New Technologies in the Treatment of Patients with Ulcers of the Cardiac Region of the Stomach

The dissertation addresses the problem of treating ulcers of the cardiac region of the stomach using new technologies, including ozone, laser, and nitric oxide (NO) therapy. Peptic ulcer disease remains one of the pressing issues in modern gastroenterology, while ulcers of the cardiac region are distinguished by diagnostic difficulties, frequent complications, and low effectiveness of conservative treatment. The research is aimed at developing and optimizing intragastric treatment methods involving local ozone, laser, and NO therapeutic effects.

The work comprises a literature review, clinical investigation, anatomo-physiological study of microvessels and lymphatic vessels of the cardiac region of the stomach, and statistical analysis of results. It has been established that the lowest density of microvessels and lymphoid tissue in the cardiac region of the stomach is one of the causes of ulcer formation in this location. The proposed local treatment methods significantly accelerate ulcer healing and reduce the recurrence rate.

The problem of peptic ulcer disease continues to be one of the most pressing issues in modern gastroenterology (Miagkova L.P. et al., 1991). According to WHO data, the morbidity rate of peptic ulcer disease increases annually by 56% (Ivashkin V.T. et al., 2002).

In recent years, significant progress has been achieved in the diagnosis and treatment of patients with peptic ulcer disease of the stomach and duodenum. A substantial contribution to the development of the modern understanding of peptic ulcer disease and its treatment methods has been made by domestic and foreign authors (Komarov F.I., Ivashkin V.T., 1997). Nevertheless, information on this disease continues to remain incomplete, and on certain questions of etiopathogenesis — fragmentary, which hinders the development of a unified classification and methodological approaches to the diagnosis and treatment of the disease.

One of the promising directions in improving the diagnosis of peptic ulcer disease is the application of endoscopic research methods (Savelyev V.S., Vladikin A.S., 1977; Kuzni M.M. 2000; Ivashkin V.T. 2000). Their implementation in clinical practice has significantly improved diagnostic effectiveness and expanded the understanding of pathogenetic features of peptic ulcer disease on the basis of the study of macroscopic and histological changes in the area of the ulcer defect and in the zone of periulcerous inflammation (Nechipan A.M. 1987; Aruii L.I. et al., 1998; Grinevich V.B. et al., 1993).

Data from the modern literature indicate great possibilities for the therapeutic treatment of patients with peptic ulcer disease using modern anti-ulcer preparations. Despite this, a continued increase in morbidity is observed, particularly among elderly persons (Shein A.A., 1993), which prompts the search for clear diagnostic criteria at early stages of the disease and the development of rational treatment schemes (Dorofeev G.I., Uspensky V.M., 1984; Maloe Yu.S., 1993; Grigoriev I.A., Yakovenko L.V., 1998; Morozov I.A. et al., 2000).

Despite certain achievements in the treatment of patients with peptic ulcer disease, the classic treatment methods using the latest preparations allow ulcer healing in no more than 70–80% of patients, with scarring periods of 25–45 days (Krylov A.A., 1992), and the recurrence rate can reach 50–60% (Dudchiko M.A. et al., 1988).

One of the features of the current course of peptic ulcer disease is its «aging», expressed in an increase in both disease recurrences in the elderly and senile age and newly diagnosed forms in persons over 60 years old (Minushkin O.I. et al., 1995). In elderly and senile patients, peptic ulcer disease frequently coexists not only with chronic diseases of the digestive organs (cholecystitis, pancreatitis, colitis, etc.), but also with other diseases of internal organs, among which cardiovascular diseases (ischemic heart disease, hypertension) are most common.

In patients with peptic ulcer disease that developed against the background of existing ischemic heart disease, ulcers are reliably more often localized in the stomach (42.3% versus 14% of patients in whom peptic ulcer disease preceded ischemic heart disease) (Blyavin G.D., Vliev M.D., 1985; Chernoousov A.F. et al., 2002).

According to literature data, gastric ulcers in elderly and senile persons are a manifestation of long-standing peptic ulcer disease or symptomatic ulcers, referred to as «senile» (Potekhin G.I. et al., 1997).

A special place among gastric ulcers is occupied by an ulcer localized in the cardiac region of the stomach. This is explained by diagnostic difficulties due to the location, frequent development of complications, and difficulty in choosing a treatment strategy (Vanyan E.N. et al., 1982). The frequency of cardiac ulcers ranges from 0.3 to 8.4% (Grigoriev P.Ya., 1993).

Atypical course, severe complications, often fatal outcomes, and low effectiveness of conservative treatment indicate the relevance of this problem.

Currently, with the emergence of new technologies, possibilities have arisen for their use in endoscopy. In light of the monograph by N.E. Chernyshovskaya (2004) «Modern Technologies in Endoscopy», methods of clinical lymphology that have proven themselves positively in surgical practice, as well as ozone, laser, and EDO therapy, are proposed for use. All of the above-mentioned methods possess a pronounced immunomodulatory effect, which is of great significance for the reparative regeneration of ulcerative processes (Efimenko N.A. et al., 2001).

The aim of the study is to improve the results of treatment of patients with ulcers of the cardiac region of the stomach by developing and implementing intragastric ozone, laser, and NO therapy in clinical practice.

To achieve the goal, the following research tasks have been defined:

1. To study the trophism of the tissue and the lymphoid apparatus of the wall of various regions of the stomach with a chain of clarification of the causes of ulcer occurrence in the cardiac region of the stomach.

2. To provide a comparative assessment of the diagnostic significance of clinical, endoscopic, and morphological research methods in the diagnosis of cardiac region gastric ulcers.

3. To study the dynamics of IgA, IgM, and IgG indicators in gastric juice and Helicobacter pylori in cardiac region gastric ulcers.

4. To optimize the treatment method for patients with ulcers of the cardiac region of the stomach using intragastric treatment methods depending on the duration of the disease, extent of the process, and concomitant pathology.

5. To analyze the results of treatment of patients with ulcers of the cardiac region of the stomach using laser, ozone, and NO therapy.

Scientific Novelty

It has been established that the causes of ulcer occurrence in the cardiac region of the stomach are the lowest density of microvessels and the lowest density of lymphoid tissue in it compared to other regions.

To improve the results of treatment of patients with ulcers of the cardiac region of the stomach, a method of endoscopic treatment has been optimized, including laser, ozone, and NO therapy.

The most effective method of preventing recurrence of cardiac region gastric ulcers is NO therapy, which allows a reduction in the recurrence rate.

Practical Significance

The implementation of the proposed local treatment methods for patients with ulcers of the cardiac region of the stomach in clinical practice allows a significant acceleration of ulcer healing and a reduction in treatment duration by 1.5–2.5 times compared to traditional therapy.

The use of intragastric ozone, laser, and NO therapy contributes to a substantial reduction in the recurrence rate of cardiac region gastric ulcers (by 5–7 times) compared to traditional treatment.

The developed methods of local intragastric ozone, laser, and NO therapy can be successfully used in surgical, gastroenterological, and therapeutic practice in the treatment of patients with ulcers of the cardiac region of the stomach.

Implementation of Research Results

The work has been implemented in the gastroenterological, surgical, and endoscopic departments of the 3rd Central Military Clinical Hospital named after A.A. Vishnevsky.

Work Dissemination

The main provisions of the dissertation were presented and discussed at a scientific-practical conference of endoscopists of medical departments and institutions of the Ministry of Defense of the Russian Federation (2000); the main provisions of the dissertation were presented and discussed at a scientific-practical conference of endoscopists of medical departments and institutions of the Ministry of Defense of the Russian Federation (Moscow, 2000); at the Congress of Lymphologists of Russia (Moscow, 2000); at the 1st Congress of Lymphologists of Russia (Moscow, 2003); at the 6th Russian National Congress «Man and Medicine» (Moscow, 1999); at a scientific-practical conference dedicated to the 30th anniversary of the department and the 25th anniversary of the clinical base of the Military Medical Academy (Moscow, 1999).

Publications

Based on the materials of the dissertation, 13 printed works have been published, and a patent for invention «Method for treating ulcers of the stomach and duodenum» No. 2147877 was obtained under application No. 99119852 dated 13.09.99.

Provisions for Defense

1. One of the causes of ulcer occurrence in the cardiac region of the stomach is a decrease in tissue trophism and their immune protection, which is expressed in a reduction in the density of microvessels in the cardiac region of the stomach compared to its other regions, and a reduction in the density of lymphoid tissue associated with the mucosa in the cardiac region compared to the body of the stomach and the pyloric region. In the cardiac region, due to the small volume of lymphoid tissue associated with the stomach wall, the process of antibody production is always under tension.

2. The use of intragastric ozone, laser, and NO therapy for local treatment of ulcers of the cardiac region of the stomach allows stabilization of immune indicators in the IgM and IgA classes.

A necessary condition for reliable prevention of recurrence of cardiac region gastric ulcers is NO therapy.

Intragastric laser therapy in patients with a newly diagnosed ulcer of the cardiac region of the stomach in the absence of a negligible amount of H. pylori allows achieving epithelialization within 15±0.5 days. In cases of combined ulcers of the cardiac and antral regions of the stomach or the duodenal bulb, with significant H. pylori prevalence, lymphotropic administration of polyoxidonium and ozonized physiological solution, and application of «Ozonid» oil to the ulcer of the antral region or the duodenal bulb 12 times, reduces the scarring period of ulcers to 11±0.2 days. The use of intragastric nitric oxide in patients with ulcers of the cardiac region of the stomach with severe concomitant pathology promotes epithelialization of ulcers within 5±0.4 days. Against the background of ozone and NO therapy, H. pylori prevalence decreases from 99.2% to 12.4%.