Rehabilitation after a stomach ulcer for a soldier. Physical rehabilitation for gastric ulcer

Exercise therapy for stomach ulcers

1. Clinic of peptic ulcer

peptic ulcer medical exercise

Peptic ulcer is a chronic, cyclically occurring disease with a varied clinical picture and ulceration of the mucous membrane of the stomach or duodenum during periods of exacerbation.

The leading symptom in the clinical picture of peptic ulcer is pain. Its distinctive features should be considered periodicity (alternation of periods of exacerbations and remissions), rhythm (relationship of pain with food intake), seasonality (exacerbation in spring and autumn, and in some patients - in winter and summer), the increasing nature of pain as the disease develops, changes and disappearance of pain after eating, antacids; application of heat, anticholinergics, after vomiting.

According to the time of onset of pain after eating, they are divided into early, occurring shortly after eating, late (after 1.5 - 2 hours) and night. Early pain is characteristic of ulcers located in the upper part of the stomach. For ulcers of the antrum of the stomach and ulcers of the duodenum, late and nocturnal pains are characteristic, which can also be "hungry", as they decrease or stop after eating.

Pain in peptic ulcer reaches its maximum strength at the height of digestion and only "hungry" pains disappear after eating. In the presence of perigastritis or periduodenitis, the pain is aggravated by physical exertion. The decrease or cessation of pain after an accidental vomiting leads to the fact that patients, when pain occurs, cause vomiting artificially. No less typical for peptic ulcer is a lightning-fast cessation of pain after taking alkalis. No wonder I.P. Pavlov compared their action with the effect of nitroglycerin in angina pectoris.

Vomiting in peptic ulcer disease occurs without previous nausea, at the height of pain in the midst of digestion, with different localization of the ulcerative process, its frequency varies. The secretion of active gastric juice on an empty stomach is often accompanied by vomiting. Frequent morning vomiting of the remnants of food eaten the day before indicates a violation of the evacuation function of the stomach.

Of the dyspeptic phenomena in peptic ulcer, heartburn occurs more often (in 60-80% of all patients with peptic ulcer). From a diagnostic point of view, it is important that it is noted not only during periods of exacerbations, but may precede them for a number of years and has the same typical features as pain (periodicity, seasonality). Heartburn is associated with impaired motor function of the esophagus and stomach, and not with secretory function, as previously thought. When inflating the esophagus, stomach, duodenum with a rubber balloon, you can cause a burning sensation of varying degrees, up to a sensation of "burning convulsions".

Appetite in peptic ulcer disease is not only preserved, but sometimes even sharply increased. Since pain is usually associated with eating, sometimes patients have a fear of eating. Some people with peptic ulcers periodically experience increased salivation, preceded by nausea. Often there is a feeling of pressure of gravity in the epigastric region. These phenomena are characterized by the same patterns as pain.

Constipation is often noted during an exacerbation. They are due to the nature of the nutrition of patients, bed rest and mainly neuromuscular dystonia of the large intestine of vagal origin. The general nutrition of patients with peptic ulcer is not disturbed. Weight loss can be observed during an exacerbation of the disease, when the patient restricts food intake due to fear of pain. With superficial palpation of the abdomen, tension of the right rectus muscle can be detected, which decreases as the pathological process subsides.

According to the clinical course, acute, chronic and atypical ulcers are distinguished. Not every acute ulcer is a sign of a peptic ulcer.

A typical chronic form of peptic ulcer is characterized by a gradual onset, an increase in symptoms and a periodic (cyclic) course.

The first stage - the prelude of an ulcer, is characterized by pronounced disturbances in the activity of the autonomic nervous system and functional disorders of the stomach and duodenum, the second - by the appearance of organic changes, initially in the form of a structural reorganization of the mucous membrane with the development of gastroduodenitis, the third - by the formation of an ulcer in the stomach or duodenum, the fourth - the development of complications.

The duration of periods of remission in peptic ulcer disease ranges from several months to many years. The recurrence of the disease can be caused by mental and physical stress, infection, vaccination, trauma, medication (salicylates, corticosteroids, etc.), insolation.

Causes of occurrence: damage to the nervous system (acute psychotrauma, physical and mental overwork, nervous diseases), hormonal factor (impaired production of digestive hormones - gastrin, secretin, etc., impaired histamine and serotonin metabolism, under the influence of which the activity of the acid-peptic factor increases) .

2. Treatment of peptic ulcer

The complex of rehabilitation measures includes medicines, motor regimen, exercise therapy and other physical methods of treatment, massage, therapeutic nutrition. Exercise therapy and massage improve or normalize neuro-trophic processes and metabolism, helping to restore the secretory, motor, absorption and excretory functions of the digestive canal.

Conservative treatment of peptic ulcer is always complex, differentiated, taking into account the factors contributing to the disease, pathogenesis, localization of the ulcer, the nature of clinical manifestations, the degree of dysfunction of the gastroduodenal system, complications and concomitant diseases.

During the period of exacerbation, patients should be hospitalized as early as possible, since it has been established that with the same treatment method, the duration of remission is higher in patients treated in a hospital. Treatment in a hospital should be carried out until the ulcer is completely scarred. However, by this time, gastritis and duodenitis still persist, and therefore treatment should be continued for another 3 months on an outpatient basis.

The antiulcer course includes: 1) elimination of factors contributing to the recurrence of the disease; 2) medical nutrition; 3) drug therapy; 4) physical methods of treatment (physiotherapy, hyperbaric oxygen therapy, acupuncture, laser therapy, magnetotherapy).

Elimination of factors contributing to the recurrence of the disease provides for the organization of regular meals, optimization of working and living conditions, a categorical prohibition of smoking and alcohol consumption, and a prohibition of taking medications with an ulcerogenic effect.

Drug therapy has as its goal: a) suppression of excess production of hydrochloric acid and penim or their neutralization and adsorption; b) restoration of the motor-evacuation function of the stomach and duodenum; c) protection of the mucous membrane of the stomach and duodenum and treatment of helicobacteriosis; d) stimulation of the processes of regeneration of cellular elements of the mucous membrane and relief of inflammatory-dystrophic changes in it.

Physical methods of treatment - thermal procedures during the period of exacerbation subsiding (applications of paraffin, ozocerite) with an uncomplicated course of the disease and no signs of hidden bleeding.

With long-term non-scarring ulcers, especially in elderly and senile patients, laser irradiation of the ulcer defect is used (through a fibrogastroscope), 7-10 irradiation sessions significantly shorten the scarring time.

In some cases, there is a need for surgical treatment. Surgical treatment is indicated for patients with peptic ulcer disease with frequent relapses with continuous therapy with maintenance doses of antiulcer drugs.

During the period of remission of peptic ulcer, it is necessary: 1) exclusion of ulcerogenic factors (cessation of smoking, drinking alcohol, strong tea and coffee, drugs from the group of salicylates and pyrazolone derivatives); 2) compliance with the regime of work and rest, diet; 3) sanatorium treatment; 4) dispensary observation with secondary prevention

Patients with newly diagnosed or rarely recurrent peptic ulcer should undergo seasonal (spring-autumn) prophylactic courses of treatment lasting 1-2 months.

Prevention

Distinguish between primary and secondary prevention of peptic ulcer disease. Primary prevention is aimed at active early detection and treatment of pre-ulcerative conditions (functional indigestion of hypersthenic type, antral gastritis, duodenitis, gastroduodenitis), identification and elimination of risk factors for the disease. This prevention includes sanitary-hygienic and sanitary-educational measures to organize and promote rational nutrition, especially among persons working on the night shift as transport drivers, adolescents and students, to combat smoking and alcohol consumption, to create favorable psychological relationships in the work team and at home, explaining the benefits of physical culture, hardening and organized recreation.

The task of secondary prevention is to prevent exacerbation and recurrence of the disease. The main form of prevention of exacerbation is clinical examination. It includes: registration of persons with peptic ulcer in the clinic, constant medical supervision over them, prolonged treatment after discharge from the hospital, as well as spring-autumn courses of anti-relapse therapy and, if necessary, year-round treatment and rehabilitation.

Therapeutic physical culture is prescribed after the subsidence of acute manifestations of the disease.

Tasks of exercise therapy:

normalization of the central nervous system tone and cortico-visceral relationships,

improvement of the psycho-emotional state;

activation of blood and lymph circulation, metabolic and trophic processes in the stomach, duodenum and other digestive organs;

stimulation of regenerative processes and acceleration of ulcer healing;

reduction of spasm of the muscles of the stomach; normalization of secretory and motor functions of the stomach and intestines;

prevention of congestion and adhesive processes in the abdominal void.

Therapeutic massage is prescribed to reduce the excitation of the central nervous system, improve the function of the autonomic nervous system, normalize the motor and secretory activity of the stomach and other parts of the gastrointestinal tract; strengthening the abdominal muscles, strengthening the body. Apply segmental-reflex and classical massage. They act on the paravertebral zones. At the same time, in patients with gastric ulcer, these zones are massaged only on the left, and with duodenal ulcer - on both sides. The area of the collar zone is also massaged.

Physiotherapy is prescribed from the first days of the patient's stay in the hospital, its tasks are:

reducing the excitability of the central nervous system, - improving the regulatory function of the autonomic nervous system;

elimination or reduction of pain, motor and secretory disorders;

activation of blood and lymph circulation, trophic and regenerative processes in the stomach, stimulation of ulcer scarring.

First, medical electrophoresis, electrosleep, solux, UHF therapy, ultrasound are used, and when the exacerbation process subsides, diadynamic therapy, microwave therapy, magnetotherapy, UV radiation, paraffin-ozocerite applications, coniferous, radon baths, circular showers, aeroionotherapy.

The post-hospital period of rehabilitation is carried out in a clinic or sanatorium. Apply exercise therapy, therapeutic massage, physiotherapy, occupational therapy.

Recommended spa treatment, during which: walks, swimming, games; in winter - skiing, skating, etc.; diet therapy, drinking mineral water, taking vitamins, UV radiation, contrast showers.

The main forms of exercise therapy that are used at the stationary stage of physical rehabilitation:

.Morning hygienic gymnastics.

.Physiotherapy.

.Self-study.

.Walks in the open air.

.Therapeutic walking.

LH classes are first carried out in relation to the bed motor regimen.

The tasks of this motor mode include:

assistance in the regulation of the processes of excitation and inhibition in the cerebral cortex;

improvement of redox processes.

counteracting constipation and congestion in the intestines;

improvement of circulatory and respiratory functions.

In the first lessons, it is necessary to teach the patient abdominal breathing with a small amplitude of abdominal wall oscillations. These exercises, causing minor changes in intra-abdominal pressure, help to improve blood circulation and gentle massage of the abdominal organs, reduce spastic phenomena and normalize peristalsis. Movements in large joints of the limbs are performed first with a shortened lever and a small amplitude. You can use exercises in static tension of the muscles of the belt of the upper limbs, abdominals and lower limbs. It is necessary to turn in bed and move into a sitting position calmly, without significant stress. The duration of the LH classes is 8-12 minutes.

Complex 1

Preparatory part

Same. Free breathing 2-3 times Slow

Lying on your back, arms along the body. Take the right (left) note to the side - inhale, return to and. p. - exhale. 2-3 times Slow Do not hold your breath

The same, hands down in the "lock" Raise your hands up, stretch - inhale, return to and. p. - exhale. 2-3 times Slow Do not hold your breath

The same Raise your hands through the sides up, inhale through your nose for 4 s, then slowly lower your hands - exhale for a duration

from 2-3 times Slow 6. Lying on the left (right) side Take the left leg to the side - inhale, lower - exhale, the same on the other side 4-5 times Medium Do not hold your breath

Lying on your back Relaxation exercises 30-40 s

Main part

Sitting on a chair, leaning back on the back of the chair, hands - left on the chest, right on the stomach Diaphragmatic breathing: inhale - 4 s, pause - 8 s, exhale - 6 s 2-3 times Slow

Sitting, straight legs shoulder-width apart Raise your arms up - inhale, bend over to the left leg - exhale, the same to the other leg 2-3 times Slow Do not hold your breath

Sitting, resting your back on the back of a chair Hands across the sides (pulling your shoulders back) forward - inhale, joining your palms together, pressing your fingers to each other, hold your breath for 8 seconds, lowering your arms to relax - active exhale 2-3 times Slow after each exercise free inhalation and exhalation

Sitting on the edge of the chair, hands in support behind Raise the right (left) leg up, bend, straighten and lower 4-5 times Slow Breathing is arbitrary

The same, hands on the waist Turning the body to the right (left), reaching the back of the chair with the elbow 2-3 times Slow Breathing voluntary

The same, hands lowered Tilt to the left, left hand down, right into the armpit; the same in the other direction 3-4 times Slow Breathing arbitrary

Standing behind the chair, resting your hands on the back Alternate swinging movements of the legs to the side crosswise 3-4 times Medium Breathing is voluntary

Standing, left hand on the chest, right hand on the stomach Diaphragmatic breathing: inhale - 4 s, inhale hold - 8 s and exhale - 6 s 2-3 times Slow

Standing, rubbing your hands against the back of the chair, head back, legs together Press strongly with the brushes on the back of the chair, straining the muscles of the legs and body for 8 s, relax, lowering your arms down 2-3 times Slow Breathing is arbitrary

Standing, bend your arms in front of your chest, legs shoulder-width apart Pull your elbows to the sides in jerks, then straight arms to the sides with your palms up 2-3 times Slow Breathing is arbitrary

StandingWalking: inhale for 4 steps, hold your breath for 8 steps and exhale for 6 steps. Pause on exhalation 2-3 steps 2-3 times Slow Breathing voluntary

Final part

Sitting, hands to the shoulders Rotation in the shoulder joints forward and backward 3-4 times in each direction Medium Breathing is voluntary

The same Squeeze and unclench your fingers, while raising and lowering your feet 4-6 times. Medium Respiration voluntary

Same. Bring the hands to the shoulders, raise the arms up, lower the hands to the shoulders, lower the arms and relax 2-3 times. Medium Respiration voluntary

The same, hands on the hips Palms up - inhale, palms down, relaxed - exhale 4-5 times. Average.

The same Close your eyes, relax the muscles of the whole body for 30-40 seconds. Slow. Breathing calm

When performing exercises with isometric muscle tension at this stage of treatment, it is necessary to pay attention to rhythmic breathing without delay. In the future, it is possible to recommend breathing exercises aimed at increasing the duration of the respiratory phases and the intervals between them. The volume of static exercises should not exceed 10-15% of the total physical load.

At the second and third stages (rehabilitation department - polyclinic, dispensary), the optimal duration of isometric tension increases until a submaximal time of volitional breath holding is reached.

With a noticeable subsidence of pain and other exacerbation phenomena, the disappearance or decrease in the rigidity of the abdominal wall, a decrease in soreness and an improvement in the general condition, a ward motor regimen is prescribed (approximately 2 weeks after admission to the hospital).

The tasks of the ward motor regimen are supplemented by the tasks of household and labor rehabilitation of the patient, restoration of the correct posture when walking, and improvement of coordination of movements.

Exercises from I.P. lying down, sitting, standing, kneeling in an emphasis are performed with a gradually increasing effort for all muscle groups (with the exception of the abdominal muscles), with incomplete amplitude, at a slow and medium pace. Short-term moderate tension of the mouse of the abdominal press is allowed in the supine position. Gradually, diaphragmatic breathing deepens. The duration of the LH classes is 15-18 minutes.

With a slow evacuation function of the stomach, more exercises lying on the right side should be included in the LH complexes, with moderate - on the left side. During this period, patients are also recommended massage, sedentary games, walking. The average duration of a lesson in the ward mode is 15-20 minutes, the pace of the exercises is slow, the intensity is low. Therapeutic exercises are carried out 1-2 times a day.

Complex 2.

Preparatory part

Lying on the back, left hand on the chest, right hand on the stomach Counting the pulse. Diaphragmatic breathing 5-6 times Slow Breathing even

The same Free breathing 2-3 times Slow. Standing Combined walking (on toes, on heels, cross step, etc.) with movements for the upper and lower 2-3 minutes Slow Do not hold your breath

3. Standing Slow walking: 4 steps - inhale, 6 steps - exhale 30-40 Slow

Standing, feet shoulder width apart Raising arms through the sides up - inhale 4 s. Rise on your toes, pause on inspiration for 8 s, then exhale sharply, lowering your arms 2-3 times Slow While holding your breath while inhaling, produce an isometric tension of the muscles of the body

Standing Raise I catch my hand to the side, right up, turn the body to the left - inhale, return to and. p. - exhale 3-4 times Medium Do not hold your breath

The same, legs together, hands forward, palms down Raise the right leg with a swing, reaching the left hand, lower the leg 5-6 times. p. - exhale 3-4 times Slow Do not hold your breath

Main part

Kneeling Raise your hands up - inhale, sit on your heels - exhale 3-4 times Slow Do not hold your breath

The same Raise your hands up - inhale, sit down on the floor to the right - exhale; the same to the left 3-4 times Slow Do not hold your breath

Standing on all fours With the right knee, reach (without lifting it from the floor) the left hand, return to and. p.3-4 times Medium Do not hold your breath

10. The same, brushes inward Inhale - bend over, touching the floor with your chest, exhale 3-4 times Medium

11. The same, hands forward Take a deep breath for 6 seconds, lean back, sit on your heels without lifting your hands off the floor - a slow exhalation for 8 seconds 3-4 times Medium

12. Lying on the stomach, head down on the hands, raise the right (left) leg up, return to and. p.2-3 times Medium Breathing voluntary

13. The same with the right knee, turning it to the side, reach the right elbow, return to and. p.2-3 times Medium Breathing voluntary

14. Lying on the left (right) side Take the leg back - inhale, protruding the abdominal wall forward, bend the leg at the knee joint, press it to the stomach - exhale 2-3 times Slow Breathing is arbitrary

15. Lying on your back, hands - left on the chest, right - on the stomach, feet on yourself. Diaphragmatic breathing: inhalation for 6 s, pause for inhalation - 12 s, exhalation for 6 s 2-3 times Slow

16. Lying on a slip, arms along the body Deep breath, hold your breath for 12 with jerks at the same time, pressing your right (left) knee to your stomach - exhale 2-3 times Slow

17. Lying on blue, hands behind the head Flexion and extension of the legs in the hip, knee, ankle joints alternately - imitation of cycling 40-50 s Medium Breathing is arbitrary

The same, arms along the body Raise your arms up - inhale, relax your elbows down - exhale, relax 2-3 times Slow Breathing is arbitrary

The same Raise the legs up, spread the legs apart and cross them (“scissors”). 20-30 s Slow Breathing is arbitrary

20. The same, legs apart Raise your hands up - inhale, lower them relaxed to the floor to the left - exhale, the same in the other direction 2-3 times Slow Breathing is arbitrary

21. Kneeling, hands behind your back Deep breath 6 s, lean forward - exhale 8 s 2-3 times Slow

Final part

22. Standing, hands down Walking is normal, walking with the movement of the hands up - inhale, lower the hands down with muscle relaxation - exhale 1-2 minutes Slow Breathing is arbitrary

23. The same In walking, swaying the arms with relaxation 30-40 s Slow Breathing voluntary

24. The same Alternate shaking of the lower leg with muscle relaxation 1 min Slow Breathing voluntary

After the disappearance of pain and other signs of exacerbation, in the absence of complaints and in general satisfactory condition, a free motor mode is prescribed.

The tasks of this mode include: general strengthening and improvement of the patient's body; improvement of blood and lymph circulation in the abdominal cavity; restoration of household and labor skills.

In LH classes, exercises are used for all muscle groups (sparing the abdominal area and excluding sudden movements) with increasing effort from various starting positions. Includes exercises with dumbbells (0.5 - 2 kg), stuffed balls (up to 2 kg), exercises on the gymnastic wall and bench. Diaphragmatic breathing is carried out with maximum depth. Walking is brought up to 2-3 km per day, walking up the stairs - up to 4-6 floors, outdoor walks are desirable. The duration of the LH class is 20-25 minutes.

Complex 3.

Preparatory part

1. Standing Pulse count. Diaphragmatic breathing 5-6 times Slow Breathing even

2. Standing Combined walking (on toes, on heels, cross step, etc.) with movements for the upper and lower extremities 3-5 min Medium Do not hold your breath

3. The same Dosed walking, for 6 steps - inhale, for 12 - breath holding, for 8 - exhale. 1-2 minutes Medium Do not hold your breath

4. The same, the right hand is above, the left is below. Jerks with the hands back, the same, changing hands. 5-6 times Medium Breathing is arbitrary

5.O. c. Raise hands up - inhale, sit down, hands forward - exhale 5-6 times Medium Breathing is arbitrary

6.O. c. Hands to the left, right foot to the side on the toe; hands swing to the right, simultaneously with the right foot swing to the left, return to and. p.3-4 times with each leg Quick Breathing arbitrary

7. Standing Diaphragmatic breathing: inhale - 6 s. exhalation - 8 s5-6 times Medium

Main part

8. Standing, stick at the bottom Raise the stick up - inhale, return to and. p. - exhale. 5-6 times Medium Breathing is arbitrary

9. Standing, stick forward Turn the torso and head to the right, return to and. p., the same in the other direction. 3-4 times in each direction Medium Breathing is arbitrary

10. Standing, stick down Stick up - inhale, hold your breath for 8 s, simultaneously 2 tilts to the right (left), then exhale sharply 2-3 times Slow After each exercise, deep inhale and exhale

11. Standing, stick forward Alternately, swing your legs to get a stick 4-5 times with each foot Fast Breathing is arbitrary

12. Standing, stick on the stomach Deep diaphragmatic breathing with protrusion of the abdominal wall forward - inhale, press the stick and pull in the abdominal wall - exhale 2-3 times Slow

13. Standing, stick forward Spring squats 3-4 times Fast Breathing arbitrary

14. Kneeling Raise the stick up - inhale 6 s, hold your breath for 12 s, exhale sharply, sit on your heels 1-2 times Slow

15. Lying on your back, put a stick nearby Raise your hands up - inhale, hold your breath for 8 seconds, while pressing your knee (left, right) to your stomach, return to and. p.1-2 times with each foot Slow

16. The same Alternately abducting the legs by sliding on the carpet 3-4 times Medium Breathing is arbitrary

17. Lying, legs bent at the knee joints, hands under the head, Inhale, lower your bent knees to the right to the floor - exhale, inhale - return to and. p., lower your knees to the left - exhale 3-4 times Medium Breathing is arbitrary

18. Lying on your back, arms under your head Raise your torso up, return to and. p.3-4 times Medium Breathing voluntary

19. The same Legs raise, bend them straighten, lower 3-4 times Medium Do not hold your breath

20. Lying on your back. Raise your arms up - inhale, lowering your elbows down relaxed - exhale 4-5 times Slow

21. Lying on the side Swinging movements, legs forward, backward, the same on the other side. 3-4 times Medium

22. Lying on the stomach, hands under the chest Raise your shoulders up, straightening your arms, bend over - inhale, return to and. p. - exhale, relax 1-2 s3-4 times Medium Do not hold your breath

23. Standing on all fours Raise the right (left) leg up, bending, return to and. p.4-5 times with each leg Medium Breathing arbitrary

24. The same Raise the right (straight) leg to the side, look at the toe, return to and. p.4-5 times with each leg Medium Breathing arbitrary

25. The same To get the left hand with the right knee by sliding along the carpet, return to i. p.3-4 times with each leg Medium Breathing arbitrary

26. Kneeling, stick down Raise the stick up - inhale, return to and. p. - exhale. 3-4 times Slow Do not hold your breath

27. Standing, feet shoulder-width apart, stick perpendicular to the floor Bend the left leg at the knee joint, return to and. p., bend the right leg, return to and. p.3-4 times Medium Do not hold your breath

28. Standing, ball in hands Stand in a circle and, on command, pass the ball to a friend on the left, the same to the right. 3-4 times Medium Do not hold your breath

29. The same Passing the ball to the right (left) by hitting the floor 3-4 times Fast Breathing do not hold

30. The same Raise the ball up - inhale, lower - exhale 2-3 times Slow

Final part

31. Standing Raise your hands up - inhale 6 s, lower your hands - exhale 8 s 2-3 times Slow

32. The same Slow walking, relaxation exercises, breathing exercises. Sit down, relax, count the pulse and breathing

Breathing exercises should be included in the LH complex. At the same time, the task is to teach the patient to properly perform deep diaphragmatic breathing, to teach volitional control of respiratory movements aimed at increasing the duration of the respiratory phases and the intervals between them, which contribute to the activation of redox processes and increase the tone of the whole organism.

Diaphragmatic breathing has a massaging effect on the abdominal organs, improves lymph and blood circulation, as well as intestinal motility and prevents the development of constipation. Based on this, there is a need for an individual dosage of breathing exercises in relation to general developmental ones.

So, at the stationary stage of rehabilitation treatment in bed motor mode, the ratio of respiratory and general developmental exercises should be 1:2, 1:3, 1:4. With the expansion of motor activity on the ward and free motor modes, this ratio is also determined individually and is 1:5, 1:6, 1:7.

Dosed therapeutic walking has a positive effect on the functional state of the digestive system, stimulates metabolism, blood circulation, respiration and muscles of the whole organism.

Therapeutic dosed walking can be prescribed at all stages of rehabilitation treatment after the disappearance of the pain syndrome, indicating in the appointment the number of the route, the pace of walking, the intensity of physical activity. The degree of physical activity is consistent with the nature of the disease, the functional state of the digestive organs and the body as a whole.

There are various types of therapeutic walking: subsidized walking, subsidized walking, hiking at close distances (10-20 km), walking along special routes (terrenkur), in winter - skiing. Patients with peptic ulcer are recommended to walk at a slow pace (60-80 steps per 1 minute) and walk at an average pace (80-100 steps per 1 minute).

Treatment with dosed walking is prescribed by a doctor and is carried out under the supervision of a physiotherapy instructor. Therapeutic walking is shown in the morning and evening, in winter it is better to do it in the middle of the day. Clothing should be light and appropriate for the season. Each patient must be taught proper breathing while walking. Dosed walking on flat terrain is combined with rhythmic breathing: inhale through the nose for 2-4 steps: exhale through the nose or mouth (lips folded in a tube) for 4-5 or 6-7 steps.

The success of treatment largely depends on the gradual increase in physical activity. Therefore, when prescribing subsidized walking, one should take into account the severity of the disease, the duration of remission, the initial background of the secretory and motor functions of the stomach, as well as the data of gastrofibroscopy and radiography.

Peptic ulcer of the stomach and duodenum is one of the most common diseases of the gastrointestinal tract. Literature data indicate a high percentage of patients in all countries. Up to 20% of the adult population suffers from this disease throughout their lives. In industrialized countries, peptic ulcer affects 6-10% of the adult population, with duodenal ulcers predominating compared to gastric ulcers.

Factors contributing to the occurrence of peptic ulcer are various disorders of the nervous system, infection with Helicobacter pylori, for a number of patients hereditary predisposition may be important, as well as neuropsychic overstrain, dietary errors, alcohol abuse, spicy food, chronic diseases of the gastrointestinal tract and other factors.

It is currently accepted that peptic ulcer of the stomach and duodenum develops as a result of an imbalance between the factors of aggression of gastric juice and the factors of protection of the mucous membrane of the stomach and duodenum in the direction of the predominance of factors of aggression. Under the influence of various etiological factors, there is a violation of the neuroendocrine regulation of the secretory, motor, endocrine functions of the stomach and duodenum with an increase in the activity of the parasympathetic division of the autonomic nervous system.

Comprehensive treatment and rehabilitation of patients with gastric and duodenal ulcers include: drug treatment, diet therapy, physiotherapy and hydrotherapy, drinking mineral water, exercise therapy, therapeutic massage and other therapeutic agents. The anti-ulcer course also includes the elimination of factors contributing to the recurrence of the disease, provides for the optimization of working and living conditions, the categorical prohibition of smoking and alcohol consumption, and the prohibition of taking medications with an ulcerogenic effect.

The use of physical exercises in diseases of the gastrointestinal tract allows you to use all four mechanisms of their therapeutic action: tonic effect, trophic effect, formation of compensation and normalization of functions. Exercise therapy improves or normalizes neurotrophic processes and metabolism, helping to restore the secretory, motor, absorption and excretory functions of the digestive canal.

An important therapeutic measure is diet therapy. Therapeutic nutrition in patients with gastric ulcer must be strictly differentiated depending on the stage of the process, its clinical manifestations and associated complications. The basis of dietary nutrition in patients with peptic ulcer of the stomach and duodenum is the principle of a sparing regimen for the stomach, that is, the creation of maximum rest for the ulcerated mucosa.

To determine the effectiveness of exercise therapy, medical and pedagogical observations are carried out on the patient, which determine his condition, the impact of the exercises used, a separate lesson, a certain period of treatment. Of great importance are also special studies of the functional state, which give an objective assessment of the patient, his individual characteristics, adaptation to physical activity.

The main forms of exercise therapy that are used at the stationary stage of physical rehabilitation: morning hygienic gymnastics, therapeutic exercises, self-study, outdoor walks, therapeutic walking. Exercise therapy is used in three motor modes: bed, ward and free.

At the first lessons (bed motor mode), it is necessary to teach the patient abdominal breathing with a small amplitude of oscillations of the abdominal wall. Movements in the large joints of the limbs are performed first with a shortened lever and a small amplitude. You can use exercises in static tension of the muscles of the belt of the upper limbs, abdominals and lower limbs. It is necessary to turn in bed and move into a sitting position calmly, without significant stress. The duration of the LH classes is 8-12 minutes.

On the ward motor mode, exercises from I.P. lying down, sitting, standing, kneeling in an emphasis are performed with a gradually increasing effort for all muscle groups (with the exception of the abdominal muscles), with incomplete amplitude, at a slow and medium pace. Short-term moderate tension of the mouse of the abdominal press is allowed in the supine position. Gradually, diaphragmatic breathing deepens. The duration of the LH classes is 15-18 minutes.

In the free motor mode, in the LH classes, exercises are used for all muscle groups (sparing the abdominal area and excluding sudden movements) with increasing effort from various starting positions. Diaphragmatic breathing is carried out with maximum depth. Walking is brought up to 2-3 km per day, walking up the stairs - up to 4-6 floors, outdoor walks are desirable. The duration of the LH class is 20-25 minutes.

Physiotherapy is prescribed from the first days of the patient's stay in the hospital. First, drug electrophoresis, electrosleep, solux, UHF therapy, ultrasound are used, and when the exacerbation process subsides, diadynamic therapy, microwave therapy, magnetotherapy, UV radiation, paraffin-ozocerite applications, coniferous, radon baths, circular shower, aeroionotherapy.

The data obtained by us can be used in the practice of physical rehabilitation specialists and exercise therapy instructors in various medical institutions, as well as used in physical education universities in the process of training in the discipline "Physical rehabilitation in diseases of the internal organs."

Bibliography

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indicating the topic right now to find out about the possibility of obtaining a consultation.

1. Diet therapy - table number 2 (mechanically and chemically sparing diet);

2. Bed mode, then ward mode;

3. Drug therapy as prescribed by a doctor (delivery of drugs):

A. Eradication therapy:

· T. Pyloride 0.4 x 2 r / day at the end of the meal;

T. Clarithromycin 0.25 x 2 times a day;

· T. Metronidazole 0.5 x 2 times a day at the end of meals;

within 7 days;

B. Antacids:

Susp. Maalox - 15 ml. - 15 minutes after eating x 4 times a day, the last time at night;

B. Salnikov's mixture:

Sol. Novocaini 0.25%-100.0

S. Glucosae 5%-200.0

Sol. Platyphyllini 0.2%-1.0

Sol. No-Spani-2.0

Ins. – 2ED

In / in the cap x 1 time / day - No. 3;

D. Upon completion of eradication therapy:

· T. Pyloride 0.4 x 2 r / day at the end of the meal - continue;

· R-r. Delargin 0.001 - in / m - 1 time / day - No. 5.

4. Physiotherapy as prescribed by a doctor (assistance in the implementation of procedures): SMT, ultrasound on the epigastrium, novocaine electrophoresis.

5. Exercise therapy: Bed rest: At this time, static breathing exercises are shown, which enhance the processes of inhibition in the cerebral cortex. Performed in the initial position lying on the back with relaxation of all muscle groups, these exercises are able to bring the patient into a drowsy state, help reduce pain, eliminate dyspeptic disorders, and normalize sleep. Simple gymnastic exercises for small and medium muscle groups are also used, with a small number of repetitions, in combination with breathing exercises and relaxation exercises, but exercises that increase intra-abdominal pressure are contraindicated. The duration of classes is 12-15 minutes, the pace of the exercises is slow, the intensity is low. As the condition improves, when transferring to the ward regime: To the tasks of the previous period, the tasks of household and labor rehabilitation of the patient, restoration of the correct posture when walking, improvement of coordination of movements are added. The second period of classes begins with a significant improvement in the patient's condition. Exercises are performed in the prone position, sitting, kneeling, standing with gradually increasing effort for all muscle groups, still excluding the abdominal muscles. The most acceptable is the supine position: it allows you to increase the mobility of the diaphragm, has a gentle effect on the abdominal muscles and improves blood circulation in the abdominal cavity. Patients perform exercises for the abdominal muscles without tension, with a small number of repetitions. With a slow evacuation function of the stomach, more exercises lying on the right side should be included in the LH complexes, with moderate - on the left side. During this period, patients are also recommended massage, sedentary games, walking. The average duration of a lesson in the ward mode is 15-20 minutes, the pace of the exercises is slow, the intensity is low. Therapeutic exercises are carried out 1-2 times a day.

6. Taking biological samples for analysis (blood, urine, etc.), assistance in the implementation of instrumental studies (FGS (FGS control - upon admission, after 10 days, before discharge), gastric intubation, X-ray examination of the stomach, etc.) .

COMPLEX PHYSICAL REHABILITATION OF PATIENTS WITH GASTRIC ULCER AND DUODENAL ULCER AT THE STATION STAGE

Introduction

Chapter 1. General characteristics of peptic ulcer of the stomach and duodenum

1.1 Anatomical and physiological features of the stomach and duodenum

1.2 Etiology and pathogenesis of peptic ulcer of the stomach and duodenum

1.3 Classification and clinical characteristics of peptic ulcer of the stomach and duodenum

Chapter 2. Comprehensive physical rehabilitation of patients with peptic ulcer of the stomach and duodenum

2.1 General characteristics of the means of physical rehabilitation for peptic ulcer of the stomach and duodenum

2.2 Exercise therapy in the physical rehabilitation of patients with gastric and duodenal ulcers

2.2.1 Mechanisms of the therapeutic effect of physical exercises in gastric and duodenal ulcers

2.2.2 Purpose, tasks, means, forms, methods and techniques of exercise therapy for peptic ulcer of the stomach and duodenum at the stationary stage

2.3 Therapeutic massage for peptic ulcer of the stomach and duodenum

2.4 Physiotherapy for this pathology

Chapter 3. Evaluation of the effectiveness of physical rehabilitation in gastric and duodenal ulcer

List of used literature

INTRODUCTION

The urgency of the problem. In the general structure of diseases of the digestive system, the pathology of the stomach and duodenum occupies a leading place. In about 60-70% of adults, the formation of peptic ulcer, chronic gastritis, duodenitis begins in childhood and adolescence, but they are especially common at a young age (20-30 years) and mainly in men.

Peptic ulcer is a chronic, relapsing disease prone to progression, with involvement in the pathological process along with the stomach and duodenum (in which ulcerative defects of the mucous membrane are formed during periods of exacerbation) of other organs of the digestive system, the development of complications that threaten the life of the patient.

Peptic ulcer of the stomach and duodenum is one of the most common diseases of the gastrointestinal tract. Available statistics indicate a high percentage of patients in all countries. Up to 20% of the adult population suffers from this disease throughout their lives. In industrialized countries, peptic ulcer affects 6-10% of the adult population, with duodenal ulcers predominating compared to gastric ulcers. About 5 million people are registered in Ukraine with gastric and duodenal ulcers. Peptic ulcer of the stomach and duodenum affects people in the most able-bodied age - from 20 to 50 years. The disease is more common in men than in women (the ratio of men and women is 4:1). At a young age, a duodenal ulcer is more common, at an older age - a stomach ulcer. Among urban residents, peptic ulcer is more common than among the rural population.

At present, given the urgency of the problem, its not only medical but also social significance, the pathology of the stomach and duodenum, pathogenesis, new methods of diagnosis, treatment and prevention of stomach diseases attract the attention of not only clinicians-therapists, but in connection with a significant "rejuvenation » diseases and pediatricians, and geneticists, pathophysiologists, immunologists, specialists in physical rehabilitation.

Significant experience has been accumulated in the study of peptic ulcer of the stomach and duodenum. Meanwhile, many aspects of this problem have not yet been resolved. In particular, the issues of using physical rehabilitation means in the complex treatment of this disease are very relevant. In this regard, there is a need for continuous improvement of the means, forms, methods and techniques of therapeutic physical culture and therapeutic massage, which led to the choice of this research topic.

Goal of the work - to develop an integrated approach to the physical rehabilitation of patients with gastric and duodenal ulcers at the inpatient stage of rehabilitation treatment.

To achieve this goal, the following tasks:

1. To study and analyze the literature on the problem of physical rehabilitation of patients with gastric and duodenal ulcers.

2. To characterize the anatomical and physiological features of the stomach and duodenum.

3. To reveal the etiology, pathogenesis, classification and clinic of peptic ulcer of the stomach and duodenum.

4. Draw up a program of complex physical rehabilitation of persons with gastric and duodenal ulcers, taking into account the period of the course of the disease and the stage of rehabilitation.

5. Describe methods for evaluating the effectiveness of exercise therapy in gastric and duodenal ulcers.

The novelty of the work consists in the fact that we have compiled a program of complex physical rehabilitation of persons with peptic ulcer of the stomach and duodenum, taking into account the period of the course of the disease and the stage of rehabilitation.

Practical and theoretical significance. The program of complex physical rehabilitation of patients with peptic ulcer of the stomach and duodenum presented in the work can be used in medical institutions, as well as in the educational process for training specialists in physical rehabilitation in the discipline "Physical rehabilitation for diseases of internal organs".

Scope and structure of work. The work is written on 77 pages of computer layout and consists of an introduction, 3 chapters, conclusions, practical recommendations, a list of references (59 sources). In the work there is 1 table, 2 drawings and 3 sets of therapeutic exercises.

CHAPTER 1. GENERAL CHARACTERISTICS OF Peptic ulcer of the stomach and duodenum

1.1 Anatomical and physiological features of the stomach and duodenum

The stomach is the most important organ of the digestive system. It represents the widest part of the digestive tract. It is located in the upper abdomen, mainly in the left hypochondrium. Its initial section is connected to the esophagus, and the final section is connected to the duodenum.

Fig.1.1. Stomach

The shape, volume and position of the human stomach are highly variable. They can change at different times of the day and night, depending on the filling of the stomach, the degree of contraction of its walls, the phases of digestion, body position, individual structural features of the body, the state and effect of neighboring organs - the liver, spleen, pancreas and intestines. The stomach with increased contraction of the walls often has the shape of a bull's horn, or siphon, with reduced contractility of the walls and its omission - the shape of a bowl.

As food moves through the esophagus, the volume of the stomach decreases and its walls contract. Therefore, to fill the stomach during X-ray examination, it is enough to introduce 400-500 ml of a contrast suspension in order to get an idea of all its departments. The length of the stomach with an average degree of filling is 14-30, the width is from 10 to 16 cm.

Several sections are distinguished in the stomach: the initial (cardiac) - the place where the esophagus passes into the stomach, the body of the stomach - its middle part and the output (pyloric, or pylorus), adjacent to the duodenum. There are also anterior and posterior walls. The border along the upper edge of the stomach is short, concave. It is called the lesser curvature. On the lower edge - convex, more elongated. This is the greater curvature of the stomach.

In the wall of the stomach on the border with the duodenum there is a thickening of muscle fibers, circularly arranged in the form of a ring and forming a locking apparatus (pylorus), closing the exit from the stomach. The same, but less pronounced obturator apparatus (pulp) is present at the junction of the esophagus into the stomach. Thus, with the help of locking mechanisms, the stomach is limited from the esophagus and duodenum.

The activity of the locking apparatus is regulated by the nervous system. When a person swallows food, reflexively, under the influence of irritation of the walls of the esophagus by food masses passing through the throat, the pulp opens, located in the initial section of the stomach, and food passes from the esophagus to the stomach in a certain rhythm. At this time, the pylorus, located in the outlet section of the stomach, is closed, and food does not enter the duodenum. After the food masses stay in the stomach and are treated with gastric juices, the pylorus of the exit section opens, and the food passes into the duodenum in separate portions. At this time, the pulp of the initial section of the stomach is closed. Such harmonious activity of the pylorus and cardiac sphincter ensures normal digestion, and food intake causes pleasant sensations and pleasure.

If the gastric obturator apparatus is narrowed under the influence of cicatricial, ulcerative or tumor processes, a severe painful condition develops. With the narrowing of the pulp of the initial section of the stomach, the act of swallowing is disturbed. Food stays in the esophagus. The esophagus is stretched. Food is putrefied and fermented. When the pylorus narrows, food does not enter the duodenum, but stagnates in the stomach. It stretches, gases and other products of decay and fermentation accumulate.

In case of violation of the innervation of the stomach or damage to its muscular membrane, the sphincter ceases to fulfill its obturator role. They gape constantly. Acidic stomach contents can back up into the esophagus and cause discomfort.

The walls of the stomach consist of 3 membranes: external serous, middle muscular and internal mucosa. The mucous membrane of the stomach is the most important part of it, which plays a leading role in digestion. At rest, the mucous membrane is whitish, in the active state it is reddish. The thickness of the mucous membrane is not the same. It is maximum in the outlet section, gradually thins out and is equal to 0.5 mm in the initial part of the stomach.

The stomach is richly supplied with blood and innervated. The nerve plexuses are located in the thickness of its walls and outside the organ.

As noted, the stomach performs important functions for the body. Due to the presence of a developed muscular and mucous membranes, a closing apparatus and special glands, it plays the role of a depot, where food coming through the esophagus from the oral cavity accumulates, its initial digestion and partial absorption take place. In addition to the depositing role, the stomach performs other important functions. Of these, the main one is the physical and chemical processing of food and its gradual rhythmic transportation in small portions to the intestines. This is carried out by the coordinated motor and secretory activity of the stomach.

The stomach performs another important function. It absorbs water in small amounts, some soluble substances (sugar, salt, protein products, iodine, bromine, vegetable extracts). Fats, starch, etc. are not absorbed in the stomach.

The excretory function of the stomach has been known for a long time. In severe kidney disease, a large amount of waste accumulates in the blood. The gastric mucosa partially secretes them: urea, uric acid and other nitrogenous substances, as well as dyes alien to the body. It turned out that the higher the acidity of gastric juice, the faster the accepted dyes are released.

Therefore, the stomach is involved in the day-to-day metabolism. It partially removes from the body products formed as a result of the breakdown of proteins that are not used by the body and can cause poisoning. The stomach affects the water-salt metabolism, to maintain a constant acid-base balance, which is very important for the body.

The influence of the stomach on the functional state of other organs has been established. The reflex effect of the stomach on the gallbladder and bile ducts, intestines, kidneys, cardiovascular system and central nervous system has been proven. These organs also affect the function of the stomach. This relationship leads to dysfunction of the stomach in case of diseases of other organs, and vice versa, diseases of the stomach can cause diseases of other organs.

Thus, the stomach is an important organ for normal digestion and vital activity, which has a complex structure and performs numerous functions.

Such diverse functions provide the stomach with one of the leading places in the digestive system. On the other hand, violations of its function are fraught with serious diseases.

1.2 Etiology and pathogenesis of peptic ulcer of the stomach and duodenum

Currently, a group of factors has been identified that predispose to the development of gastric and duodenal ulcers.

I group associated with functional and morphological changes in the stomach and duodenum, leading to disruption of gastric digestion and a decrease in mucosal resistance, followed by the formation of a peptic ulcer.

II group includes disorders of regulatory mechanisms: nervous and hormonal.

III group - characterized by constitutional and hereditary features.

IV group - associated with the influence of environmental factors.

Group V - associated with comorbidities and drugs.

Currently, a number of exogenous and endogenous factors are known that contribute to the emergence and development of gastroduodenal ulcers.

TO exogenous factors relate:

malnutrition;

Bad habits (smoking, alcohol);

Neuropsychic overstrain;

Occupational factors and lifestyle;

Medicinal effects (the following drugs have the greatest damaging effect on the gastric mucosa: non-steroidal anti-inflammatory drugs - aspirin, indomethacin, corticosteroids, antibacterial agents, iron, potassium, etc.).

TO endogenous factors relate:

genetic predisposition;

Chronic Helicobacter pylori gastritis;

Metaplasia of the gastric epithelium of the duodenum, etc.

Among them, the most significant is hereditary predisposition. It is detected in patients with duodenal ulcers in 30-40% and much less often in gastric ulcers. It has been established that the prevalence of peptic ulcer in relatives of probands is 5-10 times higher than in relatives of healthy people (FI Komarov, AV Kalinin, 1995). Hereditary ulcers are more likely to become aggravated and more likely to bleed. The predisposition to duodenal ulcer is transmitted through the male line.

There are the following peptic ulcer genetic markers:

An increased number of parietal cells in the glands of the stomach and, as a result, a persistently high level of hydrochloric acid in gastric juice; high serum levels of pepsinogens I, II and the so-called "ulcerogenic" fraction of pepsinogen in the gastric contents;

Increased release of gastrin in response to food intake; increased sensitivity of parietal cells to gastrin and disruption of the feedback mechanism between the production of hydrochloric acid and the release of gastrin;

The presence of O (I) blood types, which increases the risk of developing duodenal ulcers by 35% compared with individuals with other blood types;

Genetically determined deficiency in gastric mucus of fucoglycoproteins - the main gastroprotectors;

Violation of the production of secretory immunoglobulin A;

Absence of the intestinal component and a decrease in the alkaline phosphatase B index.

The main etiological factors of gastric ulcer and duodenal ulcer are the following:

infection helicobacteria. Currently, this factor is recognized by most gastroenterologists as the leading factor in the development of peptic ulcer. Helicobacter pylori infection is one of the most common infections. This microorganism is the cause of chronic Helicobacter pylori gastritis, as well as a leading factor in the pathogenesis of gastric and duodenal ulcers, low-grade gastric lymphoma and gastric cancer. Helicobacteria are considered class I carcinogens. The occurrence of duodenal ulcers in almost 100% of cases is associated with infection and colonization of Helicobacter pylori, and gastric ulcers are caused by this microorganism in 80-90% of cases

Acute and chronic psycho-emotional stressful situations. Domestic pathophysiologists have long paid great attention to this etiological factor in the development of peptic ulcer. With the clarification of the role of Helicobacter pylori, neuropsychic stressful situations began to be given much less importance, and some scientists began to believe that peptic ulcer disease was not associated with this factor at all. However, clinical practice knows many examples of the leading role of nervous shocks, psycho-emotional stress in the development of peptic ulcer and its exacerbations. The theoretical and experimental substantiation of the great importance of the neuropsychic factor in the development of peptic ulcer was made in the fundamental works of G. Selye on the general adaptation syndrome and the effect of "stress" on the human body.

Alimentary factor. At present, it is believed that the role of the alimentary factor in the development of gastric ulcer and duodenal ulcer is not only not decisive, but has not been strictly proven at all. However, irritating, very spicy, spicy, rough, too hot or cold foods are supposed to cause excessive gastric secretion, including excess production of hydrochloric acid. This may contribute to the implementation of the ulcerogenic action of other etiological factors.

Abuse of alcohol and coffee, smoking. The role of alcohol and smoking in the development of peptic ulcer has not been conclusively proven. The leading role of these factors in ulcerogenesis is problematic, if only because peptic ulcer disease is very common among people who do not drink alcohol and do not smoke, and, conversely, does not always develop in those who suffer from these bad habits.

However, it has been definitely established that in smokers, peptic ulcer of the stomach and duodenum occurs 2 times more often than in non-smokers. Nicotine causes vasoconstriction of the stomach and ischemia of the gastric mucosa, enhances its secretory capacity, causes hypersecretion of hydrochloric acid, increases the concentration of pepsinogen-I, accelerates the evacuation of food from the stomach, reduces pressure in the pyloric region and creates conditions for the formation of gastroduodenal reflux. Along with this, nicotine inhibits the formation of the main protective factors of the gastric mucosa - gastric mucus and prostaglandins, and also reduces the secretion of pancreatic bicarbonates.

Alcohol also stimulates the secretion of hydrochloric acid and disrupts the formation of protective gastric mucus, significantly reduces the resistance of the gastric mucosa and causes the development of chronic gastritis.

Excessive coffee consumption has an adverse effect on the stomach, which is due to the fact that caffeine stimulates the secretion of hydrochloric acid and contributes to the development of ischemia of the gastric mucosa.

Alcohol abuse, coffee and smoking may not be the root causes of gastric ulcer and duodenal ulcer, but undoubtedly predispose to its development and cause an exacerbation of the disease (especially alcohol excesses).

The influence of drugs. There is a whole group of drugs that can cause the development of an acute stomach ulcer or (less commonly) duodenal ulcer. These are acetylsalicylic acid and other non-steroidal anti-inflammatory drugs (primarily indomethacin), reserpine, glucocorticoids.

At present, a point of view has been formed that the above drugs cause the development of an acute stomach or duodenal ulcer or contribute to the exacerbation of a chronic ulcer.

As a rule, after discontinuation of the drug ulcerogenic drug, the ulcers heal quickly.

Diseases that contribute to the development of peptic ulcer. The following diseases contribute to the development of peptic ulcer:

Chronic obstructive bronchitis, bronchial asthma, pulmonary emphysema (with these diseases developing respiratory failure, hypoxemia, ischemia of the gastric mucosa and a decrease in the activity of its protective factors);

Diseases of the cardiovascular system, accompanied by the development of hypoxemia and ischemia of organs and tissues, including the stomach;

Cirrhosis of the liver;

Diseases of the pancreas.

Pathogenesis. Currently, it is generally accepted that peptic ulcer of the stomach and duodenum 12 develops as a result of an imbalance between the factors of aggression of gastric juice and the factors of protection of the mucous membrane of the stomach and duodenum 12 in the direction of the predominance of aggression factors (Table 1.1.). Normally, the balance between the factors of aggression and defense is maintained by the coordinated interaction of the nervous and endocrine systems.

Pathogenesis of peptic ulcer according to Ya. D. Vitebsky. The basis of the development of peptic ulcer according to Ya. D. Vitebsky (1975) is a chronic violation of duodenal patency and duodenal hypertension. There are the following forms of chronic violation of duodenal patency:

Arteriomesenteric compression (compression of the duodenum by the mesenteric artery or mesenteric lymph nodes);

Distal periduodenitis (as a result of an inflammatory and cicatricial lesion of the Treitz ligament);

Proximal periunit;

Proximal periduodenitis;

Total cicatricial periduodenitis.

With subcompensated chronic violation of duodenal patency (depletion of motility of the 12th intestine and an increase in pressure in it), functional insufficiency of the pylorus develops, antiperistaltic movements of the duodenum 12, episodic discharge of duodenal alkaline contents with bile into the stomach. In connection with the need to neutralize it, the production of hydrochloric acid increases, this is facilitated by the activation of gastrin-producing cells by bile and an increase in gastrin secretion. Acidic gastric contents enter the duodenum, causing the development of duodenitis first, then duodenal ulcers.

Table 1.1 The role of aggressive and protective factors in the development of peptic ulcer (according to E.S. Ryss, Yu.I. Fishzon-Ryss, 1995)


Protective factors:	Aggressive factors:
Resistance of the gastroduodenal system: Protective mucus barrier; Active regeneration of the surface epithelium; Optimal blood supply. 2. Antroduodenal acid brake. 3. Anti-ulcerogenic nutritional factors. 4. Local synthesis of protective prostaglandins, endorphins and enkephalins.	1. Hyperproduction of hydrochloric acid and pepsin not only during the day, but also at night: Hyperplasia of parietal cells; Chief cell hyperplasia; Vagotonia; Increased sensitivity of the gastric glands to nervous and humoral regulation. 2. Helicobacter pylori infection. 3. Proulcerogenic alimentary factors. 4. Duodenogastric reflux, gastroduodenal dysmotility. 5. Reverse diffusion of H + . 6. Autoimmune aggression.
Neuroendocrine regulation, genetic factors

With decompensated chronic violation of duodenal patency (depletion of duodenal motility, duodenal stasis), constant gaping of the pylorus and reflux of duodenal contents into the stomach are observed. It does not have time to neutralize, alkaline contents dominate in the stomach, intestinal metaplasia of the mucous membrane develops, the detergent effect of bile on the protective layer of mucus is manifested and a stomach ulcer is formed. According to Ya. D. Vitebsky, a chronic violation of duodenal patency is present in 100% of patients with gastric ulcer, and in 97% of patients with duodenal ulcer.

1.3 Classification and clinical characteristics of peptic ulcer of the stomach and duodenum

Classification of peptic ulcer of the stomach and duodenum (P. Ya. Grigoriev, 1986)

I. Localization of the ulcer.

1. Gastric ulcer.

Cardiac and subcardiac parts of the stomach.

Mediogastric.

Antral department.

Pyloric canal and prepyloric section or lesser and greater curvature.

2. Duodenal ulcer.

2.1. Bulbar localization.

2.2 Postbulbar localization.

2.2.1. Proximal duodenum 12.

2.2.2. Distal duodenum 12.

II. The phase of the course of the disease.

1. Aggravation.

2. Relapse.

3. Decaying exacerbation.

4. Remission.

III. The nature of the flow.

1. First identified.

2. Latent current.

3. Light flow.

Medium severity.

Severe or continuously relapsing course. IV. Ulcer sizes.

1. Small ulcer - up to 0.5 cm in diameter.

2. Large ulcer - more than 1 cm in the stomach and 0.7 cm in the duodenal bulb.

3. Giant - more than 3 cm in the stomach and more than 1.5-2 cm in the duodenum.

4. Superficial - up to 0.5 cm in depth from the level of the gastric mucosa.

5. Deep - more than 0.5 cm in depth from the level of the gastric mucosa.

V. Stage of ulcer development (endoscopic).

1. Stage of an increase in ulcers and an increase in inflammation.

The stage of the greatest magnitude and the most pronounced signs of inflammation.

Stage of subsidence of endoscopic signs of inflammation.

Ulcer reduction stage.

The stage of ulcer closure and scar formation.

Scar stage.

VI. The state of the mucous membrane of the gastroduodenal zone, indicating the location and degree of activity.

VII. Violation of the secretory function of the stomach.

VIII. Violation of the motor-evacuation function of the stomach and duodenum.

1. Hypertonic and hyperkinetic dysfunction.

2. Hypotonic and hypokinetic function.

3. Duodenogastric reflux.

IX. Complications of peptic ulcer.

1. Bleeding.

2.Perforation.

3. Penetration indicating the organ.

4. Perivisceritis.

5. Stenosis of the pylorus.

6. Reactive pancreatitis, hepatitis, cholecystitis.

7. Malignancy.

X. Timing of ulcer scarring.

1.Usual terms of scarring (duodenal ulcer - 3-4 weeks, gastric ulcer - 6-8 weeks).

2. Long-term non-scarring (duodenal ulcer - more than 4 weeks, gastric ulcer - more than 8 weeks).

The severity of the course of peptic ulcer.

1. Light form (mild severity) - characterized by the following features:

* exacerbation is observed 1 time in 1-3 years;

* the pain syndrome is moderate, the pain stops in 4-7 days;

* the ulcer is shallow;

*in the phase of remission, the ability to work is preserved.

2. The form of moderate severity has the following criteria:

* relapses (exacerbations) are observed 2 times a year;

* the pain syndrome is expressed, the pains are stopped in the hospital for

* characteristic dyspeptic disorders;

* the ulcer is deep, often bleeds, accompanied by the development

perigastritis, periduodenitis.

3. The severe form is characterized by the following features:

* relapses (exacerbations) are observed 2-3 times a year and more often;

* the pain is pronounced, it stops in the hospital in 10-14 days

(sometimes longer);

* sharply expressed dyspeptic phenomena, weight loss;

* the ulcer is often complicated by bleeding, the development of pyloric stenosis, perigastritis, periduodenitis.

Clinical characteristics of peptic ulcer of the stomach and duodenum.

Preulcer period. In most patients, the development of a typical clinical picture of the disease with a formed stomach and duodenal ulcer is preceded by a pre-ulcerative period (VM Uspensky, 1982). The pre-ulcerative period is characterized by the appearance of ulcer-like symptoms, however, during the endoscopic examination, it is not possible to determine the main pathomorphological substrate of the disease - an ulcer. Patients in the pre-ulcerative period complain of pain in the epigastric region on an empty stomach ("hungry" pains), at night ("night" pains) 1.5-2 hours after eating, heartburn, belching sour.

On palpation of the abdomen, there is local pain in the epigastrium, mainly on the right. A high secretory activity of the stomach (hyperaciditas), an increased content of pepsin in gastric juice on an empty stomach and between meals, a significant decrease in antroduodenal pH, accelerated evacuation of gastric contents into the duodenum (according to FEGDS and fluoroscopy of the stomach) are determined.

As a rule, such patients have chronic Helicobacter pylori gastritis in the pyloric region or gastroduodenitis.

Not all researchers agree with the allocation of the pre-ulcerative period (state). A. S. Loginov (1985) proposes to name patients with the above symptom complex as an increased risk group for peptic ulcer.

Typical clinical picture.

subjective manifestations. The clinical picture of peptic ulcer has its own characteristics associated with the localization of the ulcer, the age of the patient, the presence of concomitant diseases and complications. Nevertheless, in any situation, the leading subjective manifestations of the disease are pain and dyspeptic syndromes.

Pain syndrome. Pain is the main symptom of peptic ulcer and is characterized by the following features.

Localization of pain. As a rule, pain is localized in the epigastric region, and with a stomach ulcer - mainly in the center of the epigastrium or to the left of the midline, with a duodenal ulcer and prepyloric zone - in the epigastrium to the right of the midline.

With ulcers of the cardial part of the stomach, atypical localization of pain behind the sternum or to the left of it (in the precordial region or the region of the apex of the heart) is quite often observed. In this case, a thorough differential diagnosis with angina pectoris and myocardial infarction should be carried out with the obligatory performance of an electrocardiographic study. When the ulcer is localized in the postbulbar region, pain is felt in the back or right epigastric region.

Time of onset of pain. In relation to the time of eating, pains are distinguished early, late, nocturnal and "hungry". Pain that occurs 0.5-1 hour after eating is called early, their intensity gradually increases; pain disturbs the patient for 1.5-2 hours and then, as the gastric contents are evacuated, they gradually disappear. Early pain is characteristic of ulcers localized in the upper sections of the stomach.

Late pains appear 1.5-2 hours after eating, nocturnal - at night, hungry - 6-7 hours after eating and stop after the patient eats again, drinks milk. Late, nocturnal, hungry pains are most characteristic of the localization of the ulcer in the antrum and duodenum 12. Hunger pains are not observed in any other disease.

It should be remembered that late pain can also be with chronic pancreatitis, chronic enteritis, and nighttime pain with pancreatic cancer.

The nature of the pain. Half of the patients have pain of low intensity, dull, in about 30% of cases intense. Pain can be aching, boring, cutting, cramping. The pronounced intensity of the pain syndrome during exacerbation of peptic ulcer requires differential diagnosis with an acute abdomen.

Periodicity of pain. Peptic ulcer disease is characterized by periodic occurrence of pain. The exacerbation of peptic ulcer lasts from several days to 6-8 weeks, then the remission phase begins, during which the patients feel well, they do not worry about pain.

Relief of pain. Characterized by a decrease in pain after taking antacids, milk, after eating (“hungry” pains), often after vomiting.

Seasonality of pain. Exacerbations of peptic ulcer are more often observed in spring and autumn. This "seasonality" of pain is especially characteristic of duodenal ulcers.

The appearance of pain in peptic ulcer is due to:

irritation with hydrochloric acid of sympathetic nerve endings in the bottom of the ulcer;

motor disorders of the stomach and duodenum (pylorospasm and duodenospasm are accompanied by increased pressure in the stomach and increased contraction of its muscles);

vasospasm around the ulcer and the development of mucosal ischemia;

Decrease in the threshold of pain sensitivity in case of inflammation of the mucous membrane.

dyspeptic syndrome. Heartburn is one of the most common and characteristic symptoms of peptic ulcer. It is caused by gastroesophageal reflux and irritation of the esophageal mucosa by gastric contents rich in hydrochloric acid and pepsin.

Heartburn can occur at the same time after a meal as the pain. But in many patients it is not possible to note the connection of heartburn with food intake. Sometimes heartburn may be the only subjective manifestation of peptic ulcer disease.

Therefore, with persistent heartburn, it is advisable to do FEGDS to exclude peptic ulcer. However, we must remember that heartburn can be not only with peptic ulcer, but also with calculous cholecystitis, chronic pancreatitis, gastroduodenitis, isolated insufficiency of the cardiac sphincter, diaphragmatic hernia. Persistent heartburn can also occur with pyloric stenosis due to increased intragastric pressure and the manifestation of gastroesophageal reflux.

Belching is a fairly common symptom of peptic ulcer disease. The most characteristic eructation is sour, more often it occurs with mediogastric than with duodenal ulcer. The appearance of belching is due to both insufficiency of the cardia and antiperistaltic contractions of the stomach. It should be remembered that belching is also extremely characteristic of diaphragmatic hernia.

Vomiting and nausea. As a rule, these symptoms appear in the period of exacerbation of peptic ulcer. Vomiting is associated with increased vagal tone, increased gastric motility and gastric hypersecretion. Vomiting occurs at the “height” of pain (during the period of maximum pain), vomit contains acidic gastric contents. After vomiting, the patient feels better, the pain is significantly weakened and even disappear. Repeatedly repeated vomiting is characteristic of pyloric stenosis or severe pylorospasm. Patients often induce vomiting themselves to alleviate their condition.

Nausea is characteristic of mediogastric ulcers (but usually associated with concomitant gastritis), and is also often observed with postbulbar ulcers. At the same time, nausea, as E. S. Ryss and Yu. I. Fishzon-Ryss (1995) point out, is completely “uncharacteristic of a duodenal ulcer and rather even contradicts such a possibility.”

Appetite in peptic ulcer is usually good and may even be increased. With a pronounced pain syndrome, patients try to eat rarely and even refuse to eat because of the fear of pain after eating. Decreased appetite is much less common.

Violation of the motor function of the large intestine.

In half of patients with peptic ulcer, constipation is observed, especially during the period of exacerbation of the disease. Constipation is due to the following reasons:

* spastic contractions of the colon;

* diet, poor vegetable fiber and the absence, as a result, of intestinal stimulation;

* decrease in physical activity;

* taking antacids calcium carbonate, aluminum hydroxide.

Data from an objective clinical study. On examination, asthenic (more often) or normosthenic body type attracts attention. Hypersthenic type and overweight are not typical for patients with peptic ulcer.

Signs of autonomic dysfunction with a clear predominance of the vagus nerve tone are extremely characteristic: cold, wet palms, marbling of the skin, distal extremities; tendency to bradycardia; tendency to arterial hypotension. The tongue of patients with peptic ulcer is usually clean. With concomitant gastritis and severe constipation, the tongue may be lined.

Palpation and percussion of the abdomen with uncomplicated peptic ulcer reveals the following symptoms:

Moderate, and in the period of exacerbation, severe pain in the epigastrium, as a rule, localized. With a stomach ulcer, pain is localized in the epigastrium along the midline or on the left, with a duodenal ulcer - more on the right;

percussion tenderness - a symptom of Mendel. This symptom is detected by jerky percussion with a finger bent at a right angle along symmetrical parts of the epigastric region. According to the localization of the ulcer with such percussion, local, limited soreness appears. Sometimes the pain is more pronounced on inspiration. Mendel's symptom usually indicates that the ulcer is not limited to the mucous membrane, but is localized within the wall of the stomach or duodenum with the development of the periprocess;

local protective tension of the anterior abdominal wall, more characteristic of a duodenal ulcer during an exacerbation of the disease. The origin of this symptom is explained by irritation of the visceral peritoneum, which is transmitted to the abdominal wall by the mechanism of the viscero-motor reflex. As the exacerbation stops, the protective tension of the abdominal wall progressively decreases.

Diagnostics. To make a correct diagnosis, the following signs must be considered.

Main:

1) characteristic complaints and a typical ulcer history;

2) detection of an ulcer during gastroduodenoscopy;

3) identification of the "niche" symptom during X-ray examination.

Additional:

1) local symptoms (pain points, local muscle tension in the epigastrium);

2) changes in basal and stimulated secretion;

3) "indirect" symptoms during X-ray examination;

4) hidden bleeding from the digestive tract.

Treatment of peptic ulcer. The complex of rehabilitation measures includes medicines, motor regimen, exercise therapy and other physical methods of treatment, massage, therapeutic nutrition. Exercise therapy and massage improve or normalize neuro-trophic processes and metabolism, helping to restore the secretory, motor, absorption and excretory functions of the digestive canal.

Therapeutic nutrition is provided by the appointment of a diet that should contain the physiological norm of protein, fat, carbohydrates and vitamins. Provision is made for compliance with the principles of mechanical, thermal and chemical sparing (table No. 1A, diet No. 1 according to Pevzner).

Patients with newly diagnosed or rarely recurrent peptic ulcer should undergo seasonal (spring-autumn) prophylactic courses of treatment lasting 1-2 months.

Prevention. Distinguish between primary and secondary prevention of peptic ulcer disease. Primary prevention is aimed at active early detection and treatment of pre-ulcerative conditions (functional indigestion of hypersthenic type, antral gastritis, duodenitis, gastroduodenitis), identification and elimination of risk factors for the disease. This prevention includes sanitary-hygienic and sanitary-educational measures to organize and promote rational nutrition, especially among persons working on the night shift as transport drivers, adolescents and students, to combat smoking and alcohol consumption, to create favorable psychological relationships in the work team and at home, explaining the benefits of physical culture, hardening and organized recreation.

The task of secondary prevention is to prevent exacerbation and recurrence of the disease. The main form of prevention of exacerbation is clinical examination. It includes: registration of persons with peptic ulcer in the clinic, constant medical supervision of them, prolonged treatment after discharge from the hospital, as well as spring-autumn courses of anti-relapse therapy and, if necessary, year-round treatment and rehabilitation.

CHAPTER 2. COMPREHENSIVE PHYSICAL REHABILITATION OF PATIENTS WITH GASTRIC AND DUODENAL Peptic Ulcers at the Stationary Stage

2.1 General characteristics of the means of physical rehabilitation of patients with peptic ulcer of the stomach and duodenum

An integrated approach with the obligatory consideration of the individual characteristics of the course of the process is an unshakable principle for the treatment and rehabilitation of peptic ulcer. The most effective treatment for any disease is the one that most effectively eliminates the cause that causes it. In other words, we are talking about a targeted impact on those changes in the body that are responsible for the development of an ulcerative defect in the mucous membrane of the stomach and duodenum.

The peptic ulcer treatment program includes a complex of diverse activities, the ultimate goal of which is the normalization of gastric digestion and the correction of the activity of regulatory mechanisms responsible for the disorganization of the secretory and motor functions of the stomach. This approach to the treatment of the disease provides a radical elimination of the changes that have occurred in the body. The treatment of patients with peptic ulcer should be comprehensive and strictly individualized. During the period of exacerbation, treatment is carried out in a hospital.

Comprehensive treatment and rehabilitation patients with peptic ulcer of the stomach and duodenum include: drug treatment, diet therapy, physiotherapy and hydrotherapy, drinking mineral water, exercise therapy, therapeutic massage and other therapeutic agents. The antiulcer course also includes the elimination of factors contributing to the recurrence of the disease, provides for the optimization of working and living conditions, the categorical prohibition of smoking and alcohol consumption, and the prohibition of taking medications with an ulcerogenic effect.

Drug therapy has as its purpose:

1. Suppression of excess production of hydrochloric acid and pepsin or their neutralization and adsorption.

2. Restoration of the motor-evacuation function of the stomach and duodenum.

3. Protection of the mucous membrane of the stomach and duodenum and treatment of helicobacteriosis.

4. Stimulation of the processes of regeneration of cellular elements of the mucous membrane and relief of inflammatory-dystrophic changes in it.

The basis of drug treatment of exacerbations of peptic ulcer is the use of anticholinergics, ganglioblockers and antacids, with the help of which the effect on the main pathogenetic factors is achieved (decrease in pathological nervous impulses, inhibitory effect on the pituitary-adrenal system, decrease in gastric secretion, inhibition of the motor function of the stomach and duodenum, etc. .).

Alkalizing agents (antacids) are widely included in the medical complex and are divided into two large groups: soluble and insoluble. Soluble antacids include: sodium bicarbonate, as well as magnesia oxide and calcium carbonate (which react with hydrochloric acid of gastric juice and form soluble salts). Alkaline mineral waters (Borjomi, Jermuk springs, etc.) are widely used for the same purpose. Reception of antacids should be regular and repeated during the day. The frequency and timing of admission are determined by the nature of the violation of the secretory function of the stomach, the presence and time of occurrence of heartburn and pain. Most often, antacids are prescribed an hour before a meal and 45-60 minutes after a meal. The disadvantages of these antacids include the possibility of changing the acid-base state with prolonged use in large doses.

An important therapeutic measure is diet therapy. Therapeutic nutrition in patients with gastric ulcer must be strictly differentiated depending on the stage of the process, its clinical manifestations and associated complications. The basis of dietary nutrition in patients with peptic ulcer of the stomach and duodenum is the principle of sparing the stomach, that is, creating maximum rest for the ulcerated mucosa. It is advisable to use products that are weak stimulants of sap secretion, quickly leave the stomach and slightly irritate its mucous membrane.

Currently, special anti-ulcer rations for therapeutic nutrition have been developed. The diet must be followed for a long time and after discharge from the hospital. During the period of exacerbation, products that neutralize hydrochloric acid are prescribed. Therefore, at the beginning of treatment, a protein-fat diet, restriction of carbohydrates is needed.

Meals should be fractional and frequent (5-6 times a day); diet - complete, balanced, chemically and mechanically sparing. Diet food consists of three successive cycles lasting 10-12 days (diet No. 1a, 16, 1). With severe neuro-vegetative disorders, hypo- and hyperglycemic syndromes, the amount of carbohydrates in the diet is limited (up to 250-300 g), with trophic disorders, concomitant pancreatitis, the amount of protein increases to 150-160 g, with severe acidism, preference is given to products with antacid properties : milk, cream, soft-boiled eggs, etc.

Diet number 1a - the most sparing, rich in milk. Diet No. 1a includes: whole milk, cream, cottage cheese steam soufflé, egg dishes, butter. As well as fruits, berries, sweets, kissels and jelly from sweet berries and fruits, sugar, honey, sweet berry and fruit juices mixed with water and sugar. Sauces, spices and appetizers are excluded. Drinks - rosehip broth.

Being on a diet number 1a, the patient must comply with bed rest. She is kept for 10 - 12 days, then they switch to a more stressful diet No. 1b. On this diet, all dishes are cooked pureed, boiled in water or steamed. Food is liquid or mushy. It contains various fats, chemical and mechanical irritants of the gastric mucosa are significantly limited. Diet No. 1b is prescribed for 10-12 days, and the patient is transferred to diet No. 1, which contains proteins, fats and carbohydrates. Dishes that stimulate gastric secretion and chemically irritate the gastric mucosa are excluded. All dishes are prepared boiled, mashed and steamed. Diet No. 1 for a patient with a stomach ulcer should receive a long time. You can switch to a varied diet only with the permission of a doctor.

Application of mineral waters occupies a leading place in the complex therapy of diseases of the digestive system, including peptic ulcer.

Drinking treatment is practically indicated for all patients with peptic ulcer in remission or unstable remission, without a sharp pain syndrome, in the absence of a tendency to bleeding and in the absence of persistent narrowing of the pylorus.

Assign mineral waters of low and medium mineralization (but not higher than 10-12 g / l), containing no more than 2.5 g / l of carbon dioxide, bicarbonate sodium, bicarbonate-sulphate sodium water, as well as water with a predominance of these ingredients, but more complex cationic composition, pH from 6 to 7.5.

Drinking treatment should be started already from the first days of the patient's admission to the hospital, however, the amount of mineral water for admission during the first 2-3 days should not exceed 100 ml. In the future, with good tolerance, the dose can be increased to 200 ml 3 times a day. With increased or normal secretory and normal evacuation function of the stomach, water is taken in a warm form 1.5 hours before meals, with reduced secretion - 40 minutes -1 hour before meals, with a slowdown in evacuation from the stomach 1 hour 45 minutes - 2 hours before food.

In the presence of pronounced dyspeptic symptoms, mineral water, especially hydrocarbonate, can be used more often, for example 6-8 times a day: 3 times a day 1 hour 30 minutes before meals, then after meals (after about 45 minutes) at the height of dyspeptic symptoms and, Finally, before bed.

In some cases, when taking mineral water before meals, heartburn intensifies in patients, and pain appears. Such patients sometimes well tolerate the intake of mineral water 45 minutes after a meal.

Often, this method of drinking treatment has to be resorted to only in the first days of the patient's admission, in the future, many patients switch to taking mineral water before meals.

Persons with peptic ulcer in the stage of remission or unstable remission of the disease, in the presence of dyskinesia and concomitant inflammatory phenomena from the large intestine are shown: microclysters and cleansing enemas from mineral water, intestinal douches, siphon lavages of the intestines.

Rehabilitation after a stomach ulcer for a soldier. Physical rehabilitation for gastric ulcer

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