OVERVIEW
Complex gastroduodenal ulcers are coexisting inflammatory and necrotizing lesions of the mucosa of the stomach and duodenum deep to or penetrating the muscular layer of the mucosa. This type of ulcer accounts for about 5% of patients with peptic ulcer disease. The majority of patients first suffer from duodenal ulcer, which leads to functional pyloric obstruction, causing delayed emptying, gastric dilatation and stimulation of gastrin secretion, so that increased secretion of gastric acid; and pyloric dysfunction caused by the duodenal fluid flow back into the stomach, repeated stimulation of the stomach and the formation of gastric ulcers. Gastric foci are mostly seen in the lesser curvature of the stomach, and duodenal foci are mostly seen in the bulb. The principle of treatment is to reduce the acidity in the stomach, eradicate Helicobacter pylori and protect the gastric mucosa.
Etiology
The main causes include Helicobacter pylori infection, hypersecretion of gastric acid, stress (trauma, alcohol, smoking, psychosomatic), pharmacogenetic damage, and genetic factors.
Symptoms
Patients tend to have duodenal ulcers first, followed by gastric ulcers. First, gastritis is mild and gastric acid secretion increases to form duodenal ulcer. Subsequently, gastritis worsens and gastric ulcers appear. Therefore, the clinical manifestations of patients are not specific and often resemble duodenal ulcer. The main manifestation is a more obvious rhythmic periodic epigastric pain. Abdominal pain often occurs at night between 11 p.m. and 2 a.m., i.e., when gastric acid secretion is increased and fasting, and is relieved after eating, so it is preferred to eat several times. Abdominal pain can occur throughout the year, more common in early spring and late fall, with natural onset and relief of the cycle.
Examination
1. Endoscopy
Endoscopy is the first choice for diagnosis, which can be applied to the following aspects: ① Observe the size, number, shape and clinical staging of ulcers under direct vision. ② Identify benign and malignant. ③Evaluate the effect of treatment. ④ Give hemostatic treatment to those with combined bleeding. ⑤ Also test for Helicobacter pylori.
2. X-ray barium meal imaging
X-ray barium meal is suitable for: ① Understanding gastric motility. ② Those who have contraindications to endoscopy. ③When you do not want to accept endoscopy and when there is no endoscopy. Gas-barium double contrast can show the morphology of gastrointestinal mucosa better, but it is not as effective as endoscopy. The direct X-ray sign of ulcer is niche shadow, and the indirect sign is localized pressure pain, spasmodic notching on the side of the greater curvature of the stomach, duodenal bulb agitation and bulb deformity.
3. Helicobacter pylori test
Non-invasive 13C- or 14C-urea breath test (Hp-UBT) can be chosen, which is a common method for clinical H. pylori detection. Invasive methods such as rapid urease test, staining microscopy of gastric mucosal tissue sections and bacterial culture are also available. Among them, gastric mucosal tissue section staining microscopy is also one of the “gold standards” for H. pylori detection.
4. Fecal occult blood
To know whether the ulcer is combined with bleeding.
Diagnosis
Chronic course, periodic episodes of rhythmic epigastric pain is the important history, endoscopy can confirm the diagnosis, can not accept endoscopy, X-ray barium meal found in the stomach and duodenum at the same time the existence of niche shadow can be diagnosed.
Differential diagnosis
1. Other diseases causing chronic epigastric pain
Although the disease can be detected by endoscopy, some patients still have unrelieved symptoms after the healing of peptic ulcer, so it should be noted whether there are chronic hepatobiliary and pancreatic diseases, chronic gastritis, functional dyspepsia, etc. coexisting with ulcer.
2. Gastric cancer
When gastric ulcers are found, attention should be paid to differentiate them from cancerous ulcers. Typical gastric cancer ulcers are irregular in shape, often >2cm, with nodular edge, uneven bottom and covered with dirty moss. Biopsy of the ulcer margin can be taken to differentiate it. For middle-aged and old-aged patients with gastric ulcers, when the ulcers do not heal, should be multi-point biopsy, and in the regular treatment of 6-8 weeks after the review of gastroscopy, until the ulcers are completely healed. It is generally believed that the duodenal bulb ulcer in the compound ulcer is benign, and there is a view that the gastric ulcer in the compound ulcer is also basically benign, and even completely exclude the possibility of malignancy.
3. Hypergastrinemia
Hypergastrinemia should be considered when the ulcers are multiple or located in atypical sites, the regular anti-ulcer drugs are ineffective, and gastric cancer has been excluded from the pathology. The syndrome is caused by gastrinomas or hyperplasia of gastrinotropic cells. Tumors can be detected by testing blood chromogranin A and gastrin levels and enhanced CT. It can be treated with long-acting growth inhibitor analogs, which are effective in relieving symptoms, allowing ulcers to heal, and inhibiting tumor growth.
Complications
1. Bleeding
Peptic ulcer is the most common cause of gastrointestinal bleeding. When peptic ulcer erodes the surrounding or deep blood vessels, it can produce different degrees of bleeding. Duodenal ulcer is more prone to bleeding than gastric ulcer. In mild cases, it is manifested as black stools, and in severe cases, it is manifested as vomiting blood.
2. Perforation
The ulcer develops deeply and penetrates into the wall of stomach and duodenum to form perforation, which can be divided into different parts according to the perforation:
(1) perforation into the abdominal cavity causing diffuse peritonitis: sudden severe abdominal pain, persistent and aggravated, first in the epigastrium, then extending to the whole abdomen. Signs include slab abdomen, abdominal pressure, rebound pain, hepatic turbid tone boundary disappears, and some patients have shock.
(2) The ulceration is obstructed in the adjacent substantial organs (such as liver, pancreas, spleen): the pattern of abdominal pain is changed, and it is stubborn and persistent. If penetration into the pancreas, abdominal pain may radiate to the back, and blood amylase is elevated.
(3) ulceration into the cavity to form a fistula: duodenal bulb ulcers can penetrate the common bile duct, gastric ulcers can penetrate into the duodenum or transverse colon, which can be determined by barium meal or CT examination.
3. Pyloric obstruction
Mostly caused by duodenal ulcer and pyloric ulcer. Inflammatory edema and pyloric smooth muscle spasm caused by temporary obstruction can be due to drug therapy, ulcer healing and disappear; scar contraction or adhesion with the surrounding tissues resulting in obstruction requires surgical treatment. Common symptoms include: obvious epigastric distension and pain, aggravated after meals, slightly relieved after vomiting, and the vomit is hangover; severe vomiting can lead to water loss, hypochloremic and hypokalemic alkalosis; weight loss and malnutrition. Physical examination reveals gastric peristaltic waves and water shaking sounds.
Treatment
1. Reduce the acidity in the stomach
(1) Proton pump inhibitor (PPI): it can inhibit the H+/K+-ATPase of the wall cells in the gastric mucosa, reduce the exchange of H+ and K+ ions, lower the acidity in the lumen of the stomach to pH＞6, and promote the healing of ulcer. Omeprazole, lansoprazole, pantoprazole, rabeprazole and esomeprazole are commonly used. Usually four weeks to achieve ulcer healing, elimination of abdominal pain symptoms only 1 ~ 3 days.
(2) H2 receptor blockers: histamine can stimulate gastric acid secretion, the drugs inhibit gastric acid secretion. Commonly used drugs include cimetidine, famotidine, ranitidine and nizatidine, which have similar speed of ulcer healing, symptom relief and safety. A single dose administered at night can effectively inhibit nocturnal gastric acid secretion and has little effect on daytime gastric acid secretion, does not impede the digestion and absorption of physiologically important substances such as proteins, iron and calcium, and is conducive to maintaining a normal micro-ecological environment in the gastric lumen. Its efficacy is not as good as PPI, but the cost is relatively inexpensive.
(1) Anticholinergic drugs: such as belladonna and atropine, etc., have the effect of reducing the secretion of gastric acid and pepsin and alleviating the pain; however, since this kind of drugs slows down the peristaltic movement of the gastric wall and the emptying of the stomach, and can increase the retention time of food in the gastric sinus to stimulate the release of gastrin, which is not conducive to the healing of the ulcer, and there are a variety of systemic side effects, and it is not suitable to be used for the treatment of ulcers alone.
2.Eradication of Helicobacter pylori
PPI with antibacterial drugs is used to eradicate H. pylori. The treatment program generally contains a PPI, two antibacterial drugs and/or a bismuth agent, which is called triple or quadruple therapy.
3. Gastric mucosal protection
Gastric mucosal protective agents include misoprostol, glutamine, magnesium aluminum carbonate, gefalcon, teprenone, rebarbital, aluminum thioglycollate, bismuth, and methysergide-S. The above drugs cannot promote ulcer independently.
The above drugs can not independently promote ulcer healing, but only play an auxiliary role.
4. Surgical treatment
Only for those with gastrointestinal hemorrhage, perforation, pyloric obstruction and high suspicion of cancer.
Prognosis
The prognosis is good with timely treatment and timely management of complications, and there is no increased risk of gastric cancer in this disease.