Chronic gastritis

Description:

Chronic gastritis — the proceeding recurrent inflammatory and dystrophic damage of a mucous membrane of a stomach, with inherent structural changes, and also disturbances of functions is long.  It is as a result long the existing inflammatory process there is morphological
reorganization of cells of a stomach, their atrofiinarusheny functions of gastric glands. These pathological processes not in the best way are reflected in a pepsinia and hydrochloric acid.
Chronic gastritis is divided into superficial and atrophic gastritis. These forms of chronic gastritis were allocated on the basis of endoscopic inspections and offered by the German surgeon R. Schindler in 1948. Such division into forms was generally recognized and is reflected in classification of gastritises  by MKB-10. The main sign on which there was a division into such groups - a condition of function by the secretory device. Except two main forms also special forms are had
chronic gastritis: hypertrophic gastritis,
huge hypertrophic gastritis (Menetriye's disease), lymphocytic, atrophic - hyperplastic gastritis (or polypostural, "warty"), granulematozny (against the background of a disease Krone, a sarcoidosis, Wegener's granulomatosis of gastric localization), radiation,  collagenic, eosinophilic (a synonym allergic), infectious (defeat of a gastrospirillama, cytomegaloviruses, drozhzhepodobny fungi of Candida). Chronic gastritis is widespread everywhere. Due to the low-expressiveness of clinical  manifestations this disease in many cases remains not diagnosed since patients seldom ask for medical care. On statistical data, to 85% of the population suffer from this or that form of chronic gastritis.

Reasons of Chronic gastritis:

Lead the various reasons to development of chronic gastritis. They are endogenous and exogenous character. Among the exogenous reasons the main role is played by diet errors, not careful chewing of food, irregular and unbalanced food, refusal of liquid food, the use of the rough food capable to injure a mucous membrane of a stomach, and also various spices, marinades and spices. The use of too hot food and drinks (tea, coffee, cocoa) promotes irritation
mucous membrane of a stomach. At abuse of alcohol the special option of chronic gastritis – alcoholic develops. Alcohol causes disturbance of a gastric slizeobrazovaniye, its consumption leads to exfoliating of superficial epithelial cells of a mucous membrane and blocks their reproduction, leads to disturbance of processes of blood circulation in a mucous membrane of a stomach.
Alcohol can cause not only the chronic course of gastritis, single-step reception of a large amount of alcohol can cause developing of acute erosive (hemorrhagic) gastritis.
Against the background of long alcoholization the heavy mucosal atrophy of a stomach therefore the last is left to stand too long on intestinal type develops. Such changes meet practically always at an alcoholism. The term "alcoholic gastritis" is included in MKB as an independent nosological form. Development and progressing of chronic gastritis can be promoted by smoking. The mechanism of influence of cigarette smoke consists in stimulation of secretion of hydrochloric acid obkladochny cells that leads to development of their hyperplasia and hyperfunction, causes disturbances of gastroduodenal motility, breaks processes of a slizeobrazovaniye; leads to developing of chronic diseases of various bodies and systems of an organism. So, progressing of chronic bronchitis and emphysema of lungs promotes development of a hypoxia of a mucous membrane of a stomach with its subsequent morphological changes.
Chronic gastritises of a toxic etiology include professional, medicinal and eliminative. Medicinal gastritis develops at use of some medicines  
(salicylates, streptocides, some antibiotics, Prednisolonum, potassium chloride, foxglove drugs, antituberculous remedies, etc.) which make an adverse effect on a mucous membrane of a stomach.
Professional toxic gastritis can be caused by the increased concentration of dust or chemicals in air of workrooms which when swallowing irritate a mucous membrane of a stomach (coal, cotton, metal dust, vapors of alkalis and acid etc.). On the origin the eliminative gastritises connected with allocation through a mucous membrane of a stomach of various toxic substances are toxic. The uraemic gastritis arising at allocation through a wall of a stomach of end products of a nitrogen metabolism at patients with a chronic renal failure can be an example of eliminative gastritis. The reasons of endogenous gastritises are connected chronic Iza by acute bolevaniye of internals. So, insufficiency of adrenal glands causes development of the expressed stomach mucosal atrophy with decrease in products of hydrochloric acid. The chronic gastritis developing at patients with iron deficiency anemias and a hypovitaminosis has endogenous character. Still widespread is a term "hypoxemic gastritis" which it is accepted to call damages of a mucous membrane of a stomach at больныхс heart and respiratory failure (at heart diseases, emphysema of lungs etc.), however the changes of a mucous membrane of a stomach revealed at such patients most often have dystrophic character.
A certain place in an etiology of chronic gastritis is taken also by hereditary factors though their specific role in developing of a disease is studied not enough. Are most studied
hereditary mechanisms at chronic atrophic gastritis against the background of B12-scarce anemia.

More or less significant role of allergic mechanisms of a pathogeny is defined only at eosinophilic gastritis.

However, all listed above etiological factors of chronic gastritis at the present stage of development of medicine faded into the background. Main an etiological agent of gastritis  is the bacterium under the name Helicobacter pylori.  
Helikobakter represents the bacteria of a curved or spiral-shaped form  which are localized under pristenochny slime on a surface  of epithelial cells in the field of intercellular connections, getting sometimes into depth of gland. Helicobacter pylori have the expressed ureazny activity and, carrying out urea hydrolysis, cause degradation of glycoproteins of gastric slime, than  promote increase in the return diffusion through a mucous membrane of a stomach.
Now the helikobakter is considered by many authors as the etiological agent of emergence and progressing of chronic gastritis of type B which development begins with antral department, and further passing to fundal department of a stomach. The accurate interrelation between expressiveness of symptoms  of chronic gastritis and detectability of Helicobacter pylori in a mucous membrane of a stomach is noted.
Identification of this fact defines pathogenetic therapy and an obosnovyvayetnaznacheniye of colloid subcitrate of bismuth which suppresses growth of a bacterium in a stomach cover. The direct interrelation between the frequency of identification of a helikobakternoyinfektion in a mucous membrane of a stomach and age of patients is noted. So, in the absence of the phenomena the gastritaureazny test positive at 62% of persons was more senior than 60 years.
On the contrary, at persons of young age and at children, even in the presence at them symptoms of chronic gastritis, HP in a mucous membrane came to light rather seldom. All this demonstrates that the question of value of a helikobakter in development of chronic gastritis demands further researches.

Symptoms of Chronic gastritis:

There is a set of various classifications of chronic gastritis – on a current, the nature of pathological process, histologic changes. In recent years the international classification accepted on the 9th International congress of gastroenterologists gained distribution:
1. Not atrophic (type B – superficial, antral diffusion, antral intersticial).
2. Atrophic which is divided into autoimmune (type A) and multifocal.
3. Special forms:
• Chemical (type C, reflux gastritis)
• Radiation
• Lymphocytic (veriloformny)
• Noninfectious (isolated)
• Granulematozny
• Eosinophilic (allergic)
Local and general symptoms which manifestation is depending on type of inflammatory process are characteristic of chronic gastritis. Most often chronic gastritis is not followed by the expressed symptoms and is not reflected in the general condition of the patient. It results in low negotiability of patients behind medical care.
However for chronic gastritis nevertheless there are typical signs, and at the directed poll it is easy to reveal them. The main manifestation is dyspepsia which includes:
• the pain in epigastriums, periodic character arising in 1,5-2 h after acceptance of food of Bol amplifies at an exercise stress that is a characteristic symptom for gastritis of type B;
• discomfort in the area an epigatriya after food;
• eructation rotten, heartburn;
• "metal" smack in a mouth;
• hypersalivation, loss of appetite;
• the phenomena dyspepsia also include rumbling and abdominal distention, nausea, a meteorism;
• disturbance of a chair (tendency to a lock or diarrheas).
At objective inspection of the patient external symptoms of a disease, especially at an early stage of a disease can not come to light. In process of progressing of a disease inflammatory process extends to other departments of a stomach and the disease gains diffusion character with a mucosal atrophy of a stomach and secretory insufficiency.
When progressing a disease weight loss, pallor of integuments are observed. For patients with autoimmune gastritis with not rarity intercurrent B12-scarce anemia is, and then hypovitaminosis symptoms are shown (perleches in mouth corners, bleeding of gums, a hyperkeratosis, fragility of nails, a hair loss). Language is laid over by a white or yellow-white plaque, prints of teeth on a side surface are visible. There is a moderate diffusion morbidity in a stomach. The stomach is usually soft, it is sometimes blown up, at a palpation rumbling is defined; the lower bound of a stomach is defined perkutorno or auskultativno, on capotement and is located below normal level.
In most cases chronic gastritis is followed by other diseases of bodies of a GIT. It complicates differential diagnosis as often these diseases are primary, and chronic gastritis - their investigation.

Diagnosis:

Except objective inspection of the patient for diagnosis it is necessary to carry out additional methods.
Determination of level of acidity which can be determined by a probe or tubeless method is important. Most often I use the thin elastic probe which take hydrochloric acid with further definition рН. First of all determine the level of the basal secretion caused by mechanical irritation mucous a probe stomach, and also stimulated secretion (after secretion stimulation by an irritant). As an irritant apply a histamine or insulin. By results of carrying out a rn-metriya total quantity of a gastric juice which normal makes from 150 to 240 ml in 2 hours of carrying out a research is estimated; the general acidity and an output - hour.
In a stomach body acidity normal on an empty stomach makes 1,5–2,0 рН. Acidity on a surface of the epithelial layer turned into a gleam of a stomach 1,5–2,0 рН. In the depth of an epithelial layer of a stomach рН makes about 7,0. Normal acidity in an antruma of a stomach 1,3–7,4 рН.

For comparison, value рН =7 corresponds to neutral value of acidity. At рН the 7th acid medium is lower, at рН higher than 7 — alkaline.
One more, not less important method of a research of a stomach is the fibroezofagogastroduodenoskopiya which is carried out by means of the thin endoscope and allowing to estimate a condition of a mucous membrane of a stomach "from within", and also to carry out a biopsy. The biopsy undertakes also for the purpose of detection of a bacterium Helikobakter.
The infection can be found by means of the histologic, bacteriological and bystry ureazny test.
Histologic method.
The standard of diagnosis and detection of a helikobakterny infection is direct histologic visualization of a bacterium after coloring of biopsy cuts. Coloring of biological material by methods to Vartin-Starri, by hematoxylin and eosine, to Gimza, Ghent is used. Advantages of this method cannot be revaluated - wide availability, convenience of storage and transportation, a possibility of assessment at any time any specialist who if necessary will carry out the retrospective analysis. This method is suitable for assessment of degree of a morphological izmenennost of a mucous membrane, the level of its obsemenennost. However this method is not deprived of shortcomings. The main minuses of a method are the need of existence of histologic laboratory, a long time of carrying out and difficulty connected with interpretation and registration of results. One of kinds of a histologic method is immunohistochemical (immunoperoksidazny technology), however its use after performing antibiotic treatment is not justified since at existence of nekhelikobakterny flora can yield false positive result.
Bacteriological method. This method does not possess such prevalence as previous, owing to complexity of performance, high cost and other factors. It is connected with that, the helikobaktrny infection is very whimsical and difficult for cultivation. Нр is a microaerophile, and their incubation is successful only at strictly certain parameters (5-6% of oxygen, 8-10% of carbon dioxide, 80-85% of nitrogen, relative humidity — 95%). Results of an incubation are estimated from 3 to 7 day, and in case of the previous treatment — up to 2 weeks. On a blood medium of Nr usually in three-five days creates small, round, smooth, transparent, rosinchaty colonys with a diameter of 1 - 3 mm, characteristic biochemical characteristics of which are positive ureazny, katalazny and oksidazny activities.
The method is considered irreplaceable when carrying out an antibiotikogramma - definition of sensitivity of Nr to antibiotics and other antibacterial drugs, especially in cases resistant to the carried-out therapy.
Molecular methods.
The molecular method is necessary for bystry definition of a helikobakterny infection in bioptata for the diagnostic purposes or other not gastric samples for the epidemiological purposes. By means of the polymerase chain reaction having 100% specificity and sensitivity ureA - a gene or DNA of Nr come to light. By means of a method of hybridization 16 S GRNK a fragment of Nr comes to light.
There are several indications for carrying out molecular typing. First, this method is applied to understand the nature of repeated infection after a successful eradikation (whether new it is an infection or reproduction of the remained bacteria). Secondly, for definition of nature of infection of Nr (one or different strains) within one family or spouses with duodenal ulcers. In the third, for establishment of possible iatrogenic infection. Besides, there were messages on an opportunity by means of molecular typing initially to establish resistance to macroleads (erythromycin, a klaritromitsin).
To noninvasive diagnostic methods of NR-of an infection the serological method and the respiratory test with urea are.
The serological method  includes definition of antikhelikobakterny antibodies.
As colonization of Nr causes a system immune response, in serum of infected there are antibodies of the classes IgG and IgA directed against different bacterial antigens (in 3-4 weeks after infection). Usually antibodies (serumal IgG, IgA, IgM, secretory IgA, IgM in saliva or gastric contents) are defined by an immunoenzyme method. Serological definition of protivokhelikobakterny antibodies in blood serum is the simplest, most available method in the financial plan which is often used for primary screening.
The respiratory test with urea. The respiratory test with urea shows nearly 100% sensitivity and specificity, and simple in performance.  This method is based on reception of solution of urea which is split by Helicobacter pylori urease therefore marked carbon dioxide is released. Definition of the emitted gas  in expired air is made in 30 minutes.
To the patient is given two small marked tight a sack with special valves. Through a one-time mouthpiece the patient does a full exhalation and closes the valve a rubber bung. After that drinks a glass of orange juice in which 75 mg of urea are dissolved previously, (which has no smack and is completely harmless to an organism). In 30 minutes the patient does one more full exhalation in the second capacity and gives them to the researcher. Both sacks are connected to the relevant channels of infrared spectroscopic system and measurement of a difference of concentration of CO2 in both sacks is taken. About existence of Helicobacter pylori judge by a difference of concentration of carbon dioxide in 2 tests and if it makes more than 3,5 result it is considered positive. According to the European protocol, the main indications for use of the respiratory test is an establishment of existence of an infection and control of the fact of destruction of Helicobacter pylori after the carried-out antikhelikobakterny treatment. The positive take when carrying out the respiratory test should be interpreted as existence of an active infection of Helicobacter pylori, and at observance of all rules of its carrying out yields nearly 100% result.
The false-negative result is possible at test in time or at once after performing antibiotic treatment.

Radiological diagnosis of chronic gastritis is not less significant  method of a research of hollow bodies. Quite often it is only an available method of a research. The special research using X-ray contrast substances is conducted that allows to estimate a tone of walls of bodies of a GIT, a relief mucous a stomach, to find direct and indirect symptoms of a new growth or stomach ulcer or a duodenum. It is possible to carry a possibility of definition to the main advantages of X-ray inspection of a stomach motor эвакуаторной functions of a stomach (at undisturbed motor эвакуаторной functions the contrast entered with the diagnostic purpose is evacuated in 1,5 hours), identification of signs of narrowing of a gleam of a pylorus, deformation of a bulb of a 12-perstny gut, existence of diverticulums, tumors and strictures of a gullet, gastroesophagal and duodeno-gastralny refluxes, phrenic hernias, and also a possibility of diagnosis at patients with the increased endoscopic risk.

Treatment of Chronic gastritis:

The course of performing long complex therapy is necessary for treatment of chronic gastritis. For selection adequate treatment it is necessary to consider the disease duration, the nature of gastric secretion, existence of intercurrent diseases.
Usually treatment of uncomplicated chronic gastritis is carried out in out-patient conditions.
First of all it is necessary to observe a dietary regimen. In the period of an aggravation the diet No. 1a is shown, further pass to a diet No. 1b, and then - No. 1 and No. 5. At an exacerbation of chronic gastritis the boiled, soared food has to prevail, the use fried, acute, and also the food capable to irritate mechanically a mucous membrane is inadmissible. I eat food fractionally, on 5-6 times a day. It is necessary to minimize consumption of salt, extractive substances, essential oils.
Modern schemes of treatment of the chronic gastritis associated with the NR-infection represent a combination of the 3rd or 4th drugs of antibacterial, kislotosupressivny and cytoprotective action. Only the multicomponent modes of therapy allow to achieve an eradikation of an infection of H. pylori and reduction of an inflammation of a mucous membrane of a stomach. At the choice of antibacterial drugs it is necessary to consider sensitivity of a helikobakterny infection to many used antibiotics. For all the time of studying of this bacterium any its strain which would be insensitive to bismuth drugs is not revealed. The most widespread medicine containing bismuth is De-nol. The combination of drugs of bismuth and antibiotics allows to overcome resistance of H. pylori to the carried-out medicamentous therapy, considerably increasing efficiency of antikhelikobakterny therapy. Continuation of administration of drugs of bismuth after the termination of a course of an eradikation gives the chance more fully to eliminate the phenomena of gastritis and to achieve high-quality healing of a mucous membrane of a stomach.
In treatment of the chronic gastritis which is not connected with an infection Helikobakter of a pilora, an important role is played by the drugs having the cytoprotective effect. These drugs protect a mucous membrane of a stomach from influence of factors of aggression, accelerating processes of healing of the available damages. Treatment in many respects depends on the level of acidity of a gastric juice. At the high level of acidity use of kislotosupressivny means and antacids is necessary. At decrease in secretory function of a stomach appoint replacement therapy drugs of a gastric juice. At disturbance of motive function of a stomach recommend stimulators and regulators of motility.