RU2532492C1 - Method for endoscopic treatment of gastroduodenal ulcers - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, particularly to gastroenterology, and concerns an endoscopic treatment of gastroduodenal ulcers. The method involves conducting therapeutic endoscopy in the first phase of an ulcerous process. An insufflator is used to apply diotevine 0.05-0.3 g first on an ulcer base, and then diovine 0.1-0.5 g to cover the whole ulcer.

EFFECT: method provides the more effective antiulcer therapy, reducing the length of treatment, including by the fast ulcer clearance from the necrotic tissue in a combination with the repair process stimulation.

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Description

The invention relates to medicine, surgery, in particular to gastroenterology, and for endoscopic treatment of gastroduodenal ulcers.

The ulcerative process is a complex set of diverse protective reactions that develop in the body in response to the appearance of peptic ulcers. It manifests itself in the form of destructive and regenerative processes in the area of an ulcer and general reactive changes on the part of the body. Gastroduodenal ulcers of any genesis and etiology are united in their biological laws of healing. This means that the principles of treatment should be the same for ulcers of any etiology, and therapeutic tactics should be determined by the phase and characteristics of the course of the ulcer process. A number of authors divide the morphological processes in a peptic ulcer into two phases: destructive or destructive-inflammatory and reparative or proliferative-regenerative. In the phase or stage of acute inflammation and destruction in the bottom and edges of the ulcer, a zone of ftbrinoid necrosis is found, a pathological microflora that supports the course of the inflammatory process in the ulcer. This phase requires the creation of sparing conditions that protect the mucous membrane from aggression factors (hydrochloric acid, pepsin). During this phase, it is necessary to act on the ulcer defect, cleansing it of necrotic tissues and pathological microflora. Activate reparative processes in the ulcer should only be in the second phase after cleansing the ulcer from necrotic tissue and fibrin.

For these purposes, mechanical cleansing of the ulcer crater is used, treating it with an endoscopic curette, a special brush, and biopsy forceps / cm .; Diveev R.Kh. Endoscopic application of peptic ulcer with Bioplant material in the complex of treatment of peptic ulcer of the stomach and duodenum: Atoref. Dis ... cand. honey. sciences. The disadvantage of this technique is the risk of subsequent bleeding or perforation of the ulcer.

Mechanical treatment or rehabilitation of chronic ulcers can be done by electrocoagulation, but it is impossible to control the depth of exposure, which can lead to the involvement of unchanged tissues in the process and even to perforation. In addition, scab rejection can cause bleeding / see: Agrba V.E. The latest approaches in the treatment of peptic ulcer by local effects on the ulcer process / B.E. Agrba, A.V. Stepanov // Peptic ulcer: modern ideas about the etiology, diagnosis and treatment: collection of scientific. tr - Moscow, 1990. - S.134-139 /.

A known method of local endoscopic treatment of peptic ulcers by irrigation or treatment of a peptic ulcer with liquid medicinal substances through a catheter (sea buckthorn oil, rosehip oil, aekol, etc.). Targeted use of drugs is more effective than oral, because they fall directly into the pathological focus. However, drugs in the area of peptic ulcer accumulate in minimal quantities and their effect is short-lived.

A known method of treating peptic ulcer by chipping peptic ulcers with various medications. The introduction of drugs is carried out during therapeutic endoscopy directly into the area of the ulcer and the surrounding mucous membrane from several points during one procedure. Thus, drugs that block nerve endings (novocaine, alcohol-novocaine mixtures), anti-inflammatory drugs (hydrocartisone, heparin) that improve regeneration (solcoseryl, dalargin, thymalin, derinat, etc.) are introduced. This method reduces the healing time of ulcers, but injections into the ulcer area for a long time worsen the "quality of life" of patients, aggravate pain, and contribute to the formation of erosion and acute ulcers due to possible infection of injection sites / see: I. Girfanov . Endoscopic use of sodium salt of DNA in the complex treatment of gastroduodenal ulcers: Abstract. dis ... can. honey. sciences. - Ufa, 2008 .-- 23 s /. As for the introduction of reparants, it should be noted that their use in the first phase of the ulcerative process does not make sense, because the presence of a pronounced inflammatory-infiltrative shaft prevents the penetration of drugs to the pathological focus, regardless of the route of administration. Therefore, it is necessary to activate the reparative processes in the ulcer only in the second phase of the ulcer process, after cleansing the ulcer defect from necrotic tissues and fibrin / see: N. Itigina Local treatment of stomach ulcers and duodenum using endoscopic techniques in a surgical clinic: Abstract. dis ... can. honey. sciences. - M., 1984. - 18 p. /.

There is also a local method of treating gastroduodenal ulcers with endoscopic applications of film-forming polymers (lifuzol, statisol, medical adhesives MK-6, MK-7, MK-8, etc.). The disadvantage of this method is that the adhesive compositions, polymerizing, form a rigid film, tearing away from the ulcer surface during the first hours after application. Therefore, to achieve a therapeutic effect, repeated therapeutic endoscopies with repeated applications after 1-2 days are required, and for complete healing of a ulcerative defect, 10-11 such applications are necessary. In addition, adhesive compositions cause the development of a rough scar in the area of the ulcer.

A known method of endoscopic treatment of gastroduodenal ulcers, comprising applying to the ulcer defect a gel containing anilocaine and miramistin. The course of treatment is up to 7 procedures that are performed every other day / see: Patent for invention No. 2295957 dated 03/27/2007 Bull. No. 9 /. However, conducting multiple endoscopies is an additional traumatic agent, violates peristalsis, enhances dyspeptic and pain syndromes. In addition, the implementation of this method requires a large number of medical procedures: until the ulcer defects are completely healed, the course of treatment is 10-14 applications, and the healing time for ulcer defects remains significant / cm. Sataev V.U. Endoscopic use of autofibronectin for duodenal ulcers in children: Abstract. dis. Ph.D., Bashkir state. honey. university. - Ufa, 1998, 28 pp. /.

There is a method of treating peptic ulcer by insufflation of a gel sorbent on an ulcer surface (see: Patent for the invention No. 1805918 from 03.30.93. Bull. No. 12). When applied to ulcer defects, gel sorbents form a protective gel layer on them, resistant to the action of the gastric and duodenal contents, create conditions for the active course of reparative processes / cm. Cherednikov E.F. Comprehensive treatment of gastroduodenal ulcers with the use of gel sorbents: Dis ... doctor of medical sciences. - Voronezh, 1998 .-- 210 p. /.

The specified method for the treatment of gastroduodenal ulcers is the closest to the proposed, therefore, can be considered as a prototype.

The disadvantages of the prototype may include the following.

1. The sorbents used - Sephadex and Gelevin - do not have necrolytic, antimicrobial, and other effects, since they are not endowed with such additional properties.

2. Gel sorbents do not give a directed, multicomponent effect on the ulcer defect.

3. The described method of treatment is provided by using one sorbent throughout the course.

4. The known method of local treatment with one gelatin does not take into account the phases of the course of the ulcer process, and as a result of this, it does not quickly enough reduce the healing time of peptic ulcers, the time spent in the hospital and the duration of treatment.

Biologically active drainage sorbents are known, which are granular polymer preparations endowed with antimicrobial, analgesic, proteolytic action, possessing high sorption ability, swelling upon contact with aqueous solutions with the formation of soft gels. They are obtained by polymerization of polyvinyl alcohol molecules with the addition of an anesthetic anilokain, antioxidant dioxidine, proteolytic enzymes terriletin or collagenase from hydrobionts. These include diovin with an antimicrobial effect (with an antiseptic dioxidine), anilovin with a local anesthetic effect (with an anesthetic anilokain), diotevin with an antimicrobial and proteolytic effect (with an antiseptic dioxidin and a proteolytic enzyme terriletin), collasorb with a proteolytic enzyme (with a proteolytic hydrolytic enzyme (collagen proteolytic ) and others. These biologically active draining sorbents are widely used in the form of dressings for local treatment of purulent wounds / see: Adamyan A.A. and other Biologically active dressings in the complex treatment of purulent necrotic wounds. - Moscow, 2000.-39 p. /.

However, a combination of these biologically active draining sorbents was not used in the complex treatment of gastroduodenal ulcers.

The technical result is the development of a method for the local treatment of gastroduodenal ulcers, which allows to increase the effectiveness of antiulcer therapy and reduce treatment time.

The technical result is achieved by the fact that during the therapeutic endoscopy with an insufflator in the first phase of the ulcer process, first apply dotevin in the amount of 0.05-0.3 g to the bottom of the ulcer defect, and then diovin in the amount of 0.1- to the entire ulcer 0.5 g to cover the entire ulcer surface. The ratio of the size of the ulcerative defect with the number of insufflated sorbents is presented in the table (see table 1).

Table 1

The ratio of the size of the ulcer defect with the number of insufflated sorbents in the local treatment of gastroduodenal ulcers

The largest size of the ulcer defect (cm) Up to 0.5 0.5 - 1.0 1.1 - 1.5 1.6- 2.0 2.1 and more Diotevin, (amount of sorbent in g) 0.05 0.1 0.15 0.2 0.3 Diovin, (amount of sorbent in g) 0.1 0.2 0.3 0.4 0.5

The developed method was used by us in 23 patients (the main group) with gastroduodenal ulcers treated in the general surgical and general therapeutic departments of the Municipal Health Institution of the city of Voronezh GKBSMP No. 1.

The main criteria in assessing the results of treatment were clinical: assessment of the size of ulcerative defects during endoscopic observation with an interval of 2-3 days, the timing of the appearance of granulations, the timing of the onset of epithelization and healing of ulcers, the presence of relapses of peptic ulcers within a year.

Clinical observations showed that in the main group of patients (23 people) compared with the comparison group (19 people) who underwent endoscopic treatment of peptic ulcers with gelatin, clinical and endoscopic disease remission occurred much earlier. By the 3rd day of treatment with biologically active draining sorbents, ulcerative defects were cleared of fibrinous-necrotic masses, young granulation tissue appeared at the bottom, and marginal epithelization was noted. The healing period of ulcers in the main group of patients was 10.0 ± 0.20 days.

In the comparison group, the duration of ulcer defect cleansing was 5.3 ± 0.22 days, and the healing time of ulcers was 13.2 ± 0.48 days.

When monitoring patients for up to one year, relapse of ulcers in the main group of patients receiving endoscopic treatment with biologically active granular sorbents was not observed, while in the comparison group with endoscopic treatment with gelatin, relapses of peptic ulcers were noted in 3 of 19 patients (15 ,8%). The results of treatment are presented in table No. 2.

Table number 2

Comparative indicators of the effectiveness of treatment of patients with gastroduodenal ulcers

Indicator (day) The proposed method (n = 23) The known method (n = 19) Ulcer cleansing 3.1 ± 0.09 5.3 ± 0.22 The appearance of granulations 3.0 ± 0.09 4.9 ± 0.26 The abatement of inflammation 3.6 ± 0.09 7.4 ± 0.28 The appearance of epithelization 3.1 ± 0.09 5.5 ± 0.35 Ulcer healing 10.0 ± 0.20 13.2 ± 0.48

Thus, we have developed a method that includes the use of biologically active draining sorbents in a new direction - local treatment of gastroduodenal ulcers. The combined use of diotevin and diovin is carried out in the treatment of the first phase of the ulcer process, and the important components of the method are: the method of applying draining sorbents and calculating the dose of drugs taking into account the size of the ulcer defect. The use of diotevin for topical treatment of peptic ulcers leads to the rapid cleansing of ulcerative defects from necrotic tissues and fibrin, and the use of diovin stimulates reparative processes in the ulcer. This method provides a multicomponent effect of these drugs: the combination of two draining sorbents accelerates the regeneration processes in peptic gastroduodenal ulcers due to the rapid change in the phases of the ulcer process - reducing the time and severity of the destructive-inflammatory phase and activating the proliferative-regenerative phase of the ulcer process, eliminates the progression factors of the destructive ulcerative process.

The developed technique allows you to get a new effect unknown from the prior art: the absence of disease recurrence within a year after treatment.

An example of the implementation of the proposed method of treatment in a surgical hospital clinic of the faculty surgery of the Voronezh State Academy. N.N. Burdenko.

Patient T., 52 years old (medical history No. 64566), was admitted to the surgical department of the Municipal Health Institution of the city of Voronezh; Held bleeding.

There is no ulcerative history. The patient suffers from coronary heart disease, stable angina pectoris, FC3, about which he is forced to take disaggregants (analogues of aspirin). On the eve I felt weakness, dizziness, a black decorated chair, about which I was sent for inpatient treatment in the general surgical department.

Esophagogastroduodenoscopy No. 1960 dated 12/13/10. The esophagus is not changed, its socket is closed. The stomach is medium in size, contains a moderate amount of mucus and fluid with hematin flakes. The mucous membrane is moderately thickened, its folds are uneven, longitudinal. In the cardiac section, along the posterior wall of large curvature, there is an ulcer of 1.5 cm by 0.5 cm, shallow, with hematin. Conclusion: ulcer of the cardiac section of the stomach. Held bleeding.

12/14/10. The patient's condition is satisfactory. Complaints of general weakness. There was no nausea, vomiting, or stool. Slept well. The temperature is normal. The tongue is wet. The abdomen is soft, painless. A blood test from 12/14/10: hemoglobin - 10 ⁶ g / l, red blood cells - 3.1 × 10 ¹² / l, white blood cells - 6.4 × 10 ⁹ / l. Esophagogastroduodenoscopy No. 4347 dated 12/14/10: An ulcer of the cardiac section of the stomach of the previous sizes, in the bottom - fibrinous-necrotic masses. Biopsy. Produced pneumo-insufflation on a ulcerative defect of diotevin in the amount of 0.15 g and diovin in the amount of 0.3 g according to the developed method.

12/15/10. The patient's condition is satisfactory. No special complaints. Body temperature 36.4º. Pulse 76 beats per minute. Blood pressure 120/70 mm Hg. The tongue is clean, moist. The abdomen is soft, painless. The stool was after an enema.

12/19/10. The condition is satisfactory. No complaints. The sleep is good. The chair is decorated, the usual color. Hemodynamics is stable. The abdomen is soft, painless. An esophagogastroduodenoscopy No. 4686 was performed: the ulcer of the cardiac section of the stomach decreased in size, 1.2 cm by 0.5 cm, its bottom was almost cleansed of fibrinous necrotic plaque, young granulation tissue appeared, marginal epithelization, and the inflammatory phenomena around it decreased significantly. The ulcer produced insufflation of diotevin in an amount of 0.1 g and diovin in an amount of 0.3 g according to the proposed method.

12/22/10. The patient's condition is satisfactory. No complaints. Body temperature 36.4º. The sleep is good. The chair is regular, regular color, urination is not impaired. Pulse 76 beats per minute. The tongue is wet, clean. The abdomen is soft, painless. The control esophagogastroduodenoscopy No. 4758 was performed: The ulcer of the cardiac section of the stomach almost completely healed in the form of a linear scar.

12/22/10. The patient in satisfactory condition was discharged for outpatient treatment.

12/12/12. Control esophagogastroduodenoscopy: No recurrence of an ulcer was found.

Claims (1)

 A method for endoscopic treatment of gastroduodenal ulcers, comprising the combined application of biologically active drainage sorbents on the ulcer surface, characterized in that, in order to increase the efficiency and reduce the treatment time, during the treatment endoscopy with an insufflator in the first phase of the ulcer process, the ulcer defect is first applied to the bottom diotevin in an amount of 0.05-0.3 g, and then diovin in an amount of 0.1-0.5 g to cover the entire ulcer surface.