内科学教学课件：胃、十二指肠疾病

2022-3-281胃、十二指肠疾病胃、十二指肠疾病2022-3-282必要的病理生理基础必要的病理生理基础1. 关于消化道粘膜保护机制关于消化道粘膜保护机制2. 关于幽门螺旋杆菌（关于幽门螺旋杆菌（helicobactor pylori, Hp ）2022-3-283胃粘膜为什么可以抵御盐酸的腐蚀？胃粘膜为什么可以抵御盐酸的腐蚀？2022-3-2842022-3-2852022-3-286粘液粘液 HCO-3pH17血流血流上皮前上皮前上皮上皮上皮后上皮后PGE2022-3-287Nobel Prize 2005 Robin Warren and Barry Marshall. The team discovered the bacterium behind stomach inflammation and ulcers. 2022-3-288幽门螺旋杆菌幽门螺旋杆菌(helicobactor pylori HP)感染感染-胃粘膜损伤主要病因胃粘膜损伤主要病因2022-3-289血流血流胃 酸2022-3-2810致病因素致病因素1. 鞭毛鞭毛 2022-3-2811致病因素：致病因素：1. 鞭毛2. 粘液酶粘液酶 2022-3-2812致病因素：致病因素：1. 鞭毛2. 粘液酶3. 粘附素粘附素 2022-3-2813致病因素：致病因素：1. 鞭毛2. 粘液酶3. 粘附素4. 尿素酶尿素酶 2022-3-2814致病因素：致病因素：1. 鞭毛2. 粘液酶3. 粘附素4. 尿素酶5. 空泡毒素空泡毒素(Vac A) 细胞毒素相关基因蛋白细胞毒素相关基因蛋白 (CageA) 诱导自身抗原诱导自身抗原2022-3-2815Chapter 3第三章Gastritis 胃胃 炎炎2022-3-2816definition 损伤损伤damage 粘膜炎症粘膜炎症 inflammation 上皮细胞再生上皮细胞再生regeneration 胃病胃病 gastropathy 胃炎（胃炎（gastritis）2022-3-2817第一节第一节 急性胃炎急性胃炎1. Acute gastritis Conception: acute inflammation of gastric mucosa。Acute: definite etiologic causeObvious pathologic change of endoscopyTemporarily or self-healing 同义词：同义词： “急性糜烂出血性胃炎急性糜烂出血性胃炎” Acute erosive &hemorrhagic gastritis “急性胃粘膜病变急性胃粘膜病变” “急性胃粘膜损害急性胃粘膜损害” “应激性溃疡应激性溃疡” “急性糜烂出血性胃病急性糜烂出血性胃病”2022-3-2818Etiology & mechanism 1. Stress2. Chemical injury3. Acute infection2022-3-2819Etiology & mechanism1. StressSevere disorders of other organs, great operation, trauma, shock, serious burns, sepsis, multiple organ failure, et al.Mesenteric Ischemia ,disturbance of mucosal circulation, H+ ion contra-diffusion , PGE2Curlings ulcer(burns); Cushings ulcer(central nervous system)2022-3-2820Etiology & mechanism1. Stress2. Chemical injuryDrugs:NSAIDs(non-steroidal anti-inflammatory drugs), some antiboitics, Ferreous drugs, KCl, anti-tumor drugsAlcohol;2022-3-2821Etiology & mechanism1. Stress2. Chemical injury3. Acute infection: Bacteria (helicobacter pylori, H.pylori) , virus, and their toxins2022-3-2822Etiology 1. Stress2. Chemical injury3. Acute infection2022-3-2823Pathology Neutrophil infiltration Erosion Hemorrhage Shallow Ulcer 2022-3-2824Clinic manifestation 1.Symptom most of the patients has no symptom.but can has obvious symptomepigastric pain ; distention; Dyspepsia; nausea; vomitingHemorrhage small amount, or obvious bleeding Hematemesis (bloody vomitus ) Melena ( black stools ) self-limited 2022-3-2825Clinic manifestation 2. Physic Sign epigastric tenderness 2022-3-2826Diagnosis Etiology Emergent endoscopy within 1248 hours after bleeding Multiple erosions, difused bleeding spots, mucosal edema 2022-3-2827Endoscopy 2022-3-2828Treatment Treating primary diseases Control the causes Prevention: for serious disease or condition Antiacids: H2 receptor antagonists, PPI. Mucosa protectors粘膜保护剂粘膜保护剂 Antibiotics 抗菌药物抗菌药物2022-3-2829第二节第二节 慢性胃炎慢性胃炎2. Chronic gastritisConception: chronic gastric mucosal damage (or inflammation). the main etiologic factor is H. pylori.概念：粘膜损伤、慢性过程概念：粘膜损伤、慢性过程 主要致病因素是主要致病因素是Hp.2022-3-2830Epidemiology Prevalence: Above 50% H. pylori : above 80-95% H. pylori is the most important factor2022-3-2831Classification Complicated 1. Traditional classification：Whitehead(1972): Superficial gastritis Atrophic gastritisStrikland (1973): Type A gastritis Type B gastritis 2. Sydney system(1990, 1996, 2000): according to endoscopy and histology 3. China system(2000, 2003, 2006,2012): non-atrophic atrophic ( multifocal atrophic; autoimmune) special forms2022-3-2832Etiology & Pathogenesis Robert Kochl1843-1910l德国内科医生德国内科医生 和细菌学家和细菌学家l获获1905年诺贝尔医学年诺贝尔医学奖奖 炭疽病、结核病和霍乱炭疽病、结核病和霍乱 .柯赫氏法则柯赫氏法则 (Kochs Postulates)l 该病原体存在于所有患该病原体存在于所有患该病的患者中；该病的患者中；l 该病原体的分布与体内该病原体的分布与体内病变分布一致；病变分布一致；l 清除病原体后疾病可以清除病原体后疾病可以好转。好转。l 在动物模型中可诱发与在动物模型中可诱发与人相似的疾病。人相似的疾病。2022-3-2834Etiology & Pathogenesis1. H. pylori -the main cause of gastritisEvidence of “the main cause” 80%95% patients of gastritis infected by H.p The same distribution of H.p and inflammation (antrum) Eradication of H.p cure the gastritis Models of gastritis caused by H.p2022-3-2835Etiology & Pathogenesis1. H. pylori -the main cause of gastritisInjury mechanism:Toxins produced by HP VacA protein(Vacuolating cytotoxin A); Cag A protein(cytoxin associated gene A) Bacterial adhesins; Enzymes : urease; phospholipase2022-3-28362022-3-2837Etiology & Pathogenesis1. H. pylori -the main cause of gastritisInjury mechanism:Toxins produced by Hppro-inflammation effect Induce IL-8 and other inflammatory factors2022-3-2838Etiology & Pathogenesis1. H. pylori -the main cause of gastritisInjury mechanism:Toxins produced by HPpro-inflammation effectAntigen mimicry Cross immune 2022-3-2839Etiology & Pathogenesis1. H. pylori -the main cause of gastritisInjury mechanism:Toxins produced by HPpro-inflammation effectAntigen mimicry The process of Hp induced gastritis 2022-3-2841Enviroment & food70-90%30-40%70-80%70%30-50%70-90%20%70-80%2022-3-2842Etiology & Pathogenesis H.P & environment & host hostHpenviroment2022-3-2843Etiology & Pathogenesis1. H. pylori -the main cause of gastritis2. Autoimmune and heredity Type A gastritis, atrophic gastritis in corpus.Pathogenesis : Autoimmune Anti-parietal cell antibody parietal cell gastric acid Anti-intrinsic factor antibody vitamin B12 absorptionpernicious (malignant) anemia 2022-3-2844Etiology & Pathogenesis1. H. pylori -the main cause of gastritis2. Autoimmune and heredity 3.Other factorsReflux of duodenal contents bile acid; pancreatic digestive enzyme NSAIDsFoods and systemic diseases 2022-3-2845Pathology Historical characters: Inflammation Atrophy Metaplasia2022-3-2846Pathology 1. H.pylori 2. Inflammation 3. Activity4. Atrophy5. Metaplasia (intestinal , pseudopyloric) 6. Dysplasia(epithelial neoplasia) -Precancerous lesion 2022-3-2847H.pylori 慢性胃炎有慢性胃炎有5种组织学变化应分级，即种组织学变化应分级，即Hp、慢性炎、慢性炎症、活动性、萎缩和肠化，分成无、轻度、中度症、活动性、萎缩和肠化，分成无、轻度、中度和重度和重度4级。级。2022-3-2848Inflammation 2022-3-2849Activity 2022-3-2850Atrophy2022-3-2851Metaplasia2022-3-28522022-3-28532022-3-28542022-3-28552022-3-2856Clinical manifestation Most of the patient have no obvious symptom. Dyspepsia: epigastric discomfort or distention; irregularly epigastric pain; eructation; sour regurgitation; nausea; vomiting; heartburn. Tenderness Hemorrhage of upper gastro-intestine pernicious (malignant) anemia: type A 2022-3-2857Laboratory tests1. H.pylori 2. Analysis of gastric juice 3. Gastrin“血清学活检”4. Auto antibody5. Vitamin B12 test Content and absorption 2022-3-2858PG IPG IIgastrin2022-3-2859Endoscopy Superficial 2022-3-2860Endoscopy Atrophic 2022-3-2861Endoscopy Superfacial or atrophic gastritis Sydney system: Erythematous/Exudative, Reflux, Flat erosive, Raised erosive, Atrophic, Hemorrhagic, Rugal hyperplasia 2022-3-2862DiagnosisEndoscopy & biopsy & HP.& auto-antibody2022-3-2863Treatment 1. H.Pylori eradicationIncidence :obviously abnormal : erosion; atrophy; metaplasia; dysplasiadyspepsia 幽门螺杆菌阳性疾病强烈推荐推荐消化性溃疡(不论是否活动和有无并发症史)胃黏膜相关淋巴组织（MALT）淋巴瘤慢性胃炎伴消化不良症状慢性胃炎伴胃黏膜萎缩或糜烂早期胃肿瘤已行内镜下切除或手术胃次全切除长期服用质子泵抑制剂胃癌家族史计划长期服用NSAID（包括低剂量阿斯匹林）不明原因的缺铁性贫血特发性血小板减少性紫癜（ITP）其他幽门螺杆菌相关性疾病（如淋巴细胞性胃炎、增生性胃息肉、Mntrier病）个人要求治疗根除幽门螺杆菌的适应证2022-3-2865Treatment 1. HP eradication2. Antacids and Gastric acid secretion inhibitorsH2R blockers PPI , acid neutralize agents for pain and heart burn & erosion2022-3-2866Treatment 1. HP eradication2. Antacids and Gastric acid secretion inhibitors3. Gastric mucosa protective agents: sucralfate, colloidal bismuth subcitrate; hydrotalcite aluminum for erosion, hemorrhage , reflux 2022-3-2867Treatment 1. HP eradication2. Antacids and Gastric acid secretion inhibitors3. Gastric mucosa protective agents: 4. Enhancing gastric motility:metoclopramide; domperidone; cisapride; mosapride for distention and reflux 2022-3-2868Treatment 1. HP eradication2. Antacids and Gastric acid secretion inhibitors3. Gastric mucosa protective agents: 4. Enhancing gastric motility5. Anti-Reflux of bile and anti-NSAID6.Other treatments:Anti stress Vitamin B12Anti oxidants: vit E, vit C, Traditional Chinese Medicine2022-3-2869Treatment Individualized principleIndividualized principle 1. HP eradication2. Antacids and Gastric acid secretion inhibitors for pain and heart burn & erosion3. Gastric mucosa protective agents for erosion, hemorrhage , reflux 4. Enhancing gastric motility: for distention and reflux 2022-3-2870Prognosis Most patients of gastritis Can be control H.pylori eradication is the key treatment Seldom severe atrophic gastritis would develop into gastric cancer 15%20% company with peptic ulcer2022-3-2871第三节第三节 特殊类型胃炎特殊类型胃炎一一. 化学性胃炎化学性胃炎 胆汁、胆汁、NSAID 二二. 感染性胃炎感染性胃炎 机体免疫力低下时。急性化脓性胃炎可致死。机体免疫力低下时。急性化脓性胃炎可致死。三三. Menetrier病病 粘膜增生，低胃酸，丢失蛋白。须与癌，淋巴瘤及淀粘膜增生，低胃酸，丢失蛋白。须与癌，淋巴瘤及淀粉样变鉴别粉样变鉴别四四. 其他其他 嗜酸细胞性胃炎嗜酸细胞性胃炎 非感染性肉牙肿性胃炎非感染性肉牙肿性胃炎 放射性胃炎放射性胃炎 充血性胃病充血性胃病 痘疮样胃炎痘疮样胃炎2022-3-2872小结 急性胃炎：主要是出血急性胃炎：主要是出血 慢性胃炎：慢性胃炎：Hp为主要病因为主要病因 诊断靠胃镜诊断靠胃镜+活检活检+Hp 治疗治疗 根除根除Hp, 个体化原则个体化原则 癌前病变癌前病变 特殊类型胃炎：掌握名称特殊类型胃炎：掌握名称