, chamomile, plantain, elecampane) are used. , antiallergic (licorice), laxatives (rhubarb, buckthorn, trefoil watch, zoster).

In addition, for peptic ulcers with preserved and increased secretion of gastric juice, the following fees are recommended:

The following medicinal plants can be added to the above fees or taken separately from them:

Calamus root powder(on the tip of a knife) - take 3-4 times a day 20-30 minutes before meals for heartburn for 2-3 weeks.

Fresh cabbage juice - significantly accelerates the scarring of gastric ulcers and duodenal ulcers. Freshly prepared cabbage juice is taken at "/G glass or 1 glass 3-4 times a day 20-40 minutes before meals. The course of treatment is 1.5-2 months. Not all patients tolerate cabbage juice well.

Some patients successfully take potato juice(especially for duodenal ulcers), it neutralizes well

acidic gastric juice Prescribe 2 glasses 3-4 times a day before meals for 1.5-2 months.

A good analgesic and enveloping agent is flax seed(brew at the rate of 2 tablespoons per 0.5 liter of boiling water, you can boil for 3-4 minutes over low heat, then pour into a thermos and leave overnight). Take 7g glass 3-4 times a day before meals.

When treating patients with callous, long-lasting ulcers, the components (or increase the amount) of those herbs that contribute to scarring of the ulcer (celandine, plantain, shepherd's purse, burdock root, chicory, calendula, fireweed, etc.).

Treatment with medicinal preparations continues for 5-6 weeks As the exacerbation subsides, you can use phytoapplications on the anterior abdominal wall and lumbar region for 20 minutes (10-15 sessions, every other day). For phytoapplications you can use the following fee:

Swamp dry grass (grass) 5 tsp.

Calendula flowers 5 tsp.

Elecampane grass 2 hours.

Celandine herb 1 tsp.

Licorice root 2 tsp.

Coltsfoot leaves 4 hours.

Lungwort herb 3 tsp.

Chamomile flowers 5 hours.

Phytoapplications are applied mainly to the epigastric region. For phytoapplication with a layer thickness of 4-6 cm for each square centimeter body requires up to 50 g of medicinal plant collection.

To prepare the phytocollection, the calculated amount of medicinal raw materials is carefully crushed, mixed, poured into 0.5 l of boiling water in an enamel bowl and steamed for 15-20 minutes (under the lid). Next, the infusion is filtered into a separate container (it can be used for baths), and the medicinal plants are squeezed out so that they remain slightly moist. Then they are wrapped in gauze, folded in four layers, or in linen cloth and placed on the epigastric region. Cellophane or oilcloth is placed on top and wrapped in a woolen blanket. Optimal temperature phytoapplications is 40-42 "WITH, procedure duration - 20 minutes.

Along with the use of medicinal plants inside and in the form of phytoapplications, therapeutic baths can also be used. For the preparation of therapeutic baths, 1-2 liters of infusion is used, which requires an average of 100-200 g of dry plant materials. Infusion is carried out for 1-2 hours in earthenware, enamel or glassware. The vessel must be tightly closed and additionally insulated with a cloth (wrapped in woolen cloth). The temperature of the water in the bath should be within 34-35 ° C. The duration of the procedure is 10-20 minutes, 2-3 times a week. Therapeutic baths can be alternated with herbal applications (prescribing these procedures every other day).

Contraindications for phytoapplication are periods of exacerbation of a febrile state, circulatory failure, tuberculosis, blood diseases, severe neuroses, bleeding, pregnancy (all periods).

Mineral waters are used primarily for the treatment of gastric and duodenal ulcers with preserved and increased secretion of gastric function. Typically, low-mineralized mineral waters are recommended, without carbon dioxide or with minimal carbon dioxide content, with a predominance of hydrocarbonate and sulfate ions, having a slightly acidic or neutral, alkaline reaction. Such waters are “Borjomi”, “Essentuki” No. 4, “Smirnovskaya” No. 1, “Slavyanovskaya”, “Luzhanskaya”, “Berezovskaya”, “Jermuk”. Typically, slightly heated mineral waters (38-40 °C) without gas are used, which enhances their antispastic effect and reduces the carbon dioxide content. S. N. Golikov (1993) recommends taking mineral waters for duodenal ulcers 1.5-2 hours after meals, and for mediogastric ulcers - 1 hour after meals, i.e. the time of taking mineral water almost corresponds to the time of taking antacids for peptic ulcer. This method of taking mineral water enhances the antacid effect of food, lengthens the time of intragastric alkalization. With a stomach ulcer with low acidity, it is advisable to take water 20-30 minutes before meals.

First take small amounts of mineral water 0/y 1 / 2 glass, then gradually, with good tolerance, you can increase the amount of water to 1 glass per reception).

Patients tolerate different mineral waters differently. Especially often there is a poor tolerance of water "Essentuki" No. 17 (heartburn, nausea, diarrhea), which makes it necessary to be careful when prescribing it to patients with peptic ulcer.

In dispensaries and at home, bottled mineral waters can be prescribed. The average duration of a course of treatment with mineral waters is about 20-24 days.

The effectiveness of complex treatment of peptic ulcer increases with the use of physiotherapy methods. The choice of physical treatment factors is largely determined by the phase of the disease. Physiotherapy is carried out only in the absence of complications of peptic ulcer - pyloric stenosis, perforation and penetration of the ulcer, bleeding, malignancy of the ulcer.

In the acute phase may be appointed sinusoidal modulated currents(SMT), which have an analgesic and anti-inflammatory effect, improve blood and lymph circulation in the gastroduodenal zone. SMT is prescribed for the epigastric region, the duration of the procedure is 6-8 minutes, the course of treatment is 8-12 procedures, the tolerability is good. When using SMT, pain syndrome is stopped faster and ulcers heal in a shorter time. The same positive impact is also had dia-dynamic Bernard currents(10-12 procedures).

In the phase of exacerbation of peptic ulcer, it is also widely used microwave therapy, including decimeter waves, they are released by the "Volna-2" or "Romashka" devices with localization of the effect on the epigastric region for 6-12 minutes, the course of treatment is 10-12 procedures. This method is especially effective in the localization of the ulcer in the pyloroduodenal zone.

Impact can also be used ultrasound on epigastric after preliminary intake of 1-2 glasses of water in order for the gas bubble to move into upper divisions and did not interfere with the penetration of ultrasonic waves to the posterior wall of the stomach. During one procedure, 3 fields are sequentially affected: the epigastrium (0.4-0.6 W/cm2) and two paravertebral areas at the level of Th VII-XII (0.2 W/cm2) for 2-4 minutes per area. The course of treatment is 12-15 procedures, every other day.

Also widely used electrophoresis on the epigastric region of novocaine, papaverine (especially with severe pain).

An effective procedure that quickly relieves pain and promotes rapid healing of an ulcer is dalargin electrophoresis to the epigastric region. The technique is transverse, the anode is located in the projection of the pyloroduodenal zone, the pad is moistened with a solution of dalargin containing 1 mg of the drug. The current density in the first procedure was 0.06 mA/cm 2 , the duration was 20 min. Subsequently, every 5 procedures, the current density increases by 0.02 mA, the duration of exposure increases by 5 minutes. The course of treatment is 12-15 procedures.

It also has a positive effect intranual electrophoresis with dalargin.

In recent years, for the treatment of peptic ulcer has become widely used hyperbaric oxygenation, which reduces regional hypoxia of the gastroduodenal zone, stimulates metabolic and reparative processes in it, contributing to the fastest improvement in the patient's condition and the speedy healing of the ulcer. Treatment is carried out in a large therapeutic pressure chamber or in oxygen chambers such as "Oka", "Irtysh-MT", etc. Sessions are prescribed in the mode of 1.5-1.7 atm., Patients stay in the pressure chamber for 60 minutes, the course of treatment is 10-18 procedures.

In the presence of contraindications to the above procedures, as well as for the elderly, it is possible to recommend magnetic therapy, when an alternating magnetic field is used ("Pole-1"). This procedure reduces pain and is well tolerated by all patients. A continuous sinusoidal mode with a frequency of 50 Hz is used, the maximum magnetic induction is 20 mT, the duration of the procedure is 8-12 minutes, the course of treatment is 8-12 procedures every other day.

In the acute phase, you can also use galvanization - a positive electrode is applied to the epigastric region, a negative electrode is applied to the lower thoracic spine, the current density is 0.1 mA/cm*, the duration of the procedure is 10-20 minutes, the course of treatment is 8-10 procedures.

At home, in the acute phase, you can apply light heat in the form of a warming half-alcohol compress to the epigastric region.

In the decaying phase exacerbation thermal procedures are prescribed (mud, peat, ozocerite, paraffin applications, galvanic mud on the epigastric region) daily or every other day (10-12 procedures); UHF in pulse mode to the epigastric region; electrophoresis of medicinal substances(papaverine, novocaine, dalargan) on the epigastric region (12-15 procedures); hydrotherapy in the form of shared baths. A sedative effect is given by baths with mineral water of low concentration, at a temperature of 36-37 ° C, the duration of the bath is 10 minutes, the course of treatment is 8-10 procedures, every other day. Baths with mineral water are not indicated in the period of a pronounced exacerbation of the disease, as well as in the presence of complications. Valerian baths are also advisable.

IN phase remission, physiotherapy procedures are prescribed in order to prevent exacerbations. Ultrasonic and microwave therapy; diadynamic, sinusoidal modulated currents; electrophoresis of drugs; pine, pearl, oxygen, radon baths; local thermal procedures on the epigastric region (applications of paraffin or ozocerite, heated to 46 ° C, daily for 30-40 minutes, 12-15 procedures); mud applications(silt, sapropel, peat mud at a temperature of 42-44 ° C for 10-15 minutes every other day, 8-10 procedures per course).

Heat treatment has a positive effect on blood circulation in the gastro-duodenal zone, normalizes the motor-evacuation function of the stomach, and helps reduce intragastric pressure.

Preventive courses of physiotherapy are most conveniently carried out in dispensaries and sanatoriums, where they are combined with diet therapy and drinking mineral waters. Positive results were obtained when patients were included in complex treatment acupuncture(10-12 sessions).

For chronic non-healing ulcers of the stomach and duodenum, they resort to local gastric treatment. To do this, use targeted injection of the periulcerous zone with a solution of novocaine (1 ml of a 2% solution), tselnovocaine, solcoseryl, irrigation with sea buckthorn oil, and a solution of silver nitrate. Positive results were obtained when treating the ulcer and surrounding mucosa 2 times a week with solid ethyl. Recently, the application of film-forming agents (gastrozol, lifuzol) to the ulcerative surface and surrounding mucosa (1-2 cm) has become widespread. Aerosol film-forming adhesive is injected during endoscopic examination. Therapeutic gastroduodenoscopy is repeated after 2-3 days, the course of treatment is 8-10 procedures.

New method local impact on the ulcer is low-energy laser radiation. Irradiation of the ulcer and its edges is carried out through a light guide through the biopsy channel of the endoscope 2 times a week.

The most effective are helium-cadmium, argon and especially krypton lasers. On average, duodenal and gastric ulcers heal in 16-17 days.

When treating callous ulcers, first, to destroy the sclerosing formations blocking the reparative processes, the edges of the ulcer are treated with powerful radiation from an argon laser, then a soft helium-neon laser is used.

A new option for intragastric laser therapy is local therapy with pulsed-periodic yellow-green radiation from a copper vapor laser. In this case, 100% healing of the ulcer is observed (stomach ulcer heals after 1-8 sessions, duodenal ulcer - after 1-4 sessions).

If during the 4-week treatment of duodenal ulcers and 8-week treatment of gastric ulcers there is no “healing effect” (scarring), the ulcer can be considered resistant to treatment. In this case, the attending physician must:

Determine the discipline of the patient (compliance with the regimen and rhythm of nutrition, medication, smoking cessation, alcohol abuse, etc.);

To analyze the rationality and validity of drug therapy and physiotherapy procedures;

Exclude malignancy or penetration of the ulcer, periulcerous sclerosing changes ("calcified" ulcer), Zollinger-Ellison syndrome, hyperparathyroidism, systemic mastocytosis;

Reveal possible factors, restraining scarring ulcers (medication for other diseases, undiagnosed cholecystolithiasis, CAH, intestinal dysbacteriosis, etc.);

When ascertaining the resistance of an ulcer to treatment, the following treatment tactics are recommended:

Increase the dose of the previously used antisecretory drug or replace it;

Add gastrocytoprotectors to the antisecretory drug (sucralfat 0.5-1.0 g 3 times 30 minutes before meals and at bedtime or Cytotec 250 mcg 4 times a day after meals);

If there is no effect, prescribe a "triple" antibiotic therapy (de-nol + metronidazole + antibiotic), since Helicobacter pylori infection often underlies resistant ulcers. It is advisable to use the combined preparation "gastrostat" containing bismuth subcitrate (108 mg), metronidazole (200 mg), tetracycline (250 mg). It is prescribed one tablet 5 times a day at regular intervals for 10 days;

In the absence of the effect of gastrostat, prescribe a combination of omeprazole, metronidazole and clarithromycin;

Actively use local methods treatment of long-term non-healing ulcers (above).

Sanatorium-resort treatment of patients with peptic ulcer is important rehabilitation event. It includes a wide range of therapeutic measures aimed at normalizing the functions of not only the gastroduodenal zone, but also the body as a whole.

The following resorts are recommended for patients with peptic ulcer disease: Berezovsky Mineral Waters, Birshtonos, Borjomi, Goryachiy Klyuch, Darasun, Jermuk, Druskininkai, Essentuki, Zheleznovodsk, Izhevsk Mineral Waters, KraInka, Pärnu, Morshin, Pyatigorsk, Sairme, Truskavets, etc.

Contraindications for spa treatment are: peptic ulcer during a period of severe exacerbation, recent bleeding (within the last 6 months) and a tendency to bleed, pyloric stenosis, suspicion of malignant degeneration, the first 2 months after gastrectomy, severe exhaustion.

In addition to balneological resorts, treatment can also be carried out in local sanatoriums. In Belarus, these are the sanatoriums “Krinitsa”, “Narech”, “Porechye”.

Medical examination tasks:

1. Timely (early) identification of patients with peptic ulcer
the active conduct of targeted preventive examinations.

2. Regular (at least twice a year, especially in spring and autumn) examination of patients with peptic ulcer disease to assess the dynamics of the ulcerative process, identify complications and concomitant diseases ( general analysis blood, urine, study of gastric secretion, FGDS).

3. Anti-relapse treatment.

5. Health education: promotion of a healthy lifestyle, rational nutrition, explaining the dangers of smoking, drinking alcoholic beverages.

6. Employment of patients is decided jointly with representatives of the administration and trade union organization.

Preventive (Anti-relapse) treatment is usually carried out in a clinic or in a sanatorium, and also, if possible, at a balneological or mud bath resort. The most important components preventive treatments are:

1. compliance with a therapeutic diet and nutrition regimen (at home, in a dietary canteen or in a sanatorium);

2. complete cessation of smoking and drinking alcohol;

3. prolongation of sleep time up to 9-10 hours;

4. exemption from shift work, especially at night, long and frequent business trips;

5. drug treatment;

6. physiotherapy;

7. sanitation of the oral cavity (treatment of caries, prosthetics);

8. treatment of concomitant diseases;

9. psychotherapeutic influences.