消化性潰瘍の病態生理からみた内科的治療のあり方

Pathophysiology of Gastric and Duodenal Ulcers

　今日，消化性潰瘍は胃・十二指腸の疾患の中でも，もっともpopularな疾患であるが，最近は，難治性の腓抵性潰瘍や著明な胃変形を伴う典型的な線状潰瘍に遭遇することが著しく少なくなっている．そして，消化性潰瘍はむしろ自然治癒傾向が強く，容易に療痕治癒しやすい一方，きわめて再発しやすく，周期的に新たな潰瘍の発生を繰り返すことこそ，この疾病の特徴であり，個々の潰瘍は治癒しても，潰瘍症は治らないといわれる所以である．

　近年のわが国における消化器病学の進歩がもたらした特記すべき大きな変化の一つは，早期胃癌診断学の進歩により，胃の潰瘍性病変の良性悪性の鑑別が著しく確実性を増し，かつてのように，悪性変化が疑わしいとの理由で，良性の消化性潰瘍が手術されることは著しく少なくなり，消化性潰瘍の手術適応の幅がかなり狭められたことであろう．保存的治療が困難な合併症を伴わぬ限り，消化性潰瘍は原則として内科的治療の対象となることは，多くの臨床家が承認していることと思われる．

　Peptic ulcer has a pronounced tendency to spontaneous healing, leaving only a scar. It also recurs as easily. This disease is therefore characterized by the repetition of healing and recurrence.

　Differential diagnosis by X-ray and endoscopy has become so accurate in this country that surgical operation is hardly performed for benign gastric ulcer for the sole reason that malignant changes could not be ruled out. The consensus of many workers in this field is against surgical treatment if a peptic ulcer is unaccompanied with complications.

　Nevertheless, the present status of medical therapy for peptic ulcer is still open to many questions.

　I have inquired into the way medical treatment of peptic ulcer should be from the viewpoint of Pathophysiology. First of all, I have examined the results of hospitalization for medical management of peptic ulcer, studying also the significance of clinical factors that might influence the healing tendency of gastric ulcer. Secondly, the relationship has been studied between the degree of atrophy of the fundic gland area and the capability of the gastric juice to secrete (hydrochloric) acid and pepsin. It has also been tried to clarify the difference between gastric and duodenal ulcers, difference in Pathophysiology of gastric ulcer as revealed by various sites of ulcer, and peculiarity of gastric ulcer in the old. Thirdly, by pH telemeter I have examined pH changes in the gastric juice after the ingestion of various foodstuffs or administration of antacids. Finally, a summary has been made of controlled studies with double blind test of the currently available anti-ulcer drugs consisting of antacids and anticholinergics.

　Based on the results obtained,I would like to emphasize first of all the importance of rest in both mind and body in the medical management of peptic ulcer. In the second place, of great importance is the appropriate selection of drugs according to the pathophysiologic difference in ulcer location. To obtain continuous antacid effect, one must also take into account intragastric pH changes, and should manage accordingly the dosis or frequency of drug administration. Thirdly, in the dietary treatment of peptic ulcer one should not neglect the counteractive and buffer effect of eating on the gastric juice. It is true that, in acute and active stage of ulcer when the subjective symptoms are severe, the patient must be put on a diet to a certain degree, but it is again emphasized that too strict, long-term dietary restrictions would do more harm than good to the patient.