Basic methods of peptic ulcer treatment
Peptic ulcer is a chronic disease and requires a long and systematic treatment, and at some stages it is shown the placement of the patient in a hospital, outpatient treatment and in some cases surgery. Spa treatment plays an additional role.
Bce these stages of treatment have no smug value and lead to good results only when combined. Scheduled treatment can be carried out only if the patient is dispensary for ulcer disease.
An obligatory condition for successful treatment is the elimination of the hazards that contribute to the development of peptic ulcer. In this regard, the doctor must intervene in the organization of the patient's life, establish a rational daily routine, and if necessary, to deal with employment issues. It must be assumed that the ulcer should not lead to disability of patients. In the vast majority of cases, patients can continue their professional activity, unless it is associated with special hazards (excessively heavy physical work, work associated with toxic substances, work that does not allow regular meals, etc.).
At all stages, a comprehensive treatment should be applied, based on a therapeutic diet. Naturally, therapeutic nutrition should be different depending on the form and stage of the disease, the individual characteristics of the patient and the conditions of therapeutic nutrition (hospital, sanatorium, outpatient treatment).
Differentiated use requires other methods of complex treatment, among which a special place is occupied by methods that primarily affect the nervous system.
Inpatient treatment is shown, always when a patient has an unhealed ulcer, regardless of how pronounced the clinical symptoms are. It is wrong to think that in hospital conditions only seriously ill people with complications and longstanding illness should be treated. It is more rational to start treatment at an early stage, as there is a better chance to fully cure the ulcer.
Basic diets used in hospital treatment
As early as at the end of the last century, systematic courses of therapeutic nutrition started to be developed, which were conducted in hospital conditions. An example of this is the antipeptic diet developed by W. Leube. At the beginning of the course of treatment, only rectal nutrition was allowed and only later it was allowed to gently take food through the mouth.
This diet was based on the idea of maximum gastrointestinal compassion. At that time, the gastric grooming was taken into account mainly in terms of simple clinical observation over the tolerance of certain types of food. However, the authors also considered the clinical and experimental data on the duration of stay of different kinds of food in the stomach. The data of I.P. Pavlov's school about the influence of food on secretory activity were not known at that time. That is why the Leibe diet, along with the food products included in all later anti-eptic diets, contains such strong secretion irritants as meat broths, raw stapled meat, spinach, and others. Although in the light of modern knowledge, it is possible to object to some details of this diet, but in general, the principles of maximum gastric gentle stomach sparing have proved to be justified and formed the basis of most modern anti-eptic treatment methods.
The Lenhartz diet was proposed as a counterbalance to the ideas of Leiba. This author believed that the Leibe diet does not give the body enough material for successful healing of ulcers. He highlighted the need to influence the body by improving its nutrition. According to Lenhartz, immediately after bleeding the patient was allowed to eat: first, only liquid food was given, then the diet was quickly expanded and in a short time the calorie was increased to high numbers.
So, historically there have been two main ideas of ulcer treatment: maximum gastric gentleman's grip and favorable effect on the general state of the body.
Of the more modern diets, a diet developed by Kalka (H. Kalk) is common. The principle of gradualness in this diet is expressed in the fact that it is expanded every day by introducing new dishes or increasing the amount of food. On the organizational side, such a diet is certainly much more difficult to build in hospital and clinical settings.
Treatment begins with total starvation. Liquid is injected by drip enemas or under the skin. We also recommend intravenous injection of 40% hypertensive glucose solution (several times a day, 20-25 ml). Nutrition through the mouth begins with an injection of 5% sugar solution. Then gradually add milk, mucous soups, porridges, eggs, butter and other products usual for anti-eptic diets, slightly limiting the amount of milk and eggs.
The diet is mainly carbohydrate in nature. A strict version of the treatment of Calc considers it necessary to apply to hemorrhage and severe peptic ulcer, but many clinicians recommend treating all patients with ulcer start with a few hungry days.
Against the treatment of "hunger" says not only its exhausting effect on the body, but also the fact that hunger does not create a state of rest for the stomach. On the contrary, there is a "hungry peristalsis" and "hungry secretion", in an empty stomach often accumulates a significant amount of active gastric juice. Therefore, we believe that the use of "hungry days" is inexpedient in patients with uncomplicated ulcers and shown for a short period of time only with severe stenosis and ulcers flowing with significant phenomena of peritoneal irritation (in the preperforative state).
Some clinicians in addition to a regular diet of ulcers advise to give 2 times a day before meals 30-100 g of pure vegetable (olive or Provencal) oil. The favorable effect of the oil is due to its high caloric value, the ability to inhibit secretion and stimulate intestinal function. The data from the physiological experiment confirm the inhibitory effect on the secretion of fat introduced before meals. With the introduction of fat for 1 - 1.5 hours before meals, H. I. Leporsky noted a decrease in the sokogon effect of vegetables by 30-50%. The greatest deceleration is observed when taking moderate amounts of fat. Therefore, for therapeutic purposes, H. I. Leporsky recommends 25-40 g of oil at a time. We successfully use fish oil, which is all the more useful because it contains large amounts of vitamins A and D.
Sugar therapy for peptic ulcer, or honey treatment, is also known. It is prescribed 2-3 times a day for 50-100 g of concentrated solution of sugar or honey. According to our data, concentrated solutions of sugar or honey in the first (hyperglycemic) phase do inhibit gastric secretion, but in the second (hypoglycemic) phase they significantly stimulate secretion and cause increased stomach peristalsis. At the same time, our observations have shown that the introduction of large amounts of easily digestible carbohydrates, causing rapid and significant fluctuations in blood sugar, strongly excites the autonomic nervous system. Finally, clinical observations indicate that sweet food is not well tolerated by some patients, in some cases it causes heartburn and other dyspeptic events. Therefore, we believe that sugar therapy is contraindicated for patients with excitable autonomic nervous system and patients with persistent heartburn. It can be used in exhausted patients and in patients without irritable stomach syndrome.
A. I. Yarotsky includes in his diet only those foods that have a minimal juicy effect. The use of Yarotsky's diet is divided into two periods. In the first (protein-fat) period, only raw egg whites and sweet butter are allowed to eat. On the first day of treatment, one egg white and 20 g of butter are given. Then daily add one protein and 20 g of butter. Thus, by the 10th day of treatment the patient receives 8-10 proteins and 140-180 g of butter. Proteins and butter should be given separately, because when they are introduced together under the influence of fat, the time of protein stay in the stomach is prolonged, it has time to peptonize and becomes a chemical irritant of secretion. Therefore, it is recommended to give protein in the morning, and butter in the evening. In 10 days the patient is transferred to the second (carbohydrate-fat) stage of the diet, allowing: 1) semi-liquid soups from cooked grated cereals or potatoes on water with butter; 2) liquid grated porridge or puree (from potatoes or cooked vegetables) on water with butter; 3) puddings from cereals or vegetables; 4) sweet porridge with fruit sauce or jam syrup, as well as puree from non-acidic fruits. Do not put salt in the dishes. If possible, limit the introduction of liquids, except for the one that the patient receives with soups and porridges. It is also forbidden bread (maximum 1-2 slices of white bread per day). Only exceptionally allowed meat in the form of steam cutlets. If the meat is given by lunch, then butter is excluded. A. I. Yarotskyy advises to keep such a diet for a long time.
We cannot recommend such a diet.
On the negative side it should be considered a complete disregard for the physiological needs of the patient: the diet is one-sided and inferior. Despite the sufficient caloric intake of food, in some cases, patients lose a lot of weight, often complain of disgust for food (total loss of appetite), sometimes even persistent vomiting is observed. In addition to the poor taste properties of the diet, these disorders are likely to be caused by metabolic disorders that develop under the influence of unilateral nutrition (shift towards acidosis).
Based on the idea that it is advisable to neutralize gastric juice for a more successful healing of the ulcer, Sippy (B. W. Sippy) has developed his own method of treatment. After every hour, the patient receives. 100 g of milk in half co cream. Between meals one of the following powders is given: 1) Natrium bicarbonicum (sodium bicarbonate, soda, NaHCO3), Magnesia usta (burnt magnesia) 0.5 (when constipated) or 2) Natrium bicarbonicum 1.5, Calcium carbonicum 0.5 (when inclined to diarrhea). Constant alkali injection Shippi seeks to neutralize the gastric juice. If the gastric content is found to still have free hydrochloric acid in the stomach in the evening, the amount of alkali is increased until it is possible to neutralize the entire acid. The diet is gradually expanded: oil, eggs, breadcrumbs, porridge are added, but at each meal the total weight of the meal should not exceed 200 g. This course of treatment lasts 3-4 weeks. Less strict Sippie diet is recommended for a long time. Cases of very favorable clinical effect of Sippie's diet have been described. At the same time, it was found out that the introduction of such significant amounts of alkalis is not indifferent to the body: there are observed phenomena of alkalosis, cases of formation of renal and liver stones are described. Bce, these considerations speak against the appropriateness of the Sippie diet in its original version. Sippie followers are now using less alkalis.
As early as 1910, Einhorn proposed the use of transduodenal feeding in the treatment of ulcers. The patient is injected through the nose into the small intestine with a duodenal probe with a silver-hole olive at the end. The probe is kept in situ (in place) for 12-15 days. Every 2 hours through the probe is injected near a glass of milk, glucose, then yolks, cream, fruit juice. B. H. Sight recommends transduodenal feeding 200-250 ml of milk every 2-3 hours with the addition of sugar, eggs, butter and vitamins (A, B, C and D). Very good results of transduodenal feeding were observed A. B. Dobrosklonekiy and T. A. Belolipetskaya, S. Halfen and especially B. H. Smotrov, who writes in his monograph: "This method has undoubted advantages, ensuring success when other methods do not produce the effect. It may prove to be the best method that provides not only relief of pain, but also healing of deep, even penetrating stomach ulcers".
However, this method also meets with significant objections. First of all, many patients have a hard time with such treatment. Secondly, it is unlikely that transduodenal nutrition can provide the stomach with complete rest and stop its secretory activity. According to studies by I.P. Razenkov, the second (chemical) phase of gastric secretion can be carried out as a result of absorption of food digestion products in the intestines. This position has been confirmed by both animal experiments and clinical studies (O. L. Gordon, B. H. Smotrov and B. H. Smotrov). G. Hlystov, B. Y. Shlapo-Bersky and E. F. Saxon). A certain influence on the secretory function of the stomach has a long stay of the probe. According to newer data, mechanical irritation of stomach mucosa is a strong secretion agent (C. I. Chechulin, I. T. Kurtsin, etc.). Taking into account all these considerations and great difficulties in this treatment, we cannot recommend transduodenal nutrition as one of the main methods of treatment of patients with ulcer disease. We find it more appropriate to use it in severe cases of ulcer that cannot be treated by other methods of conservative therapy.
B CCCP is a widely used peptic ulcer diet developed by M. I. Pevzner and known as "first diets". These diets consist of three diets: No 1A, 1B and 1. Each of the first two diets is prescribed for 10-14 days. The idea of sparing the stomach is carried out on Singer's diets with a large sequence: as far as possible, the mechanical stimuli of the stomach are eliminated, its secretory and motor function is relieved, food is introduced often, in fractional doses. At the same time, much attention is paid to the nutritional value of the food.
In the initial stage of treatment, all dishes are given in liquid form or in the form of jelly (diet number 1A). The patient receives food every 2-3 hours. It is allowed to eat more than two dishes in one meal. The amount of salt is limited by the lower physiological norm (to 6-8 g). Diet № 1A contains 4-5 glasses of milk, milk or mucous soups (from cereals or wheat bran) with butter, unsalted butter (70-80 g), eggs softened or in the form of steam omelette, kissel and jelly berry, fruit (non-acid) and milk. Day ration contains 50 g of sugar. Bce other food products (including bread and breadcrumbs) are prohibited.
In recent years, some changes have been introduced in the standard diet № 1A. Once a day liquid milk porridges made of mana grits or ground rice are allowed. The number of eggs is reduced to 2-3 a day. The lack of protein is compensated by the inclusion of boiled meat soufflé or zander in the diet. The new version of the diet reduces the amount of cholesterol and increases the amount of protein. This variant is better saturated and, as observations have shown, is satisfactorily tolerated by patients.
The daily diet with diet number 1A contains: protein 80 g, fat 100 g, carbohydrates 200 g; calories about 2000.
In Russian literature, especially under the influence of the statements of A. I. Yarotsky, there are often objections to the prescription of milk to patients with ulcer disease. This is usually motivated by the data from experimental research, which showed that milk is a rather significant pathogen for gastric secretion.
t the same time it is known that milk also represents some mechanical load, because in the stomach it is shaken and forms quite dense clots. However, milk is an exceptionally complete food product and contains most of the nutrients necessary for life, growth and tissue regeneration (except iron and some vitamins).
However, clinical experience suggests that milk diets have a beneficial effect on the course of peptic ulcer (on the physiological effect of milk in peptic ulcer we will stop below). We believe that it is unreasonable to exclude milk from a diet in anti-eptic treatment, especially if "scrawny" milk is a relatively strong secretion irritant, then undone, fat-rich milk causes less secretion of gastric juice than other food products. In addition, the juice released under the influence of milk has a low digestibility (H. Gordeev). However, some patients with peptic ulcer do not tolerate milk well; sometimes it causes intestinal phenomena: bloating, crucifixion, diarrhea or, less often, dyspeptic phenomena, burning in the anterior region, acidic burps, etc. Ho most of these patients still manage to get used to milk, even if at first they did not tolerate it well. For this purpose, at the beginning of treatment milk is given small portions diluted (co weak tea), necessarily in warm form. Some patients are well tolerated milk, slightly tinted cocoa or coffee. When diarrhea occurs with increased fermentation processes, it is useful to add lime water to milk (1-2 tablespoons per glass). Only very rarely, when all these remedies do not lead to a goal, milk should be replaced with mucous soups, diluted cream or vegetable milk (almond, nut).
Milk soups, like milk, have long been successfully used in the treatment of patients with ulcer. Old empirical data have been confirmed in experimental studies on dogs with Pavlovsky ventricles. These experiments showed that mucous soups only slightly excite secretion (M.I. Pevzner, G.L. Levin and C.I. Chechulin). Boas ascribed the known protective action to mucous membranes of the stomach to protect the stomach mucosa from mechanical irritations.
Eggs softened or in the form of a steam omelette contain complete protein, are rich in phospholipids and give only a small load for the stomach (egg yolks without protein, according to M. Egg yolks without protein, according to M. Pevzner, have a sharper juicy effect).
Comparatively large amounts of oil, which are part of diet number 1A, allow you to increase calorie intake. It is known that fats tend to suppress secretion, but it is necessary to consider the two-phase action of fat, as well as the fact that if the food (proteins, carbohydrates) is added oil, the acidity of gastric juice, although falling, but the time of secretion lengthen. Clinical observations suggest that butter has a good effect if it is administered in moderate amounts.
The vitamin composition of the diet deserves special attention. The study of vitamin metabolism indicates that often observed in patients with peptic ulcer significant deficiency of a number of vitamins, primarily vitamin C and group B (A. Acharkan, B. H. Sights). Clinical observations also often reveal symptoms suspected of deficiency of these vitamins: bleeding gums, capillary fragility, gingivitis and glossitis.
The cause of vitamin deficiency is probably not an ulcer disease, but the malnutrition of a patient with peptic ulcer, often following a strict, gentle diet for a long time. Studies A. I. Acharkan and other authors have shown that vitamin deficiency in patients with peptic ulcer can be eliminated by introducing food rich in vitamins, or special vitamin concentrates, or drugs. To maintain vitamin balance in the body of a patient with peptic ulcer is enough to introduce vitamins in amounts approximately corresponding to the double physiological norm.
Vitamin C should be administered at least 100 mg per day. To eliminate vitamin deficiency as quickly as possible, it is advisable to increase this amount during the first week of treatment to 300 mg per day. As observations A. have shown. I. Acharkan, large doses of vitamin C, of course, have a beneficial effect on the general condition of patients with ulcer. These amounts of vitamin C can be given to a patient receiving a diet number 1, in the form of decoction of rosehip. The extensive experience of our clinic shows that most patients are well tolerated this decoction.
Antiviral diets are usually poor in group B vitamins. Vitamin B1 is known to play an important role in carbohydrate, protein and water metabolism. It is essential for the formation of acetylcholine, provides normal tone of the digestive system and affects absorption from the intestines. Studies conducted in our clinic (B. C. Nikitin) have shown that under the influence of large doses of vitamin B1 normalizes impaired gastric secretion and favorably changes the course of trophic disorders.
Parenteral administration of large doses of vitamin B1, according to our observations, patients with peptic ulcer (c vegetative dystonia) do not always tolerate well, because this vitamin in some cases increases the excitability of the nervous system. We believe that parenteral administration of large doses of vitamin B1 is shown only at sluggish trophic ulcers and in patients with sharply reduced gastrointestinal tone.
According to observations 3. I. Malkin, nicotinic acid helps to reduce increased gastric secretion, has an antispasmodic effect and has a beneficial effect on the course of ulcer disease. Ho these data are still to be tested. He is less important is vitamin B2 (riboflavin), which stimulates healing processes (B. B. Efremov).
Vitamin A also plays an important role for the successful course of epithelization processes. A regular diet of diet #1A contains a sufficient amount of this vitamin. We consider as shown the introduction of an increased amount of vitamin A in case of sluggish healing of ulcers and peptic ulcer with symptoms of A-vitamin deficiency. The patient should receive at least 100 mg of ascorbic acid, not less than 4 mg of vitamins B1 and B2 (riboflavin), not less than 30 mg of nicotinic acid and not less than 2 mg of vitamin A. C food can not enter such a large amount of vitamins (especially group B). Vitamin deficiency patients may receive in the form of drugs.
Patient on a diet number 1A, must observe strict bed rest. Care should be taken carefully for the oral cavity (frequent mouthwash, mechanical cleaning of the tongue, lubrication of the tongue and lips with glycerin).
In case of a favorable course of the disease in 10-14 days the patient is prescribed diet number 1B.
To the menu - diets number 1A in diet number 1B add 50-70 g of white breadcrumbs, meat or fish dumplings or meat soufflé, grated white porridge with butter, grated soups from cereal. Day ration contains: protein 100 g, fat 100 g, carbohydrates 300 g; calories about 2500.
Cooking salt is given in moderate amounts - up to 10 g. Vitamins are introduced in the same form as in diet number 1A. The principle of frequent and fractional nutrition is preserved.
The introduction of solid food provides better oral cleansing. White bread, although it causes a noticeable separation of juice into the reflex phase (within the first hour), is a weak chemical secretion agent. Dried white bread is easily crushed in the stomach and leaves it relatively quickly (70 g of bread is removed from the stomach after 2-3 hours).
Meat or fish, devoid of extractive substances and cooked in the form of loose dumplings, peptic ulcer patients usually tolerate well. In experimental studies, it turned out that such meatballs and dumplings cause relatively little irritation of the stomach secretory apparatus (M.I. Pevzner et al.).
The secretion in the use of various porridges, both in quantity and quality, is very close to that of bread. Bce clinicians agree that wiped dairy uncooked porridges and wiped cereal soups used in diet #1B are usually well tolerated by peptic ulcer patients.
During the period of stay on diet #1B, the patient remains in bed. With a favorable course of the disease after the specified period (10-14 days) the patient is transferred to diet number 1, in which the diet is even more extensive.
The principle of frequent and fractional nutrition (5-6 times a day) is preserved.
Allowed: weak tea with milk or cream, whole milk, water with lemon and sugar, cream, stale bread, white bread, white breadcrumbs, cookies, butter, butter, fresh cottage cheese, non-oxide sour cream, cream cheese, non-oxide yogurt, eggs, steam omelets, soups, meatless and non-fish, grated croup, slimy pea, boiled meat, soft, nonfat, fish boiled, tender, steam cutlets, steam soufflé, boiled soft chicken, boiled soft lean pork, porridges with butter or milk, noodles, pasta, steam puddings of croup, white bread. Greens and vegetables are given in crushed form (puree) or finely chopped, boiled or baked (cabbage, sorrel, spinach are excluded). Allowed sweet berries (strawberries, raspberries); sweet fruit, boiled, grated; sweet: compote, cream, snow, jelly, kissels (non-acid). From sauces and seasonings are allowed white sauce with a little acid and Provencal, butter, sweet sour cream. Cooking salt is introduced in normal quantities. To increase the vitamin intake, the patient is given (except for those included in the dish) raw vegetable, berry and non-acidic fruit juices, broth of rosehip, vitamin concentrates and preparations.
Day ration contains: proteins 100 g, fats 100 g, carbohydrates 400-450 g; calories about 3000.
Such an expanded diet is a known load for stomach function, but allows you to give the patient a varied and complete diet. This is especially important because the patient must follow the diet type 1 for a long time and after the end of inpatient treatment.
If the disease occurs with symptoms of an "irritated stomach", then when switching from diet № 1B to diet № 1, patients often have dyspeptic events - heartburn, acid burp, etc. In such cases, the transfer should be made not immediately, but gradually, over several days. This transitional diet is allocated to a special diet № 1b. At first, only a part of bread is replaced with bread, vegetable puree and steam cutlets are allowed once a day.
With the conversion to diet number 1, i.e. after 3-4 weeks of lying down, the patient is allowed to get out of bed.
o, the principle of gentle basic functions of the stomach in disassembled diets is carried out with great consistency. It affects both the choice of dishes, and the gradualness with which the expansion of diets takes place. At the same time, the impact of diets on the general state of the body and the nervous system should not be underestimated.
The proposed anti-plague diets are quite caloric. Even the most restrictive diet 1A contains about 2000 calories, i.e. it can cover the body's need for rest.
As early as in I.P. Pavlov's laboratory it was shown that insufficient nutrition leads to weakening of conditionally reflex activity, reduction of excitation and inhibition processes in the cerebral cortex. Taking into account the influence of food diet on higher nervous activity is of great importance, because, according to the above data, in many patients with ulcer the activity of cortical activity decreases.
According to experimental studies conducted in the laboratory of I.P. Razenkov, in terms of comparative effect on conditional reflex activity, different food regimes are located in such a sequence: the greatest increase in irritable cortical process of the cerebral hemispheres causes a fatty food regime, similar, but weaker action has a meat regime, and the carbohydrate regime significantly reduces the irritable process.
Recent studies at the Institute of Nutrition (A. I. Makarychev and M. A. Sergeeva) have confirmed the importance of protein for the activity of the central nervous system. At the same time, the phosphorus-lecithin compound has been shown to have a great influence in this respect.
If we proceed from the above mentioned literature data, we should admit that the chemical composition of diets developed in the Clinic of Therapeutic Nutrition should have a stimulating effect on the cortex and increase its activity. In fact, diets 1A and 1B can be characterized as relatively rich in fats, proteins, phospholipids (eggs) and relatively poor in carbohydrates. It should be noted that the content of proteins of animal origin is quite high. In diet № 1A almost all the amount of proteins (80 g) is introduced with products of animal origin (milk, eggs, curd, meat).
Adequate calories, rich content of animal proteins should at the same time have a stimulating effect on regeneration and healing processes. In the same direction affects the addition of vitamins.
Antimicrobial diets (especially № 1A) are rich in milk. Milk diets are known to have a dehydrating effect on the body, which reduces the propensity for inflammatory reactions. Positive effects on the body of a patient with ulcer should also have a rich calcium content in milk in the most favorable ratio with phosphorus. Finally, it should be noted that, according to studies A. B. Solovyov, milk contains sympathetic substances, which is essential for patients who often have an increase in parasympathetic nerve tone.
It may be thought that the reduction of the excitability of the nervous system is also due to monotonous nutrition, frequent and fractional introduction of food, gradual expansion of the diet and some restriction of carbohydrates in the first stages of treatment.
Thus, it should be recognized that the developed anti-eptic diets not only have a local effect on the stomach, but also affect the general state of the body, on a number of pathogenetic mechanisms that play a role in the development of ulcer disease.
We stopped at analyzing a number of diets offered for the treatment of peptic ulcer. Bce they have advantages and disadvantages. The comparative assessment of different diets conducted by us and other clinicians (I. O, Neimark, I. M. Rybakov) showed that the use of different methods of anti-eptic treatment leads to good results. It seems to us that more complete diets, which have a stronger effect on the general state of the body and are relatively better tolerated by patients, deserve preference. In our opinion, the diets proposed by M.I. Pevzner meet these requirements to a greater extent, especially since the use of these diets is not very difficult.
In order to differentiate treatment more widely, a number of changes should be made to the basic peptic ulcer regimen described above.
Differential Diet Therapy
Medical nutrition in the treatment of a patient with ulcer in the hospital should be differentiated taking into account the peculiarities of clinical manifestations of the disease and individual physiological characteristics of the patient.
Therapeutic nutrition in case of different types of peptic ulcer
1. Patients with the first type of peptic ulcer, who have a pronounced phenomenon of vegetative dystonia and have the disease with symptoms of an irritated stomach (persistent heartburn, acidic regurgitation, a propensity to gatekeeper spasms, gastric hyper-secretion with the prevalence of the first phase of secretion, etc.), we recommend the use of a diet variant with a restriction of carbohydrates. In the past, we have advised to limit carbohydrates at all stages of treatment, starting with diet number 1A. Experience has shown that it is possible to reduce the number of carbohydrates only on diet number 1, because the already existing diet number 1A and 1B contain a limited number of carbohydrates and, as a rule, are well tolerated even by very excitable patients. Ha Diet No. 1 carbohydrate is reduced to 250 g, while the amount of protein and fat is increased to 120 g. Otherwise, the characteristics of the main variant of the anti-plastic diet are preserved. In this group of patients, the gradual expansion of the diet is of particular importance, so the transition from diet № 1B to diet № 1B is included.
Carbohydrate restriction is recommended in connection with experimental and clinical studies, which indicate that carbohydrate restriction decreases the excitability of the autonomic nervous system, the reflex excitability of the stomach, in particular, the first nerve-reflex phase of gastric secretion is reduced. At the same time the symptoms of stomach irritation and reactive hypoglycemia are softened.
Therapeutic nutrition in this group of patients should be combined with the use of several other methods of therapeutic influence on the nervous system.
2. In the third type of peptic ulcer, characterized by a number of nervotrophic disorders of the body, it is recommended a diet with an increased content of proteins, some vitamins and general caloric intake.
In case of a marked decline in diet, treatment begins with diet number 1B, bypassing number 1A. The amount of protein on a diet № 1 increases to 130-140 g, and calories - up to 3500-3600 due to some increase in carbohydrates (up to 500 g). In addition to the usual protein carriers, you can use a dry hematogen, which is usually well tolerated by patients.
It is also recommended to administer additional fish oil (one tablespoon 2-3 times a day) and injections of relatively large doses of vitamin B1 (20-50 mg once a day for 12-15 days).
Application of other methods of complex therapy, affecting the trophicity and having a general stimulating effect on the body, is shown.
3. Patients in whom peptic ulcer develops against the background of gastritis, you can prescribe the main version of the anti-eptic diet.
Stomach washes, intake of a weak solution of lapis (0.05-0.1 g per 200 ml) are known to be the most important additives. Gastric lavage is contraindicated in the presence of deep ulcers, in the phenomena of peritoneal irritation, as well as a tendency to bleed.
4. Patients who develop ulcer disease against the background of vascular lesions (atherosclerosis), are excluded from the diet of the egg and the amount of animal oil decreases (up to 30-40 g), increases the amount of cottage cheese, part of the milk is replaced by juices of vegetables (tomatoes, carrots), fruits and berries (black currant, strawberries), is given broth of rosehip, diluted lemon juice. Large doses of ascorbic acid are prescribed (up to 300-500 mg per day). Energetic thermal treatment is contraindicated. The usual medication therapy is used for vascular diseases.
Therapeutic nutrition in case of complications of peptic ulcer
One of the most frequent complications of peptic ulcer is bleeding. The vast majority of therapists and surgeons agree that during acute bleeding shows conservative treatment. It is also unanimously recognized that with repeated bleeding of undoubtedly ulcer origin of the patient should undergo radical surgery, if possible in the cold period.
The main method of conservative treatment of peptic ulcer bleeding until recently was complete peace. While the bleeding continued, recommended a hungry regime, allowing only frequent mouthwashes (water, including carbonated, mint solution). The liquid needed for the body was usually injected in the form of physiological solutions, glucose solutions with drip enemas or under the skin. Most clinicians have now abandoned their favorite nourishing enemas in the past, because the nutritional value of such enemas is very questionable. In addition, enemas are very irritating to the rectum. An intravenous injection (several times a day) of hypertensive (40%) glucose solution has been shown.
With a significant drop in blood pressure and an apparent weakening of heart activity were assigned cardiovascular drugs (camphor, corazole, adrenaline, etc.). Ordinary meals were allowed only after the disappearance of signs of significant profiled bleeding. In addition to bloody vomiting, such signs include a high blood content in the feces (tar or dark-cherry feces), excruciating thirst, gases with a specific smell of decomposed blood, increased body temperature, and most importantly, the continuing fall in blood pressure.
Only after the disappearance or significant reduction of these symptoms, which indicated the cessation of massive bleeding, began to feed the patient. At first, only liquid cold food was allowed: frozen milk with tablespoons, kissels, thin jelly, mucous soups, rosehip decoction (not more than 200 ml per day). With a favorable course of the disease, the amount of food was gradually increased, meat, eggs were added and then the patient was transferred to a regular ulcer diet, such as № 1A.
Recently, this method of conservative therapy, built on the principle of maximum gastric gentlemen, has been revised. Danish clinician Meilengracht (E. Meilengracht) believes that in most cases, the cause of death by bleeding is not the loss of blood, but the total exhaustion of the body and complications arising from such exhaustion. Therefore, the main task of treatment of patients with ulcer during bleeding Meilengracht believes the improvement of the general condition of their body. He attaches particular importance to a fairly complete diet.
It is good to feed a patient Mailengracht advises even in the midst of bleeding. He allows to give food in the form of liquid or puree, rich in proteins, salts, vitamins. "The stronger the bleeding, - indicates Mailengracht, - the greater the body's need for food and drink. Already on the first day of treatment, the patient should receive about 2000, and later - up to 3000 calories. Mailengracht does not consider it necessary to prescribe absolute rest to the patient. He allows them to move freely in bed, and after 2-3 weeks - to walk. In addition to diet, Mailengracht recommends prescribing alkalis, high iron doses (3-5 g per day), in case of massive bleeding - repeated blood transfusions.
On the positive side of its method of treatment Mailengracht also includes the elimination of the collapsed state in patients (often observed in large bleedings), a good mental state, the rapid disappearance of dyspeptic events, restoration of intestinal function, a significant reduction in the period of reconstruction and restoration of red blood. Ho at the same time, Meilentracht points out that his recommended energetic nutrition has no hemostatic (styptic) effect and does not shorten the duration of bleeding.
Most clinicians both at CCCP (M.I. Pevzner, M.M. Hubergritz) and abroad are quite satisfied with the results of the Meilengracht test for the treatment of ulcer bleeding. However, there is no complete unanimity in the evaluation of this method so far. Some doctors prefer to treat these patients the old way, others recommend in all cases, apply the method of Meilengracht in all cases.
We believe that in the case of profiled bleeding, when the patient bleeds, it is more appropriate to use the old methods of maximum gentlemen. Mailengracht method does not reduce the intensity and duration of bleeding. The fate of the patient with a massive bleeding often depends on the rapid termination of it. Another thing with a bleed of medium strength or small. In these cases, we believe it is certainly appropriate to use the Mailengracht method, which is also shown after the termination of massive bleeding, when the main task is to restore the patient's strength as quickly as possible.
Small but prolonged gastric bleeding requires special attention. In these cases, patients should also be nourished vigorously, increase the amount of protein in the food and inject additional vitamins C and K. However, such patients should be carefully examined, because the cause of persistent bleeding may be another stomach disease (cancer, degenerated ulcer, polyp), blood disease or, finally, C-vitaminosis. An energetic Meilenstracht diet is certainly shown in all cases in the recovery phase after the end of bleeding.
In all cases of ulcer bleeding it is necessary to administer large doses of vitamin C (200-300 mg per day). A. B. Palladium recommends prescribing patients with bleeding also vitamin K or, even better, a water-soluble vitamin K preparation - vicasol (15-20 mg daily for 5-7 days). In addition to the therapeutic nutrition, the following is shown: intravenous infusion of hypertensive solutions (10 ml 10% solution of table salt or calcium chloride), parenteral administration of indifferent horse serum, and others. Of particular importance are repeated transfusions of small hemostatic doses of compatible blood (50-100-200 ml).
In the past, the Clinic of Therapeutic Nutrition has developed special diet schemes for the treatment according to the Meilengracht principles. Experience has shown that it is possible to circumvent existing diets by making some adjustments to them. The treatment can be started with diet number 1B by adding boiled fruits and vegetables in the form of puree and enriching the diet with raw vegetable, fruit or berry juices, as well as vitamins C and K. In the future, the patient is transferred to diet number 1 and the addition of vitamins is preserved.
Often, peptic ulcer is complicated by the phenomena of stenosis. The clinical picture of stenosis sometimes depends not only on the scar contraction of the gatekeeper and duodenum, but also on the shortening of the small curvature as a result of ee scar wrinkling ("snail-shaped" or "cetacean" stomach). In addition to scar shrinkage, inflammatory infiltration in the ulcer area and gatekeeper spasm may also be the cause of stenosis, which is especially common with gatekeeper localization of the ulcer. In these cases, sometimes there is persistent, indomitable vomiting. Ho, in addition to the size of obstacles, the degree of motor failure is also highly dependent on the muscle strength of the stomach walls. During the war we often saw in exhausted patients expressed motor failure with a relatively small contraction of the gatekeeper.
Even a thorough clinical examination does not always solve the question of whether the process is reversible or irreversible. Therefore, we consider it advisable to carry out a trial ulcer treatment if there are symptoms of stenosis.
On ordinary anti-eptic diets, known corrections should be made: the intervals between meals should be extended, the volume of injected at one meal should be reduced and the caloric value increased. It is especially important to increase the amount of protein. Atropine, papaverine and platyphylline are recommended as antispatics. Thermal procedures also have an antispastic effect. In some cases, a course of parenteral administration of vitamin B1 (10-40 mg at a time) promotes increased stomach tone. If the food is stagnant, it is recommended to wash the stomach again (8-10 sessions).
Often, patients with co stenosis have symptoms of increased neuromuscular excitability (inclination to seizures, symptoms of the tail, Trusso, a symptom of the muscle roll). These phenomena are associated with disorders of water and salt metabolism (alkalosis, chloropenia), which develop when the body loses (due to vomiting) large amounts of liquid, sodium chloride. In all such cases it is necessary to administer subcutaneously at least 1-2 liters of physiological solution and intravenously 10% solution of table salt (several times a day). In severe cases of the tetanic and predetetoid condition of the organism it is recommended to administer a drip intravenous injection of several liters of physiological solution per day. In many cases, with the introduction of large amounts of water and salt it is possible to eliminate persistent, invincible vomiting.
Under the influence of such a complex treatment in patients with co stenosis often undergo all the subjective and objective signs: the disease. These patients should be further treated, as usual, depending on the type of ulcer disease. If the treatment remains unsuccessful and if, despite the treatment, the patient still shows some or other symptoms of motor failure during the objective examination, you should recommend prompt treatment. For exhausted patients with far-reaching stenosis in the presence of seizures and a sharp decrease in the amount of urine (less than 500 ml) from the beginning shows surgical intervention.
In these cases, no time should be wasted on attempts at conservative treatment, but before the operation, the patient should still be given a sufficient amount of fluid, salt (intravenous drips) and vitamins C and B1 (parenterally).
An urgent surgical intervention is required. In these cases, there is no need to talk about therapeutic nutrition.
When there is a threat of perforation and deep penetrating ulcers, when the process occurs with the phenomena of peritoneal irritation (very severe pain, increasing with movement, muscle protection, a symptom of Bloomberg), the patient is prescribed full rest, strict bed rest, cold on the bedside and a very strict diet: only liquid food - mucous soup, milk, liquid tea 1/2-3/4 cup every 2 hours is allowed. In more severe cases, 1-2 hungry days are prescribed at the beginning of treatment. Approximately the same should be treated for patients with limited perforation. This treatment is best done in the surgical departments, so that in case of danger (open perforation) immediately perform the operation. If the course of the disease is favorable, as the irritation of the peritoneum subsides, patients are gradually transferred to regular diets according to the type of disease. If the subacute phenomena co peritoneum subsides and remain signs of chronic (but still active) perivisceritis, should be prescribed "zigzags" in the form of an anti-inflammatory diet (gastric variant) in combination with an energetic thermal treatment (mud, poultices).
According to our experience, in cases of active adhesion process occurring with symptoms of peritoneal irritation, a course of penicillin therapy (300000 units 2-3 times a day for 10-14 days) is of great benefit.
If there is a suspicion of the transition of an ulcer into cancer
According to our long-term observations (10-20 years) conducted jointly with G. F. Markova, in about 8% of cases there is a transition of stomach ulcer into cancer. This is a difficult opportunity to be reckoned with. Relatively more often, the development of cancer is observed at the localization of the ulcer in the gatekeeper area and in the subcardial section of the stomach. Suspicion should cause increasingly large ulcers, especially flat ulcers and ulcers with extensive edge infiltration. In such cases, it is very difficult to decide whether the infiltration of the edges of the ulcer is inflammatory or cancerous. It is necessary to conduct a trial anti-eptic treatment. If under its influence does not disappear infiltration and do not reduce the size of the ulcer, you should subject the patient to surgical treatment without waiting for the "classic" symptoms of cancer (acidity drops, weight loss, anemization, increased ROE, persistent bleeding, palpable tumor, etc.). Ho trial treatment requires a lot of precious time. At the suggestion of P.D. Tarnopolskaia, we now use for differentiation of the trial treatment with penicillin within 10 days. Inflammatory infiltration under the influence of penicillin therapy is significantly reduced, and the cancer remains unchanged. Thus, it is possible to significantly reduce the time to decide whether or not to have surgery.
Therapeutic nutrition for concomitant diseases of other digestive organs
In more than 30% of cases, peptic ulcer (especially in the localization of the gatekeeper and duodenal ulcer) is accompanied by simultaneous lesions of the biliary tract and liver.
Of course, such a combination should be taken into account when prescribing therapeutic nutrition. In diet № 1A whole eggs are replaced by protein omelette and meat soufflé. The amount of fat is limited to 70 g, and the amount of carbohydrates is increased to 250 g due to sugar and honey. Similar adjustments are made to diet number 1B, limited to 70-80 g of fat, increases by 50-100 g of carbohydrates and in addition introduced cottage cheese.
Instead of diet number 1, a variant of diet number 5 (diet number 5A) is used.
Sometimes the benefit is brought by sugar days. In case of infection of the biliary tract it is recommended a combined use of antibiotics (penicillin, streptomycin, levomycetin, biomycin). Duodenal probing is acceptable in the prevention of acute events. Mineral waters, sulfuric salts and thermal applications (poultices, mud) have a favorable effect on diseases of the liver and bile ducts.
Often, exacerbation of ulcer disease is accompanied by constipation and a number of unpleasant intestinal phenomena (bloating, crucifixion, pain). These phenomena are facilitated by the bed content of the patient, as well as a gentle diet, which does not contain a sufficient number of physiological agents of intestinal peristalsis (plant fiber, vitamin B1). Known assistance in such cases is provided by the use of sulfuric acid and magnesia salts, as well as the enrichment of the diet with vitamin B1 and the addition of vegetable and fruit juices. Moderate heat and belladonna and atropine should be tried as an antispastic agent. Often, the reason that supports constipation in patients with ulcer is hemorrhoids, back aisle cracks, rectitis. Strong measures should be taken against constipation, because the intestinal stasis reflex adversely affects the stomach, supporting it in the state of irritation.
In the accompanying colitis with diarrhea or increased fermentation processes, it is necessary to give not whole, but diluted milk or add lime water to it. If the patient does not tolerate milk at all, the latter is replaced by other food products (diluted cream, nut or almond milk, a mixture of milk and rice broth). In more persistent cases, "zigzags" in the form of a diet that sparing the intestines (diet number 4), or an anti-inflammatory diet are useful. In case of a sharp increase in fermentation processes in the intestines, an antipeptic diet with restriction of carbohydrates is used.
- Diet No. 1 (basic version)
- Diet No. 1 (with carbohydrate restriction)
- Diet No. 1 (with increased protein content)
- Diet No. 1A (peptic ulcer, basic version)
- Diet No. 1A (for stomach ulcer combined with liver disorders)
- Diet No. 1B
- Diet No. 1B (for stomach ulcer with liver disorders)
Therapeutic nutrition for disorders of the general condition of the body and depending on its physiological condition
In all cases of anti-plague treatment it is necessary to take into account the general condition of patients.
Treatment of persons with general nutritional deficiencies (severe malnutrition, nutritional dystrophy, hypovitaminosis) regardless of the type of ulcer disease should be carried out on a diet high in protein, calories and rich in vitamins. It should be remembered that, in addition to obvious eating disorders, the sluggish course of the disease is often supported by hidden eating disorders. In more severe cases, it is necessary to refuse to use diet type 1A and immediately begin treatment with diet type 1B. They have a beneficial effect on eating disorders and stimulate the recovery of the patient's strength by repeated blood transfusions.
In obesity, it is necessary to limit the calorie of food. Very often in obese patients ulcer disease is combined with disorders of the liver side. In these cases, in addition to methods already recommended by us above, you can usefully use "zigzags" in the form of an anti-inflammatory diet.
Of chronic infections combined with ulcer, lung tuberculosis is the most important. If the process is active, the patient should be referred to a specialized tuberculosis facility (clinic, sanatorium). It is desirable to reduce the duration of the patient's stay on diet #1A or immediately prescribe diet #1B. It is also possible to apply the technique adopted in the treatment of patients with trophic type ulcers, enriching the diet with proteins, vitamins A, C and D. The prescription of energetic thermal treatment and the use of all methods causing active body restructuring should be avoided.
As a rule, patients with peptic ulcer retain a good composition of red blood. Ho after bleeding, as well as in some cases of trophic ulcers in women have chlorotic anaemia, poorly recovering with conventional anti-eptic treatment. The diet in such patients should contain an increased amount of proteins (hematogen), vegetable and fruit juices. It is recommended to add vitamin C (200-300 mg), as well as iron preparations (if the patient can tolerate them well). In more severe cases, the prescription of dishes from the liver or its products, as well as repeated blood transfusions are shown.
It is necessary to pay serious attention to the state of the neuro-psychiatric sphere in all patients with ulcer and apply appropriate treatment methods.
The given norms of nutrition in diets #1, 1A, 1B and their variants are designed for a person of normal height and weight. At high height and in persons accustomed to hard physical labor, the diet may be inadequate. In such cases, it is necessary to increase the nutritional value of the food diet, starting with diet № 1B, by 10-20%, evenly increasing the amount of proteins, fats and carbohydrates. To the same extent, it is necessary to limit the caloric value of diets in people of low height.
In the treatment of adolescents should reduce the length of stay of patients on diet № 1A and take care of increased administration of vitamins.
Elderly people are recommended antipruritic diets designed for patients with vascular lesions.
Results of inpatient treatment and subsequent treatment of patients with peptic ulcer
Under the influence of systematic differentiated anti-eptic treatment is usually very early (in the first 1-2 weeks) all the painful phenomena, pain and dyspeptic events are subsided, the objective indicators of the disease are reduced (phenomena co peritoneum, painfulness at palpation and shookings, etc.). The beneficial effect of ulcer treatment on the patient is so clear that the impression of the specificity of this treatment is created. Therefore, in doubtful cases, when the diagnosis is supposed to be made, you can use a trial anti-eptic treatment - ex juvantibus. The success of such therapy to some extent speaks in favor of the ulcerative nature of suffering.
Inpatient ulcer treatment course lasts at least 4-6 weeks. In hospitals, patients with peptic ulcer often endure less - only 2-3 weeks. This period is not enough to heal the ulcer. In the best case, during this time it is possible to achieve only an improvement in the patient's condition or the disappearance of painful phenomena, but not a lasting cure. In some cases, the ulcer does not heal within 6 weeks. In this case, we give two consecutive courses of anti-eptic treatment and sometimes get good results.
By the end of treatment, most patients no longer complain of pain and dyspeptic events. In about 2/3 of cases, the ulcer "niche" disappears. According to our observations, hyper-secretion decreases in about half of the cases, and increased acidity tends to decrease only in some cases.
Ho peptic ulcer is not always treatable. The results of treatment depend to some extent on the type of disease and the localization of the lesion associated with it.
Thus, in case of duodenal localization of an ulcer during the period of stay in hospital healing is observed in 60-75% of cases, and in case of gastric ulcer - in 30-50%.
Prevalence of the disease, depth of lesion, presence of complications and other indicators characterizing the disease severity are of essential importance. This is demonstrated by the following data. Disappearance of all clinical manifestations of the disease and the symptom of the "niche" is observed in 90-100% of light cases, in 50-60% of cases of medium severity, in 20-30% of severe cases. Apparently, one should strive for the earliest possible diagnosis and early treatment of ulcer disease in order to prevent the development of severe and complicated forms of disease.
If a patient has excruciating phenomena that cannot be treated and the "niche" is not scarred, surgical intervention is necessary. Surgical treatment is also shown if the "niche" located in the area of low curvature, does not give a clear dynamic (danger of transition to cancer!) or the ulcer does not heal in a patient who has a tendency to bleed again. If the uncomplicated ulcer of the duodenum does not scar or does not fully heal the stomach ulcer (showing a tendency to heal), you can take your time with the operation and conduct further treatment in outpatient conditions, leaving the patient under constant medical supervision.
Even in cases where inpatient treatment is accompanied by full success, it should be considered only as the beginning of treatment. Long-term observations of patients who have undergone anti-eptic treatment show that, despite good immediate results, relapses of ulcer disease are often observed later.
The same harmful effects that contributed to peptic ulcer disease should be recognized as a frequent cause of relapse. Therefore, a prerequisite for successful treatment is the elimination of all factors contributing to the new development of the disease. This primarily includes excessive physical labor, work associated with nervous and mental stress, and chronic intoxications (lead, nicotine, alcohol). Ho, of course, a decisive influence on the long-term results of treatment of a patient with ulcer disease is the nature of his diet.
After inpatient treatment, the patient must stay on a diet for a long time, approximately half naked. In this case, both the diet and the quality of the diet play an equally important role. You should eat often and regularly, because long breaks in eating are very harmful. In the course of a number of months, the patient should follow a diet number 1. If he feels good, this diet can be gradually expanded after 2-4 months. It is allowed to eat the food already in its unsweatened form, but the composition of the dishes remains the same as in the diet № 1. Vegetables, porridges and meat are prescribed well cooked, but not crushed. At the same time, sweet raw fruits and vegetables are added (non-oxidized, ripe apples, fresh cucumbers, carrots). Soft pears, plums, sweet oranges, sweet berries without seeds, etc. are also allowed. Thus, the patient can get a varied and complete diet. Such a diet he must follow, as already said, for half a neck, after which a gradual transition to a rational diet is possible.
Constructing long dietary regimes, it is necessary to consider the type of ulcer disease. Patients with excitable autonomic nervous system should avoid overloading with carbohydrates. Such patients are particularly sensitive to diet disturbance and long breaks in eating. They should spare the nervous system even after leaving the hospital.
For patients with trophic disorders it is important to have good nutrition, adequate intake of proteins and vitamins. Patients with gastritis ulcer are particularly sensitive to all kinds of alimentary damage. Strict hygienic measures are necessary to protect against gastrointestinal infections, which can cause exacerbation of ulcer disease.
Known caution in eating a patient with peptic ulcer should be observed in subsequent years: you should avoid alcohol, do not eat very rough, spicy and spicy food, do not disturb the diet, etc. M.I. Pevzner strongly recommended that every 6 months (preferably in early spring and autumn) in the next 2 years after the end of ulcer treatment, the patient should be prescribed prophylactic (accelerated and reduced) courses of ulcer treatment. During the first week the patient adheres to diet №1A (with bed content), in a week he is transferred to diet №1B and is gradually allowed to get out of bed. The total duration of this preventive course is 2-3 weeks. If it is impossible to place a patient in a hospital, the preventive treatment (within 3-4 weeks) is carried out on an outpatient basis on the type of "half ulcer treatment".
Diet therapy in the conditions of sanatorium treatment
In the Soviet Union, spa treatment of patients with ulcer is widespread. Ha specialized gastrointestinal resorts such patients constitute a significant part of the total patient population (in Zheleznovodsk 70-80%, in Essentuki 30%). However, spa treatment should not be considered as the main one, but as an additional method of treatment, which can not replace the inpatient one, and serves only as a valuable complement. Referral to the resort of patients with peptic ulcer in the acute stage with an unhealed ulcer is contraindicated. It should also be recommended spa treatment for patients with stomach motor disorders, with a tendency to bleed, with active soldering process, exhausted patients, as well as those who have an ulcer accompanied by another serious general disease (tuberculosis, cardiovascular disease). The most suitable for spa treatment of patients with peptic ulcer in remission.
The main spa factors - change of environment, favorable climate and living conditions, mineral water, mud treatment - primarily have a beneficial effect on the general state of the body, nervous system, associated gastritis ulcer disease and other diseases of the digestive organs (especially liver and bile ducts).
Unfortunately, indications for referral of patients with peptic ulcer to the resort are not always taken into account. If a patient arrives at the resort in the acute phase, it should be kept in bed for 1/2-2 weeks, prescribing a diet type 1B, using only mineral water from the spa factors. After the disappearance of acute events only in the second half of the treatment of the patient can be raised from bed and carefully begin using other spa factors. The background food can serve as a diet number 1, differentiated with the peculiarities of the course of the disease.
The same diet should be prescribed to the patient, if he gets to the resort in a phase of recent exacerbation.
In case of persistent remission, depending on its remoteness, is assigned to an extended diet number 1 (food in bulk) or diet number 5, or even a general diet (in remission for more than 2 years). If exacerbations of peptic ulcer occurred during the last 2-3 years, you can use your stay at the resort for a course of preventive anti-eptic treatment.
Favorable conditions are created for the treatment of patients with ulcer in local specialized gastrointestinal sanatoriums. Here you can combine all the benefits of inpatient treatment with a number of factors that favorably affect the general state of the body and nervous system.
All patients, in whom the ulcer has not healed, are shown inpatient ulcer treatment. We do not agree with some authors that most of these patients should be treated on an outpatient basis.
Extensive experience with outpatient treatment has led us to the conclusion that its results are definitely inferior to those of inpatient treatment. We see outpatient treatment as forced. Its success or failure largely depends on the patient's social and professional conditions. Patients with ulcer should be banned from work that requires excessive physical and mental stress. Working conditions should allow for timely and regular meals. Patients should not be exposed to vegetative poisons (lead, nicotine, alcohol). Employment of patients should be conducted through the appropriate health authorities.
In outpatient treatment, they prescribe diet number 1. Only in the period of exacerbation for a period not exceeding 2-3 weeks is permitted diet type 1B. In outpatient treatment, it is desirable to change the diet depending on the type of ulcer disease and monitor the adequate vitaminization of the diet. It is recommended, if possible, for the period of exacerbation to place the patient in a night sanatorium or at least send to the dining room therapeutic food. Diet instructions should be made in writing, always taking into account the practical possibility of their implementation.
The best results in outpatient treatment is given by the method of "half ulcer therapy", proposed by M. I. Pevzner. After returning from work at home or in a night sanatorium, the patient goes to bed and remains in bed until the next morning. During 2-3 weeks, he receives a diet of type 1B, and then transferred to a diet of type 1. The duration of this treatment is 4-6 weeks.
Along with the curative nutrition in outpatient conditions can be used other methods of complex therapy - drug therapy (alkali, lapis, belladonna, atropine), methods of nonspecific body restructuring (autohemotherapy, serum of the Mantis) and cautious physiotherapy, treatment with penicillin. Energetic thermal treatment (mud cakes) can be used in outpatient conditions with great care, only with appropriate indications, under careful medical supervision and systematic monitoring of the presence of blood in the feces.
After completing the course of treatment, an outpatient patient is prescribed the same regimen for a long time as a patient who has completed a course of treatment in an inpatient clinic.
Patient with ulcer, who seeks medical help in the painless period, should be carefully examined. Sometimes, it is possible to detect asymptomatic ulcer, which is leaking, but not healed. Such patients are prescribed conventional ulcer treatment. If the clinical examination does not indicate the presence of an ulcer that has not healed, the same regime as after the anti-eptic treatment is recommended.
By: Dr. Michael Dann