内科学消化性溃疡钟良

,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,Peptic Ulcer Disease (PUD),Zhong Liang,Hua Shan Hospital,Definition,A circumscribed ulceration of the gastrointestinal mucosa occurring in areas exposed to acid and pepsin and most often caused by Helicobacter pylori infection.,(Uphold & Graham, 2003),Peptic ulcers:Gastric and Duodenal,PUD Demographics,Higher prevalence in developing countries,H. Pylori is sometimes associated with socioeconomic status and poor hygiene,In the US,:,Lifetime prevalence is 10%.,PUD affects 4.5 million annually.,Hospitalization rate is 30 pts per 100,000 cases.,Mortality rate has decreased dramatically in the past 20 years,approximately 1 death per 100,000 cases,Comparing Duodenal And Gastric Ulcers,Epidemiology (DU),Duodenal sites are 4x as mon as gastric sites,Most mon in middle age,peak 30-50 years,Male to female ratio,4:1,Genetic link: 3x more mon in 1,st,degree relatives,More mon in patients with blood group O,Associated with increased serum pepsinogen,H. pylori infection mon,up to 95%,Smoking is twice as mon,Gastric Ulcers,Common in late middle age,incidence increases with age,Male to female ratio,2:1,More mon in patients with blood group A,Use of NSAIDs - associated with a three- to four-fold increase in risk of gastric ulcer,Less related to H. pylori than duodenal ulcers,about 80%,10 - 20% of patients with a gastric ulcer have a conitant duodenal ulcer,Etiology,A peptic ulcer is a mucosal break, 3 mm or greater, that can involve the stomach or duodenum.,The most important,contributing factors,are H pylori, NSAIDs, acid, and pepsin.,Additional,aggressive factors,include smoking, ethanol, bile acids, aspirin, steroids, and stress.,Important,protective factors,are mucus, bicarbonate, mucosal blood flow, prostaglandins, hydrophobic layer, and epithelial renewal.,Increased risk when older than 50 d/t decrease protection,When an imbalance occurs, PUD might develop.,Helicobactor pylori,H. pylori,?,ulceration,Prevalence of H. pylori: 80% in developing area; 20-50% in developed area,The rate of H. pylori infection is declining in developed country,Transmission:,oral oral,fecal oral,Helicobactor pylori,It is possible that the different disease related to H. pylori infection can be attribute to different strains of organism with distinct pathogenic features,Helicobactor pylori,Helicobactor pylori,NSAID,NSAIDCOX PG,The form of NSAIDs have no relation to their damage on GI mucosa !,NSAID,Risk factor:,Advanced age,History of ulcer,Conitant use of glucocorticoids,Conitant use of anticogulants,Serious or multi-system disease,H. pylori infection,Cigarette and/or alcohol consumption,Subjective Data,Pain,”,gnawing,”,“,aching,”, or,“,burning,”,Duodenal ulcers: occurs 1-3 hours after a meal and may awaken patient from sleep. Pain is relieved by food, antacids, or vomiting.,Gastric ulcers: food may exacerbate the pain while vomiting relieves it.,Nausea, vomiting, belching, dyspepsia, bloating, chest disfort, anorexia, hematemesis, &/or melena may also occur.,nausea, vomiting, & weight loss more mon with Gastric ulcers,Objective Data,Epigastric tenderness,Guaic-positive stool,resulting from occult blood loss,Succussion splash,resulting from scaring or edema due to partial or plete gastric outlet obstruction,A succussion splash describes the sound obtained by shaking an individual who has free fluid and air or gas in a hollow organ or body cavity.,Usually elicited to confirm intestinal or pyloric obstruction.,Done by gently shaking the abdomen by holding either side of the pelvis. A positive test occurs when a splashing noise is heard, either with or without a stethoscope. It is not valid if the pt has eaten or drunk fluid within the last three hours.,Complications,Perforation & Penetration,into pancreas, liver and retroperitoneal space,Peritonitis,Bowel obstruction, Gastric outflow obstruction, & Pyloric stenosis,Bleeding-occurs in 25% to 33% of cases and accounts for 25% of ulcer deaths.,Gastric CA,Active bleeding,胃角溃疡出血录像,.avi,Gastric CA,Peptic ulcer,special,Silent ulcer,Peptic ulcer in advanced age,Peptic ulcer on posterior bulb,Peptic ulcer on pylorus tube,Giant peptic ulcer,Diagnostic Plan,Stool for fecal occult blood,Labs: CBC (R/O bleeding), liver function test, amylase, and lipase.,H. Pylori can be diagnosed by urea breath test, blood test, stool antigen assays, & rapid urease test on a biopsy sample.,Barium meal,Diagnostic Plan,Upper GI Endoscopy: Any pt 50y with new onset of symptoms or those with alarm markings including anemia, weight loss, or GI bleeding.,Preferred diagnostic test b/c its highly sensitive for dx of ulcers and allows for biopsy to rule out malignancy and rapid urease tests for testing for H. Pylori.,Gastric ulcer,Duodenal ulcer,Differential Diagnosis,Neoplasm of the stomach,Pancreatitis,Pancreatic cancer,Diverticulitis,Nonulcer dyspepsia (also called functional dyspepsia),Cholecystitis,Gastritis,GERD,MI,not to be missed if having chest pain,Treatment-,antacid,Mixture of aluminum hydroxide and magnesium hydroxide,Talcid,Treatment,acid secretion inhabitor,Proton Pump Inhibitors,PPI: Prilosec, Prevacid, Nexium, Protonix, or Aciphex for 4-8 weeks,H,2,receptor antagonists,HRA: Tagament, Pepcid, Axid, or Zantac for up to 8 weeks,不同抑酸剂的作用机理,丙谷胺,雷尼替丁,哌仑西平,G,H,2,M,PP,he+H,+,K,+,壁细胞,PPI,H,+,Treatment,H. pylori eradication,Triple therapy,for 14 days is considered the treatment,of choice.,Proton Pump Inhibitor + clarithromycin and amoxicillin,Omeprazole (Prilosec): 20 mg PO bid for 14 d,or,Lansoprazole (Prevacid): 30 mg PO bid for 14 d,or,Rabeprazole (Aciphex): 20 mg PO bid for 14 d,or,Esomeprazole (Nexium): 40 mg PO qd for 14 d,plus,Clarithromycin (Biaxin): 500 mg PO bid for 14,and,Amoxicillin (Amoxil): 1 g PO bid for 14 d,Can substitute Flagyl 500 mg PO bid for 14 d if allergic to PCN,In the setting of an active ulcer, continue qd proton pump inhibitor therapy for additional 2 weeks.,Treatment,H. pylori eradication,Quadruple therapy,for the infection of resistant organism,Omeprazole 20mg qd,Bismuth subsalicylate 2 tablets qid,Metronidazole 250mg qid,Tetracycline 500mg qid,Goal: plete elimination of H. Pylori. Once achieved re-infection rates are low.,Compliance!,Treatment,NSAID related PUD,Prevention!,H,2,RA,PPI,Misoprostol,Selective COX-2 inhibitors,H. pylori eradication,Treatment,cytoprotective agents,Sucralfate,Bismuth-Containing Preparations,Prostaglandin Analogues,GU active to healed,DU active to healed,Lifestyle Changes,Discontinue NSAIDs and use Acetaminophen for pain control if possible.,Acid suppression-Antacids,Smoking cessation,No dietary restrictions unless certain foods are associated with problems.,Alcohol in moderation,Men under 65: 2 drinks/day,Men over 65 and all women: 1 drink/day,Stress reduction,Prevention,Consider prophylactic therapy for the following patients:,Pts with NSAID-induced ulcers who require daily NSAID therapy,Pts older than 60 years,Pts with a history of PUD or a plication such as GI bleeding,Pts taking steroids or anticoagulants or patients with significant orbid medical illnesses,Prophylactic regimens that have been shown to dramatically reduce the risk of NSAID-induced gastric and duodenal ulcers include the use of a prostaglandin analogue or a proton pump inhibitor.,Misoprostol (Cytotec) 100-200 mcg PO 4 times per day,Omeprazole (Prilosec) 20-40 mg PO every day,Lansoprazole (Prevacid) 15-30 mg PO every day,Surgery,People who do not respond to medication, or who develop plications:,Vagotomy,- cutting the vagus nerve to interrupt messages sent from the brain to the stomach to reducing acid secretion.,Antrectomy,- remove the lower part of the stomach (antrum), which produces a hormone that stimulates the stomach to secrete digestive juices. A vagotomy is usually done in conjunction with an antrectomy.,Pyloroplasty,- the opening into the duodenum and small intestine (pylorus) are enlarged, enabling contents to pass more freely from the stomach. May be performed along with a vagotomy.,Evaluation/Follow-up/Referrals,H. Pylori Positive: retesting for tx efficacy,Urea breath test,no sooner than 4 weeks after therapy to avoid false negative results,Stool antigen test,an 8 week interval must be allowed after therapy.,H. Pylori Negative: evaluate symptoms after one month. Patients who are controlled should cont. 2-4 more weeks.,If symptoms persist then refer to specialist for additional diagnostic testing.,Thank you!,