recurrent ulcer
Introduction
Introduction to recurrent ulcer Recurrent ulcer refers to a new ulcer that occurs in the gastrojejunostomy or duodenal jejunal anastomosis after surgical treatment of gastric or duodenal ulcer. Therefore, it is also called gastric jejunal ulcer, jejunal ulcer, anastomotic ulcer or marginal ulcer. In all recurrent ulcers, about 95% of them are seen after duodenal ulcer, and gastric ulcer rarely occurs after surgery. basic knowledge The proportion of illness: 1.3% Susceptible people: no special people Mode of infection: non-infectious Complications: colon fistula, abdominal pain, diarrhea
Cause
Cause of recurrent ulcer
Causes
The occurrence of recurrent ulcers is related to the improper surgical procedure or technical operation of the first operation. It may also be related to patients with hypergastrinemia or taking certain ulcerative drugs after surgery.
1. Vagal nerve incision After incomplete vagus nerve resection, the reported recurrence rate of postoperative ulcers is inconsistent, with a low of 1.5% and a high of 30%. Such a large difference indicates that it is not completely related to the technique or cutting of the operator. Improving the skill and experience of the surgeon is the key to preventing or reducing the rate of ulcer recurrence after vagus nerve ablation.
2. Insufficient range of gastrectomy For DU surgery, the distal gastric resection should be more than 75%. If the gastric resection range is less than 60%, the recurrence rate will increase exponentially because the gastric resection is insufficient and the residual wall cells are excessive. The stomach acid is still in a high secretion state.
3. Gastric sinus mucosa residue Gastric sinus mucosa can secrete gastrin, such as surgery-type selection caused by gastric antrum mucosa residue, G cells secrete a large amount of gastrin, causing ulcer recurrence, such as Bancrart surgery antral mucosal peeling is not enough Then cause recurrent ulcers.
4. The jejunal input is too long or the alkaline intestinal fluid is diverted. The farther away from the ligament of the ligament, the worse the acid resistance of the jejunum. If the jejunal input is too long, it may cause anastomotic jejunal ulcer. When the side of the output sputum coincides or the Rotx-en-Y gastric jejunostomy is performed, the anastomotic jejunal ulcer is easily complicated due to the diversion of the alkaline bile and pancreatic juice.
5. Gastric retention After vagus nerve dry surgery or selective gastric vagus nerve ablation, due to low gastric tension and gastric retention, gastric wall dilation stimulates gastric sinus mucosal G cells to continuously release gastrin or directly stimulate mucosa and submucosa Mast cells release histamine, resulting in increased gastric acid secretion.
6. Others such as patients with high gastrinemia before surgery, such as gastric antrum G cell hyperplasia, gastrinoma, multiple endocrine tumor type I, hyperparathyroidism, etc. can cause gastrin levels increased, Postoperative patients take long-term ulcer drugs such as hormones, aspirin, indomethacin (indomethacin) and so on.
Prevention
Recurrent ulcer prevention
1. Different from person to person, moderate exercise: According to the age, physical condition, condition and interest of patients with peptic ulcer, choose appropriate sports, exercise intensity and exercise time. For patients with middle-aged or older, special attention should be paid to the function of the cardiovascular system and whether it can be adapted to the exercise method selected.
2, step by step, and gradually increase the amount of exercise: when starting exercise, the amount of exercise is small. With the improvement of the patient's health, the amount of exercise can be gradually increased. After reaching the exercise intensity, the exercise should be maintained at this level. It is strictly forbidden to increase or suddenly increase the amount of exercise to avoid adverse reactions.
3, choose the appropriate time: patients with peptic ulcer should not exercise vigorously after meals, nor should they eat immediately after strenuous exercise. Generally, physical exercise with a large amount of exercise should be carried out 1 hour after a meal, and a general walk after meals; it will help digestion and absorption.
4, whole body exercise, mutual cooperation: exercise therapy for patients with peptic ulcer, should pay attention to the combination of whole body exercise and local exercise, in order to achieve better rehabilitation and health care. Generally, it is mainly based on whole body exercise. At the same time, it is helpful to cooperate with some appropriate massage treatments to improve the symptoms. It may have a certain effect on improving the blood circulation of the gastrointestinal tract to promote the healing of ulcers.
5, persevere, long-term adherence: exercise therapy has a certain effect on the rehabilitation of peptic ulcer, but not a day's work, only long-term adherence, can achieve the desired results. Because the body's nervous system, internal organs and limb function are perfected, the physical fitness is enhanced by the stimulation and reinforcement of multiple appropriate exercise quantities. Usually, the symptoms of peptic ulcer disappear quickly, but it takes a certain time for the ulcer to heal.
There is no effective preventive measure for this disease. Early detection and early diagnosis are the key to the prevention and treatment of this disease.
Complication
Recurrent ulcer complications Complications, colonic abdominal pain, diarrhea
The incidence of recurrent ulcers and blood is 50% to 60%. The amount of bleeding is large and fatal. The incidence of perforation is 1% to 5%. See more chronic penetration. Penetrating into the colon can cause stomach-jejunum-colon fistula. The incidence rate is about 10%. At this time, there are many abdominal pains, diarrhea, indigestion, belching, fecal odor or vomiting when there is fecal residue, which quickly loses weight.
Symptom
Recurrent ulcer symptoms Common symptoms Abdominal pain Peptic ulcer Diarrhea Nausea indigestion Hernia
The time of recurrent ulcers occurs more than half a year after surgery to several years, but some patients can occur shortly after surgery or as late as ten years later. Pain is still the main manifestation of recurrent ulcers. Heavy but often different from the preoperative, can be in the middle abdomen, left, upper, lower abdomen, back, rhythm disappeared, food or antacids relief is not obvious, foreign countries have reported that only 40% of the cases occur, often accompanied by Symptoms, vomiting and other symptoms, mostly due to anastomotic edema, sputum or pyloric tube, duodenal bulb outlet obstruction.
Examine
Examination of recurrent ulcers
1. Analysis of gastric juice after treatment of patients with BAO>5mmol/h, MAO>15mmol/h, suggesting that the ulcer recurred, such as increased BAO and no increase in MAO, indicating that the parietal cells are in a high secretion state, there may be a high stomach of gastrinoma. The cause of prostaglandinemia, if MAO increases and BAO does not increase, indicating that the total number of parietal cells still remains, the scope of gastric resection is not enough, after vagus nerve ablation, BAO>2.0mmol/h or MAO>15mmol/h, suggest The vagus nerve is not completely cut.
2. Gastrin determination of serum gastrin> 500ng / L may be gastrinoma, gastric sinus G cell hyperplasia or gastric antrum mucosa residual, further calcium stimulation test or secretin stimulation test, such as serum Gastrin > 1000 ng / L can be diagnosed as gastrinoma.
3. Serum calcium was measured to exclude the hyperparathyroidism type I syndrome of hyperparathyroidism.
4. Radionuclide scanning gastric mucosa can ingest and secrete 99mTc, such as residual gastric antrum mucosa in the duodenal stump, intravenous injection of 99mTc, radioactive concentration in the corresponding area, its specificity of 100%.
5. Congo red test Congo red can be applied locally before or during surgery. If the vagus nerve is incomplete, the acid secretion of the gastric mucosa at the corresponding site makes the pH 3, then the Congo red turns blue-black.
6. The fake meal test is a better way to detect whether the vagus nerve is completely cut off. The patient swallows all the food after chewing breakfast, and the sham feeding acid output (SAO) is administered 1 hour, and the pentagastrin gastrin is injected subcutaneously. 6g/kg, and then measure the peak acid secretion (PAO). If SAO/PAO<0.1, it indicates that the vagus nerve is completely cut, otherwise it is not complete.
7. Fiber gastroscopy The examination of fiberopticoscopy is of great significance for the diagnosis. It can clearly distinguish the diagnosis of gastritis and ulcer. However, ulcers that occur on the jejunal side of the anastomosis after the operation of Billroth II or gastrojejunostomy are often difficult to be It is found that it is necessary to observe carefully. It is best to use a side-view type endoscope. The recurrence ulcer after Billroth I type operation is mostly located on the stomach side of the anastomosis. The suture is not used for anastomosis. Sometimes suture abscess can occur. Symptoms of ulcers, sometimes under the gastroscope, the center of the anastomotic ulcer is observed as a non-absorbent suture.
8. X-ray examination of the upper digestive tract barium meal examination for the diagnosis of recurrent ulcers is not as reliable as the diagnosis of gastric or duodenal ulcers, generally considered to be only about 50% accuracy, so barium meal imaging is negative, can not be ruled out Recurrent ulcers, anastomotic ulcers do not necessarily appear in the barium meal examination, sometimes can be diagnosed according to the tenderness and irritation of the anastomosis.
In the recent postoperative barium meal examination, the protrusion or defect of the normal anastomosis is often misdiagnosed as anastomotic ulcer, which is caused by the illusion of anastomotic edema or anastomotic suture. Therefore, postoperative It is advisable to check the barium meal for 6-8 weeks.
Diagnosis
Diagnosis and diagnosis of recurrent ulcer
diagnosis
Irregular abdominal pain after peptic ulcer, accompanied by nausea, vomiting, or abdominal pain, diarrhea, indigestion, hernia or bleeding, should consider the possibility of recurrent ulcers.
Differential diagnosis
Before diagnosing recurrent ulcers, you should first understand whether there is any operation or selection error in the first operation, or whether the patient has taken ulcerative drugs; other postoperative complications and malignant lesions are excluded.
