Стандарт діагностики та лікування виразкової хвороби шлунка та 12-палої кишки – Аптека медичної академії

Стандарт діагностики та лікування виразкової хвороби шлунка та 12-палої кишки – Аптека медичної академії

(наказ МОЗ України № 271 від 13.06.2005)

Виразкова хвороба (ВХ) шлунка та 12-палої кишки відноситься до найбільш поширеною ненним захворювань травної системи. Її діагностика і лікування проводяться відповідно до наказу № 271 від 13.06.2005 за спеціальністю «Гастроентерологія».

Клініка . Ведучими в клініці виразки шлунка і 12-палої кишки є больовий синдром, часто дозволяє визначити локалізацію виразки, а також диспепсичний (печія, відрижка, нудота і блювота), діскінетіческій і астеновегетативний синдроми.

Критерії діагностики . ендоскопічно підтверджений виразковий дефект в 12-палої кишці або шлунку (доброякісність виразки шлунка повинна бути підтверджена морфологічним дослідженням множинних біоптатів).

Езофагогастродуоденоскопія (ЕГДС) – «золотий стандарт» діагностики – при дуоденальних виразках проводиться одноразово для діагностики, при виразках шлунка – проводиться ще й повторно для контролю за загоєнням виразки; біопсія слизової оболонки (СО) застосовується для проведення швидкого уреазного тесту (експрес-діагностика Н. pylori (НР) – інфекції в ендоскопічному кабінеті) і морфологічного дослідження СО (по 2 біопта та з антрального відділу і тіла шлунка) – для діагностики атрофії, дисплазії або неопла зії, виключення рідкісних і атипових причин виразок СО. Тест на наявність інфекції HР проводиться строго обов’язково у кожного хворого на виразку (13 С-сечовинний тест, швидкий уреазний тест, серология); досліджують також загальний аналіз крові; аналіз калу на приховану кров. Рентгенологіческоеісследованіе шлунка при наявності ЕГДС в даний час практично втратило своє значення при неускладненій ВХ і застосовується, в основному, при підозрі на наявність ускладнень. Дослідження секреторної функції шлунка (інтрагастральна рН-метрія) має значення для вибору оптимальної схеми лікування. Проводяться також УЗД органів черевної порожнини, біохімічне дослідження крові, визначення групи крові, резус-фактора, досліджується коагулограмма.

Лікування. 1. При виразковій хворобі (пептичних виразках) з в’язаного з НР-інфекцією основною стратегією лікування є проведення “потрійної” антигелікобактерної тера пії протягом 7-10 днів відповідно до Маастрихтського консенсусом (на момент написа ня наказу – 2-2000, на даний час діє 3-2005).

Вже в Маастріхті-1 були сформульовані суворими показаннями до ерадикації НР-інфекції: це ВХ в активній і неактивній фазах, виразкова кровотеча, МАLТ-лімфома (рівень А), гастрит з серйозними морфологічними змінами, стан після ендоскопічної резекції з приводу раку шлунка). Рекомендованими показаннями є функціональна диспепсія (рівень В), сімейні випадки раку шлунка, тривале лікування ГЕРХ антисекреторними препаратами, планована або проведена терапія НПЗЗ. Невизначені Показання до ерадикації – профілактика раку шлунка при відсутності факторів ризику, відсутність симптомів, негастроентерологіческіе захворювання. У Маастрихті 3 розширені показання для ерадикації НР за рахунок екстрагастральних захворювань. Відтепер рекомендують проводити ерадикацію НР при ІХС (рівень В), імунної тромбоцитопенії (рівень В) і незрозумілою залізодефіцитної анемії (рівень В). Крім того, Маастрихт 3-2005 рекомендує (рівень А) проводити ерадикацію НР при недослідженою диспепсії. Відносно НПЗП-гастропатій наголошується, що ерадикації НР недостатньо для їх запобігання, проте всі пацієнти, які отримують аспірин, нестероїдні протизапальні засоби і ЦОГ-2-інгібітори, повинні проходити тестування на НР. Підкреслюється, що сам по собі НР не викликає ГЕРБ, проте всі випадки поєднання НР-інфікування та ускладненої ГЕРБ повинні спеціально розглядатися.

Перша лінія терапії в більшості випадків інгібітор протонної помпи (ІПП) + кларитроміцин + амоксицилін (у країнах, де рівень метронідазол-резистентності перевищує 40%) або метронідазол (в країнах з низькою метронідазол-резистентністю). Потрійна терапія протягом 10-14 діб в порівнянні з семиденної потрійний терапією дозволяє підвищити рівень ерадикації на 12%. Найбільш зффектівності другою лінією лікування раніше залишається класична квадротерапія із застосуванням вісмуту субцитрата (де-нол. ГАСТРОНОРМ. Вис-нол) (таб.1).

Таблиця 1

Стандартна ерадикаційної терапія при інфікуванні НР

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