Method of stomach ulcer treatment

FIELD: medicine.

SUBSTANCE: invention refers to medicine, gastroenterology and concerns methods of stomach ulcer treatment. For this purpose, patient with suffering from mediagastral localisation of ulcer defect which is not cicatrising within six weeks, or from piloroduodenal ulcers which are not cicatrising within four weeks, in addition to traditional pharmacotherapy is prescribed with fluconasol. Single dose of fluconasol is 150 mg. Preparation is introduced once a week, within three weeks. Method provides effective utilisation of antithymicotic agents within stomach ulcer therapy based on first formulated specific indications for introduction, without preliminary examination of stated categories of patients.

EFFECT: development of effective method of stomach ulcer treatment due to antithymicotic agents.

7 tbl, 3 ex

 

The invention relates to the field of medicine, gastroenterology and concerns the methods of conservative treatment of patients with peptic ulcer disease.

Known conservative methods of treatment of peptic ulcer[1, 6, 8, 9]. In the treatment of HP-associated peptic ulcer disease of the Central place is given eradication therapy[1, 6, 8, 9]. Conducting eradication therapy regulated Maastricht (European) consensus 2000, according to which, if the detection of HP infection, the patient should be assigned to first-line therapy, involving the assignment of proton pump inhibitor or ranitidine bismuth citrate in "standard" (average therapeutic) dose 2 times a day, clarithromycin 500 mg 2 times a day amoxicillin 1000 mg 2 times a day. The minimum duration of therapy is 7 days. No earlier than 4 weeks after completion of eradication therapy of not less than two tests on HP (histology and rapid urease) and in case of positive result of at least one of them according to the Maastricht consensus should be treated "second line", including the appointment of one of the proton pump inhibitors in the standard dose 2 times a day bismuth subcitrate 120 mg 4 times a day metronidazole 500 mg 3 times a day, tetracycline hydrochloride 0.5 g 4 times a day 7 days [1, 6]. Standards (protocols) diagnosis and treatment of ill the x diseases of the digestive system, approved by the RF Ministry of health in 2002 [5], the following scheme of eradication therapy.

Seven days:

1) Omeprazole or rabeprazole (pariet) 20 mg 2 times a day or lansoprazole 30 mg 2 times a day; clarithromycin 250-500 mg 2 times a day after meals; metronidazole or tinidazole 500 mg 2 times a day.

2) Pyloric (ranitid bismuth citrate) 400 mg 2 times daily with meals; clarithromycin 250-500 mg or tetracycline 1000 mg or amoxicillin 1000 mg 2 times a day; metronidazole 500 mg 2 times a day with food.

3) Colloidal bismuth subcitrate (de-Nol and other analogues 240 mg 2 times a day); metronidazol 500 mg 2 times a day or tinidazole 500 mg 2 times a day after meals; tetracycline or amoxicillin 1000 mg 2 times a day after food or clarithromycin 250 mg 2 times a day.

4) Colloidal bismuth subcitrate (de-Nol and other analogues) 120 mg 3 times a day 30 minutes before meals and 4th time 2 hours after eating before going to sleep 120 mg 4 times a day; clarithromycin 250-500 mg 2 times a day after meals; omeprazole 40 mg 2 times a day.

5) proton pump Inhibitor 2 times daily "standard" (the average therapeutic dose); colloidal substrate bismuth (de-Nol and other analogues) 120 mg 3 times a day 30 minutes before meals and 4th time 2 hours after eating before going to sleep, metronidazole or tinidazole 500 mg 2 times a day.

Ten-day scheme:

Ranitidine 300 mg 2 times a day or famotidine 40 mg 2 times a day morning and evening (no later than 20 hours). Potassium salt of disubstituted citrate of bismuth 108 mg 5 times a day after meals or de-Nol 120 mg 4 times a day; metronidazole 200 mg 5 times a day, or 250 mg 4 times a day after meals; tetracycline hydrochloride 250 mg 5 times a day or 500 mg 4 times a day.

Note: all schemes metronidazole can be replaced furazolidone 0.1 g 4 times a day, or 0.2 g, 2 times a day.

According to the above "standards (protocols) for the diagnosis and treatment of patients with diseases of the digestive system", approved by RF Ministry of health in 2002 [5] after completion of the combined 7-10-day eradication therapy treatment of relapse of peptic ulcers of the stomach should continue for 7 weeks a proton pump inhibitor used for eradication therapy prescribed once daily at the same dose in 14-16 hours, or in one of the following drugs ranitidine 300 mg or famotidine 40 mg once a day 19-20 hours or colloidal bismuth subcitrate 240 mg 2 times a day. After eradication therapy in patients with peptic duodenal ulcers named therapy for 5 weeks. In the treatment of patients not complicated peptic ulcer disease after eradication therapy long-term purpose of the above drugs is not necessary.

For the treatment of Helicobacter pylori is not associated gastroduodenal ulcers using the t combination of antisecretory drugs and protectors. According to the currently applicable in the Russian Federation standards (protocols) for the diagnosis and treatment of patients with diseases of the digestive system should be used ranitidine 300 mg/day or famotidine 40 mg prescribed 1 per day 19-20 hours Or omeprazole once a day in the 1400-1500hours, or other proton pump inhibitors assigned once. Prescribe sucralfate (Venter) 1000 mg 3 times a day 1 hour before meals and 1000 mg at night or sucralfate gel to 2000 mg per day for 4 weeks, then another 4 weeks in half dose [5].

A necessary component of conservative treatment of peptic ulcer disease is diet therapy. In the acute stage of the disease is traditionally assigned to a fractional power, and it is recommended to eat food with pronounced antacid properties. Mentioned requirements developed by the Institute of nutrition of the Academy of medical Sciences of the USSR diet №1 and its variants [1, 6].

The above-described conservative therapy has the following major drawbacks:

1) a significant portion of patients reported recurrence of the disease, the frequency of which in the first year after the relief of acute illness according to different authors ranges from 5% to 35% [1, 6, 8, 9].

2) On the background of conservative therapy may develop complications of the disease[1, 6, 7, 8, 9].

3) In 14.6-65.2% of the pain is s, received eradication therapy, the side effects and complications[1, 6, 8, 9], because of which a significant proportion of patients stop treatment without completing a course of antibiotic therapy.

4) widespread use of antibiotic therapy for the treatment of peptic ulcer disease has led to the rapid spread of HP strains resistant to antibiotics, which has led to reduced effectiveness of eradication therapy[1, 6, 8, 9].

5) On the background of the modern distribution of eradication therapy changes the ratio of HP-associated and NR-non-associated peptic ulcer disease: increased frequency of HP-negative peptic gastroduodenal ulcers and decreases the prevalence of HP-positive peptic ulcer disease. The last two factors significantly affect the prospects for further application of eradication therapy[1, 6, 8, 9].

6) the Purchase of medicines for any of the above options for the treatment of peptic ulcer disease in Russia most patients causes significant financial difficulties.

7) the Necessity of taking multiple medications for a long period of time adversely affect the mental state significant portion of patients.

Three of the latter significantly reduce compliance is Aulnay peptic ulcer disease, that adversely affects the results of the treatment of the disease. The mentioned disadvantages of conservative therapy of peptic ulcer became one of the reasons that up to the present time in Russia practiced surgical treatment is not complicated peptic gastroduodenal ulcers.

Closest to the present invention is a method of treatment of peptic ulcer, described N.M. Smirnov and M. Nekrasov (1977) [1, 6], which consists in assigning phenoxymethylpenicillin 500 mg 3 times a day 1 hour before meals for 7 days with exacerbations of ulcerative disease of the stomach, intractable for 6 weeks and in the recurrence of peptic ulcer of the duodenum, lasting more than 4 weeks, concurrently with conventional therapy, as well as in the appointment of the named drug 500 mg 2 times a day for 10 days to prevent recurrence of the disease in conjunction with other events seasonal cycle of therapy, common during the development of the described method (antacids, biogenic stimulators). From the point of view of modern concepts, the present method of treatment of peptic ulcer disease is not theoretically justified: dentists - antibiotic other useful effects of the drug is unknown, the data about the participation of sensitive microorganisms in ulcerogenesis so far not received the O. Practical experience in the application of the described method is not confirmed driven by its authors information on the positive effects and treatment by dentists on the dynamics of clinical symptoms and endoscopic relapse of peptic ulcer and reduce the frequency of relapses after prophylactic application of this drug.

A new technical result is an increase treatment effectiveness by reducing the number of complications, reduce the duration of acute illness, reduce the frequency of recurrence, increasing the percentage of patients who are able to accomplish the eradication of HP infection and improve the tolerability of recurrent ulcer formation in the gastroduodenal area by reducing the frequency of adverse effects of anti-ulcer therapy.

To solve the problem in the treatment of patients with peptic ulcer, by conducting traditional anti-ulcer pharmacotherapy, including the introduction of antibiotics, antacids, biogenic stimulators, additionally at the same time introducing fluconazole per os 150 mg 1 time per week for three weeks.

The method is as follows.

On the background of the conventional in each case pharmacotherapy of acute gastric ulcer with mediagallery localization of ulcers, gladie is I more than 6 weeks, the recurrence of peptic piloroduodenalnoy ulcers lasting more than 4 weeks, failure of eradication therapy first-line disease in patients with peptic ulcer of stomach and duodenum, before the second course of eradication therapy while receiving antibiotic, antacid funds, prescribe fluconazole usage per os 150 mg 1 time per week for three weeks.

Information on the drug fluconazole

Chemical composition (α-(2,4-differenl)-α-(1H-1,2,4-triazole-1-ylmethyl)-1H-1,2,4-triazole-1-ethanol).

Brutto-formula C13H12F2N6About

The characteristic. Antifungal drug from the group of triazole derivatives. Crystalline powder white or almost odorless, with a characteristic taste, it is soluble in water and isopropyl alcohol, sparingly soluble in ethanol.

Pharmacology. Pharmacological action antifungal. Blocks the number of cytochromes P-450-dependent enzymes and vasoconstrictive inhibits the synthesis of sterols in cell membranes of fungi. Effective for infections caused by Candida spp. Trichophyton spp., and infections caused by pathogens Blastomyces dermatitidis, Coccidiodes emmitis, fungi of the genus Microsporum spp., Criptococcus neoformans.

Use (indication). Cryptococcosis, cryptococcal meningitis, infections of the skin and lungs, prevention recid the great Patriotic war of cryptococcosis in patients with AIDS, generalized candidiasis, candidemia, disseminated candidiasis and other forms of invasive candidal infections (lesion of peritoneum, endocardium, eyes, respiratory and urinary tract), candidiasis of the mucous membranes of the oral cavity and pharynx, esophagus, bronchopulmonary candidiasis, candiduria, candidiasis of skin and mucous membranes, atrophic candidiasis of the oral cavity (associated with wearing dentures), prevention of relapse of oropharyngeal candidiasis in patients with AIDS, genital candidiasis, vaginal (acute or recurrent), including relapse prevention, candidal balanitis, prevention and treatment of fungal infections in malignant tumors (treatment with drugs or radiation therapy), antibiotic therapy, treatment with immunosuppressive drugs after transplantation, fungal infections of the skin (feet, body, groin), tinea versicolor, onychomycosis, candidiasis of the skin, deep endemic mycosis (coccidiomycosis, paracoccidioides, sporotrichosis, histoplasmosis) in patients with compromised immune systems.

Contraindications: hypersensitivity, coadministration of terfenadine with multiple doses of fluconazole 400 mg and above.

Way of application and dose. Inside, a/C.

Inside adults: with cryptococcosis and generalized candidiasis in/in, inside 400 mg on day 1, then 200 to 400 mg/day., when oropa angelina candidiasis - inside 50-100 mg/day for 7-14 days, with vaginal candidiasis - inside 150 mg in chronic form 1 once a month 150 mg for 4-12 months when mycosis - 150 mg 1 time a week.

Fluconazole is an international non-proprietary name of the active substance, who registered.

Commercial names of drugs: diflucan, ziskin, Mycosyst, nothung, flukostat.

Currently, the data obtained on the frequent presence on the mucous membrane of the gastroduodenal zone fungi [1, 2, 7]. Grounded views on the involvement of fungi of the genus Candida in ulcerogenesis [1, 3, 6], making justified to study the efficacy of antifungal antibiotics for the treatment of peptic ulcer.

The proposed treatment regimen, the dosage of the drug and the mode of its application are selected on the basis of clinical observations 794 ulcer patients aged 20-69 years, observed in hospitals, Kemerovo (medical and neurological Department of medical enterprise COOT "Nitrogen", in the gastroenterology Department of the City clinical hospital No. 2 and the City hospital No. 11, Kemerovo, clinics and medical companies, COOT "Nitrogen") and seeking advice from the Department of propaedeutics of internal diseases, Kemerovo state medical the th Academy in 1997-2004, (see table 1).

The diagnosis of peptic ulcer disease and its exacerbations in all patients selected on the basis of common criteria[1, 5, 8, 9]. In all cases of relapse of peptic ulcers of the stomach performed a biopsy of the mucosa periplanar areas and all sections of the stomach.

Fluconazole 150 mg 1 time per week was administered for 3 weeks. Patients treated with fluconazole, divided into 6 groups (table 1). Patients 1 and 2 groups fluconazole administered on the first day of treatment of relapse of peptic gastroduodenal ulcers after endoscopic examination, 2-3 days after relapse of clinical symptoms of peptic ulcer). The patients within 6 weeks not healed mediagallery ulcers, amounted to 3 group. Fluconazole was administered to the patients of the group since the beginning of the 7 weeks of relapse. Patients with endoscopic remission piloroduodenalnoy ulcers developed within 4 weeks, combined into 4 group. Therapy with fluconazole in patients of this group were held since the beginning of the 5th week of relapse. 5 group consisted of patients with HP-positive peptic ulcer disease, which at the same time with eradikatsionnoy first line therapy (omez 20 mg 2 times a day, clarithromycin 1000 mg 2 times a day for 7 days) was prescribed diflucan. In the group of patients treated with fluconazole after the inefficiency of the first year of the era of icaciones therapy proved urease tests and (or) histological research. 1 and 3, 2 and 4, 5 and 6 group matched by sex and age of patients, duration of ulcer disease and the frequency of recurrence, therapy of peptic ulcers, the prevalence and intensity of Smoking patients, the frequency of use of nonsteroidal anti-inflammatory drugs. 1 and 3, 2 and 4 groups are also comparable in terms of frequency and intensity of contamination of the mucous membrane of the gastroduodenal zone No. Eradication therapy first-line (omeprazole 20 mg 2 times a day, clarithromycin 500 mg 2 times a day amoxicillin 1000 mg 2 times a day for 7 days) 75,93% of patients 5 groups and 74,51% of patients in the United 6 the group started 2-3 days after relapse of clinical symptoms of peptic gastroduodenal ulcers, immediately after the aggravation of peptic ulcer disease was confirmed by fibrogastroscopy, and the presence of HP infection is established by holding the Sahara-test or urea breath test. The rest of the patients to these groups, the combination of omeprazole, amoxicillin and clarithromycin assigned with the positive results of the Sahara-test and (or) urease test during remission of peptic ulcer. The results of treatment with fluconazole was compared with the data obtained by the observation of comparable groups of patients with peptic ulcer disease for which treatment fluconazole has not been used (table 1). The efficiency e is educational therapy was evaluated by carrying out 2 tests of HP infection (Sahara-test and urease) 4-5 weeks after completion of eradication therapy. At the time of relapse of peptic ulcer disease all patients underwent conventional therapy [1, 5].

When comparing the percentage of patients within 6 weeks marked remission of peptic mediagallery of ulcers after treatment with fluconazole from the first day of therapy and relapse in patients who received only conventional therapy, statistically significant differences (table 2). Differences in the frequency of recurrence of peptic ulcers in these groups of patients also were not statistically significant (table 2). When comparing the percentage of patients within 4 weeks achieved remission chronic piloroduodenalnoy of ulcers after treatment with fluconazole in the appointment of the drug from the first day of therapy relapse and in patients who received only conventional treatment, frequency of recurrence in these groups of patients, a statistically significant difference was not established as well (table 3). During fluconazole treatment of peptic mediagallery ulcers, cicatrizing for 6 weeks, by the end of 9 weeks of acute (3 weeks after initiation of therapy with fluconazole) remission was achieved in 88% of patients in a comparable group of patients who received only conventional therapy, is 50%. The differences are statistically significant, P<0,025 (table 4). The frequency of recurrence of peptic gastroduodenal ulcers within 1 year endoscopic remiss and was named in groups of patients 8% 41,67%. The differences are statistically significant, P<0,025 (table 4). During fluconazole treatment of relapse of peptic piloroduodenalnoy ulcers, not cicatrizing within 4 weeks, by the end of 7 weeks of relapse (3 weeks after initiation of therapy with fluconazole) endoscopic remission developed in 81,48% of patients on the background of standard therapy in 48% of patients. The differences are statistically significant, P<0.05 (table 5). The recurrence of peptic gastroduodenal ulcers during the first year of remission was observed in 14,81% of patients 4 group and 52% of patients comparable group of patients, who underwent conventional therapy. The differences are statistically significant, P<0,01 (table 5).

Statistically significant differences in the percentage of successful eradication of HP in patients receiving fluconazole from the first day of eradication therapy, and a comparable group of patients who were only eradication therapy first-line, not set (table 6). A second course of eradication therapy "second line", carried out after treatment with fluconazole is more effective than the same treatment without the use of these drugs (table 7).

Thus, the study has allowed to establish that therapy with fluconazole 150 mg 1 time per week for 3 weeks accelerates the healing of long-term cicatrizing peptic gastroduodenal ulcers, reduced the em frequency of their recurrence and improves the results of repeated courses of eradication, that helped to formulate the above indications for the named drug to patients with peptic ulcer disease.

Examples of the implementation of this method on patients

Example 1. Sick n I s NS, 35 years old, has sought advice from the Department of propaedeutics of internal diseases, Kemerovo state medical Academy, February 10, 2005, When the survey no complaints.

The history of this disease.

Within 5 years 1-2 times per year recurs abdominal pain and dyspeptic syndromes. In March 2004, when fibrogastroduodenoscopy revealed an ulcer in the posterior wall of the upper third of the body of the stomach 1.0 cm in diameter. With repeated endoscopic examinations performed 3 weeks after the first, revealed a pale pink scar on the back wall of the upper third of the body of the stomach.

In September 2004 had anticipated a peptic ulcer is localized on the anterior wall of the stomach in the upper third of the body of the latter. Tested on HP (Sahara-test, histological examination of the gastric mucosa with colouring on Gimse) gave negative results. On the background of therapy with omeprazole 20 mg 1 time per day and Venter 1000 mg 4 times a day for 4 weeks and then half the dose for the next 4 weeks endoscopic remission was developed within 6 weeks. December 21, 2004 hadreceived abdominal pain, December 23, 2004 at endoscopic examination revealed the presence of the ulcer with a diameter of 1.5 cm in the anterior wall of the middle third of the body of the stomach. Assigned to therapy with omeprazole 20 mg 1 time per day and Venter 1000 mg 4 times a day. With repeated endoscopic examinations January 14, 2005 the dynamics of the ulcer is not marked. Therapy supplemented by injection solkoserila by 4,0 ml 2 times a day. With the re-examination on 7 February 2005 ulcerative defect without dynamics. The patient is re-examined on HP infection (Sahara-test, Clo-test, histological examination of biopsy of the gastric mucosa with colouring on Gimse) - the results are negative. On physical examination, the General condition is satisfactory. Tongue moist, coated with a light-gray tinge. The abdomen is soft, painful at the base of the xiphoid process.

Diagnosis: gastric Ulcer, HP-unassociated, often recurrent in the acute stage, chronic ulcer of the anterior wall of the middle third of the body of the stomach.

After consulting appointed fluconazole 150 mg 1 time per week for three weeks. During the first week after initiation of therapy with diflucan cropped abdominal pain and dyspeptic syndromes. When fibrogastroduodenoscopy March 1, 2005 on the front wall of the middle third of the body of the stomach marked pink scar cont the correct form about 1.5 cm in diameter.

The patient is viewed 27 February 2006. Over the last year recurrence of abdominal pain and dyspeptic syndromes are not marked. Objectively: General condition is satisfactory, the language of the net. The abdomen is soft, painless. When fibrogastroduodenoscopy February 28, 2006, the mucous membrane of the stomach and duodenal bulb and the regular color. On the front wall of the body of the stomach in the upper and middle thirds of recent scars light grey 1.5×and 1,5 1,5×1.0 cm, respectively.

Summary. Thus, in men 35 years, suffering frequently recurring NR-non-associated gastric ulcer after treatment with fluconazole has developed long-term remission chronic cicatrizing mediagallery ulcers lasting more than a year. Side effects of therapy are not checked.

The example illustrates the beneficial effect of therapy with fluconazole held during the recurrence of peptic mediagallery ulcers, on the dynamics of clinical symptoms and endoscopic relapse of peptic ulcer in the further course of the disease.

Example 2. Sick N s A.S., 34 years old, hospitalized in the gastroenterology Department of GB No. 11, Kemerovo December 29, 2004, at the direction of the district physician.

Complaints on admission:

Periodic pretty intense again epigastrium spastic nature, growing by 2.5-3 hours after a meal, intractable re taking antacids (Almagell, gastal).

History of present illness. Above abdominal pain debuted on February 16, 2004. Diagnosed ulcerative defect in the anterior wall of the duodenal bulb. Outpatients received omez 20 mg 2 times a day. When fibroduodenoscopy performed 3 weeks after the first endoscopic examination, presence of scar size 1,0×0.5 cm in the anterior wall of the duodenal bulb. Abdominal pain had anticipated 27 November 2004. When fibrogastroduodenoscopy 30 November 2004 revealed ulcerative defect duodenal 1.5-1.0 and the scar of irregular shape, size 1,0×0.5 cm light gray in color, located in the anterior wall of the duodenal bulb. When conducting Clo-test with biopsies of the mucosa of the antrum and duodenal bulb a moderate degree of urease activity. Outpatient recommended diet No. 1, is assigned within 10 days omez 20 mg 2 times a day amoxicillin 1000 mg 2 times a day, clarithromycin 500 mg 2 times a day, then continued therapy omez 20 mg 1 time a day. The severity of abdominal Bo is avago syndrome 2 weeks after the start of treatment significantly decreased. When fibrogastroduodenoscopy on December 27, 2004 dynamics of endoscopic picture is not installed. The patient is directed to the gastroenterology Department.

On physical examination, satisfactory condition. Marked bad breath, which can be described as a combination of the smell of ammonia and rancid animal fat. Tongue moist, coated with a light-gray tinge. The abdomen is soft, painful when piloroduodenalnoy zone. The diagnosis at admission: peptic ulcer of the duodenum, HP is associated with an average frequency of recurrence in the acute stage, chronic ulcer of the duodenal bulb.

Appointed: diet No. 1, omez 20 mg 1 time a day fluconazole 150 mg 1 time per week for 3 weeks.

Within 7 days of abdominal pain syndrome was arrested. January 11, 2005, at the urging of the patient was discharged to outpatient treatment. Ambulatory 19 January 2005 made fibrogastroscopy with biopsy of the mucosa of the antrum and duodenal bulb. If fibrogastroscopy in the anterior wall of the duodenal bulb had a scar irregular shape 1,0×0.5 cm light grey colour on the back wall of the duodenal bulb - scar pale pink color 1.5×1,0 see When conducting Clo-test in the set at all reasonable urease activity. From 24 to 31 January of the conducted therapy omez 20 mg 1 time per day, de Nole 120 mg 4 times a day metronidazole 500 mg 3 times a day, tetracycline hydrochloride 0.5 mg 4 times a day. Viewed 27 February 2006. Maintaining good health. Abdominal pain and dyspeptic syndromes not had anticipated. On physical examination, satisfactory condition. Language and wet clean. The abdomen is soft, painless.

When fibrogastroduodenoscopy 28 February 2006 revealed light grey scars on the anterior wall of the duodenal bulb (size 1,0×0.5 cm) and on the rear wall of the duodenal bulb 1.5×see 1,0

The Sahara-test February 28, 2006 negative. Clo-test with mucosal biopsies of the antrum showed no urease activity.

Summary. Thus, male 34 years, suffering NR-non-associated peptic ulcer of the duodenum when conducting therapy with fluconazole cropped resistant to conventional therapy of abdominal pain and dyspeptic syndromes, developed endoscopic remission of peptic piloroduodenalnoy ulcers, not cicatrizing within 4 weeks of standard therapy. After therapy with fluconazole successful eradication of HP infection, for 13.5 months peptic ulcer disease not had anticipated. Given p the emer illustrates the beneficial effect of therapy with fluconazole, held at the time of relapse of peptic piloroduodenalnoy ulcers, on the dynamics of clinical symptoms and endoscopic relapse of peptic ulcer, the effectiveness of eradication therapy and the further course of the disease.

Example 3. Patient H-th MS, 37 years old, hospitalized in the gastroenterology Department of GB No. 11, Kemerovo 14 January 2005 (Samoobrona).

Admitted to hospital complaining of regular, moderate-intensity pain in the epigastric region, growing 15-20 minutes after a meal.

History of present illness. Above abdominal pain made his debut on 6 February 2004. Diagnosed ulcerative defect on the anterior wall of the stomach in the upper third of his body. When conducting Clo-test a moderate degree of urease activity, histological examination of the biopsy of the gastric mucosa after staining Gimse set the average degree of contamination Hp. Held in the gastroenterological Department of the GB No. 11 ten-day course of eradication therapy (omez 20 mg 2 times a day amoxicillin 1000 mg 2 times a day, clarithromycin 500 mg 2 times a day), after which continued therapy with omeprazole for 7 weeks. By the end of 6 weeks after the start of observation developed endoscopic remission. Abdominal pain syndrome receiveremail the end of October 2004. If fibrogastroscopy revealed ulcerative defect on the posterior gastric wall in the lower third of his body, size 2,0×1.5 cm Hospitalized in the gastroenterology Department of GB No. 11, Kemerovo. During examination (Sahara-test) confirmed the presence of Hp infection. Prescribed diet No. 1, was repeated ten-day course of eradication therapy (omeprazole 20 mg 2 times a day, de-Nol 120 mg 3 times a day and the 4th time 240 mg overnight clarithromycin 500 mg 2 times a day), after completion of eradication therapy continued treatment with omeprazole 20 mg 1 time per day. Abdominal pain syndrome was arrested within 7 days. When fibrogastroduodenoscopy, held on 22 November 2004, identified "chronic ulcer of the rear wall of the lower third of the body of the stomach, and 1.5×see 1,0 Patient was discharged to outpatient treatment (diet No. 1, pariet 20 mg 1 time per day, Venter 1000 mg 4 times a day, then the same period of time in half dose, solution Derinat of 1.5% to 5.0 ml intramuscularly 1 time in 2 days, 7 injections. When conducting fibrogastroduodenoscopy 14 December 2004 established the presence of a chronic ulcer of the rear wall of the lower third of the body of the stomach, the size 2,0×1.5 cm and scar light grey, 1.5×1.0 cm, located on the anterior wall of the stomach in the region of the middle third of his body. Clo-test revealed a moderate urease activity sampling is in the mucosa of the antrum.

Assigned to the second (third) seven-day course of eradication therapy: pariet 20 mg 1 time per day, de-Nol 120 mg 4 times a day metronidazole 500 mg 3 times a day, tetracycline hydrochloride 0.5 g 4 times a day. 12 January 2005 had anticipated abdominal pain that was the reason for the hospitalization.

On physical examination, satisfactory condition. Marked bad breath, which can be described as a combination of the smell of ammonia and rancid animal fat. Tongue moist, coated with a light-gray tinge. The abdomen is painful at the base of the xiphoid process, there is a protective tension of the muscles of the anterior wall of the abdominal cavity. During endoscopic examination, January 14, 2005 revealed a chronic sore back wall of the lower third of the body of the stomach size 2,0×1.5 cm and light grey scar. On the front wall of the middle third of the body of the stomach 1.5×1,0 see When conducting Clo-test revealed a high urease activity of the mucosa of the antrum. Prescribed diet 1bthat 3 days later expanded to diet No. 1, assigned pariet 20 mg 1 time a day fluconazole 150 mg 1 time per week for 3 weeks. Within 5 days of abdominal pain syndrome was arrested. January 27, 2005 after completion of therapy with fluconazole initiated eradication therapy: pariet 20 mg 1 time per day, de-Nol 120 mg 4 times a day amoxicillin 1000 mg 2 times a day, clarithromycin 500 mg 2 times a day for 10 days. 5 February 2005 test fibrogastroscopy. On the back wall of the lower third of the body of the stomach chronic ulcer size 1,0×0.5 cm On the anterior wall of the middle third of the gastric body light grey scar 1.5×see 1,0 17 February 2005 after the completion of eradication therapy was discharged for outpatient treatment.

When the extract had no complaints. Objectively, the condition is satisfactory. Remains slightly pronounced described above bad breath, tongue coated from root to light-gray bloom. The abdomen is soft, painless. Re-inspected by 28 February 2006. No complaints. After February 17, 2005 abdominal pain and dyspeptic syndromes not had anticipated. When fibrogastroduodenoscopy, made of 24 February 2005 on the front wall of the middle third of the stomach revealed light grey scar 1.5×1.0 cm, on the back wall of the lower third of the body of the stomach pink scar 1.5×1.5 cm on physical examination, the General condition is satisfactory. Breath is not marked. Language and wet clean. The abdomen is soft, painless.

When fibrogastroduodenoscopy from February 21, 2006 the mucosa of the stomach and duodenum normal color. On the front wall average Proc. of the tee body of the stomach light grey scar, 1.5×1.0 cm, on the back wall of the lower third of the stomach, the rumen of the same color, 1.5×1,5 see the Sahara-the test is negative.

Histological examination of biopsies of the mucosa of the antrum and the duodenal bulb is also not revealed after staining Gimse contamination HP. Clo-test conducted with the same material, revealed no urease activity (negative result).

Summary. Thus, after applying the recommended method of treatment, managed to make a successful eradication of HP in women 37 years after three ineffective courses methodically correctly held eradication therapy. On the background of the implementation of the proposed method of treatment achieved endoscopic remission of peptic mediagallery ulcers, not cicatrizing more than 6 weeks prior to the application of the proposed method, lasting more than a year. Remission achieved without application of the proposed method, lasted a little over 7 months. The example illustrates the beneficial effect of therapy with fluconazole for the effectiveness of subsequent eradication therapy during acute ulcers.

Example 4. Patient-to M.N., 34 years, turned for advice to the Department of propaedeutics of internal diseases, Kemerovo state medical Academy on the recommendation of the teaching is Travego therapist about the inefficiency of repeated courses of eradication therapy on 5 may 2004.

History of present illness. Abdominal pain and dyspeptic syndromes recur from April 2004 in spring and autumn. In September 2002 for the first time revealed an ulcer in the anterior wall of the duodenal bulb. On the background of treatment with omeprazole for 3 weeks developed endoscopic remission. Exacerbation of the disease took place in September 2003 and March 2004. In September 2003, after conducting a de-Nol-test diagnosed with HP infection, conducted a ten-day course of eradication therapy (omeprazole 20 mg 2 times a day amoxicillin 1000 mg 2 times a laziness, clarithromycin 500 mg 2 times a day). The results of the re-Sahara-test during relapse in March 2004 is positive. Conducted eradication therapy with omeprazole 20 mg 2 times a day, de Nole 120 mg 4 times a day, clarithromycin 500 mg 2 times a day. Within 3 weeks achieved endoscopic remission. Outpatient April 27, 2004 made fibrogastroscopy with biopsy of the mucosa of the antrum, after staining Gimse set the average degree of contamination. Hp, when carrying out de-Nol-test a moderate degree of urease activity.

Objectively. The General condition is satisfactory. Marked bad breath, which can be described as a combination of the smell of ammonia and described clogo animal fat. The abdomen is soft, painless.

D-C: peptic Ulcer of the duodenum HP is associated with an average frequency of recurrence, remission.

Recommended: to the diet No. 1, fluconazole 150 mg 1 time per week for 3 weeks, then a seven-day course of eradication therapy omez 20 mg 2 times a day, de-Nol 120 mg 4 times a day metronidazole 0.5 g 3 times a day, tetracycline hydrochloride 0.5 g 4 times a day for 7 days.

Re-inspected on June 28, 2005. No complaints. Recurrence of abdominal pain and dyspeptic syndromes after March 2004 not recorded. Objectively:

The General condition is satisfactory. Breath is not marked. Language and wet clean. The abdomen is soft, painless. When fibrogastroduodenoscopy, held on 14 June 2005, the detected light grey scar irregular, 1.5×1.0 cm on the anterior wall of the duodenal bulb, the scar of the same color 1,0×1.5 cm on the lateral wall of the duodenal bulb, the scar is the same color on the back wall of the duodenal bulb. Histological examination of the biopsy of the mucosa of the antrum and duodenal bulb after staining Gimse contamination of the mucous membrane of the gastroduodenal zone Hp is not installed. De-Nol-test conducted with the same material, urease is aktivnosti not revealed. The Sahara-test from 23 June 2005 negative.

Summary. Thus, after applying the recommended method for the treatment and rehabilitation of patients with peptic ulcer in remission of the disease was able to implement a successful eradication of the patient, two earlier course of H. pylori treatment, which proved to be ineffective. After conducting the recommended method of treatment described in the case favorably changed the course of the disease: in the three years prior to the application of the proposed method twice a year had anticipated clinical symptoms of seasonal exacerbations of the disease, the recurrence of duodenal ulcers confirmed by endoscopic examination after treatment with fluconazole endoscopic remission lasts more than 14 months. This example illustrates the feasibility of applying the proposed method for the treatment and rehabilitation of patients with peptic ulcer disease.

The proposed method was applied for treatment of 78 patients with peptic mediagallery ulcers, data obtained by observation, were compared with the results of the survey and the dynamic observation of the 49 patients suffering from peptic ulcers the same localization. The comparison group matched by sex, age of patients, duration of disease and duration of relapse of peptic ulcers before the beginning of the om treatment. Within 9 weeks remission developed in 92,31% of patients treated with the proposed method, and 71,43% of patients, combined in the comparison group (P<0,005). A significant duration of relapses due to evidence for the purpose of fluconazole, a drug used only when long-term cicatrizing mediagallery ulcers. And 3 weeks after the start of treatment by the proposed method remission developed in 89,74% of patients treated with fluconazole, and 55.1% of patients in the comparison group (P<0,01). The recurrence of peptic mediagallery ulcers within the first year after the development of endoscopic remission was observed in 8,97% of patients treated using the proposed method and 28.57 percent of patients in the comparison group (P<0,01).

Side effects of therapy of recurrent peptic mediagallery ulcers was observed in 15,38% of patients treated using the proposed method and 38,78% of patients, combined in the comparison group (P<0,05).

The described method of treatment was used in 58 patients with HP-associated peptic ulcer disease with inefficiency of repeated courses of eradication therapy, the results of which were compared commissioned obtained during the survey of 47 patients treated with repeated courses of therapy of H. pylori. The comparison group matched by sex,age of patients, features of the disease. Before you start to monitor patients, combined in the comparison group, was carried out the same eradication therapy. When using named method successful eradication was observed in 87,93% of patients with peptic ulcer, when repeat courses of eradication therapy without prescription of fluconazole - 53,19% of patients (P<0,001). Relapse during the year after treatment was observed in 10,34% of observed patients in the comparison group at 44,68% of patients (P<0,001).

Side effects of therapy was observed in 12,07% of patients treated with the proposed method, and 44,68% of patients receiving repeated courses of eradication therapy without prescription of fluconazole (P<0,001).

Thus, the application of the proposed method for the treatment of patients with peptic ulcer of stomach and duodenum allows to significantly accelerate the development of endoscopic remission long-term cicatrizing mediagallery ulcers, significantly improves the results of eradication therapy in cases of failure of its repeated courses and significantly improves the frequency of recurrence of peptic ulcers. Using the proposed method can significantly reduce the frequency of side effects. The latter fact can be explained by the fact that the application of the proposed method to reduce the amount of prodolzhitelnost pharmacotherapy.

Literature sources used in the preparation of the description

1. Woodpeckers NM, Smirnov N.N., Novikov N. peptic Ulcer disease and symptomatic ulcers of the stomach and duodenum. SPb: ID Peter, 2004, 274 S.

2. Kazantseva A.M. Microflora and its changes in peptic ulcer and gastric cancer. Tbilisi, 1972, 91 S.

3. Krylov A.A., Bugaev A.I., V.I. Ulyanov Role of Candida in the pathogenesis of non-healing of gastroduodenal ulcers//Klin. medicine, 1988, No. 7, p.69.

4. The sokolovich G., Beloborodov AI, jerlov G.K. gastric Ulcer and duodenal ulcer. Tomsk: Izd-vo STT, 2001, 384 S.

5. Standards (protocols) for the diagnosis and treatment of patients with diseases of the digestive system//PA Grigoriev, AP Yakovenko, A. I. Shchukin, etc. M.: Medicine, 2002, p.12-19.

6. Chagin H.S., frost F, Nesterov NICHOLAS Ulcer and erosive lesions of the stomach and duodenum. Khabarovsk: far East, 2005, 175 S.

7. Iaik N.A., Sedov V.M., Morozov V.P. stomach Ulcers and duodenal ulcers. Moscow: Medpress-inform, 2002, 376 S.

8. R. Stainton Duodental ulcer. - London, Internal Medicine, 1995. - R.

9. G.N. tytgat was, Noseb L. Gastric ulcer. - London, Internal Medicine, 1997. - P.27-78.

Notes to tables:

Table 1

Patients on survey data which is based on the scheme of the drug and dose selection.

Table 2

The results of the use of fluconazole to treat peptides is their mediagallery ulcers in the appointment of the drug from the first day of treatment relapse.

Table 3

The results of the use of fluconazole for the treatment of peptic piloroduodenalnoy ulcers in the appointment of the drug on the first day of relapse.

Table 4

The results of the use of fluconazole to treat mediagallery ulcers, not cicatrizing for 6 weeks.

Table 5

The results of the use of fluconazole to treat piloroduodenalnoy ulcers, not cicatrizing within 4 weeks.

Table 6

The efficacy of eradication therapy in the appointment of fluconazole from the first day of treatment.

Table 7

The results of the use of fluconazole to improve the efficiency eradikatsionnoy therapy in patients with peptic ulcer disease in the first failure of the course

A method for the treatment of patients with peptic ulcer disease, including anti-ulcer pharmacotherapy, characterized in that patients with mediagallery localization of the ulcer, not cicatrizing within six weeks, or piloroduodenalnoy ulcers, not cicatrizing within four weeks, in addition enter fluconazole at a dose of 150 mg 1 time per week for three weeks.



 

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