内科学 消化性溃疡钟良PPT讲稿.ppt

内科学内科学 消化性溃疡钟良消化性溃疡钟良第1页，共41页，编辑于2022年，星期五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)第2页，共41页，编辑于2022年，星期五Peptic ulcers:Gastric and Duodenal第3页，共41页，编辑于2022年，星期五PUD Demographicsn nHigher prevalence in developing countriesHigher prevalence in developing countries n nH.Pylori is sometimes associated with socioeconomic status and poor H.Pylori is sometimes associated with socioeconomic status and poor hygienehygienen nIn the USIn the US:n nLifetime prevalence is 10%.Lifetime prevalence is 10%.n nPUD affects 4.5 million annually.PUD affects 4.5 million annually.n nHospitalization rate is 30 pts per 100,000 cases.Hospitalization rate is 30 pts per 100,000 cases.n nMortality rate has decreased dramatically in the past 20 years Mortality rate has decreased dramatically in the past 20 years n napproximately 1 death per 100,000 casesapproximately 1 death per 100,000 cases 第4页，共41页，编辑于2022年，星期五Comparing Duodenal And Gastric Ulcers第5页，共41页，编辑于2022年，星期五Epidemiology(DU)n nDuodenal sites are 4x as common as gastric sites Duodenal sites are 4x as common as gastric sites n nMost common in middle age Most common in middle age n npeak 30-50 yearsn nMale to female ratioMale to female ratio4:1 4:1 n nGenetic link:3x more common in 1Genetic link:3x more common in 1st st degree relatives degree relativesn nMore common in patients with blood group O More common in patients with blood group O n nAssociated with increased serum pepsinogenAssociated with increased serum pepsinogenn nH.pylori infection common H.pylori infection common n nup to 95%n nSmoking is twice as commonSmoking is twice as common第6页，共41页，编辑于2022年，星期五Gastric Ulcersn nCommon in late middle ageCommon in late middle agen nincidence increases with age incidence increases with age n nMale to female ratioMale to female ratio2:1 2:1 n nMore common in patients with blood group A More common in patients with blood group A n nUse of NSAIDs-associated with a three-to four-fold Use of NSAIDs-associated with a three-to four-fold increase in risk of gastric ulcer increase in risk of gastric ulcer n nLess related to H.pylori than duodenal ulcers Less related to H.pylori than duodenal ulcers about 80%about 80%n n10-20%of patients with a gastric ulcer have a 10-20%of patients with a gastric ulcer have a concomitant duodenal ulcer concomitant duodenal ulcer 第7页，共41页，编辑于2022年，星期五Etiologyn nA peptic ulcer is a mucosal break,3 mm or greater,that A peptic ulcer is a mucosal break,3 mm or greater,that can involve the stomach or duodenum.can involve the stomach or duodenum.n nThe most important The most important contributing factorscontributing factors are H pylori,are H pylori,NSAIDs,acid,and pepsin.NSAIDs,acid,and pepsin.n nAdditional Additional aggressive factorsaggressive factors include smoking,ethanol,include smoking,ethanol,bile acids,aspirin,steroids,and stress.bile acids,aspirin,steroids,and stress.n nImportant Important protective factorsprotective factors are mucus,bicarbonate,mucosal are mucus,bicarbonate,mucosal blood flow,prostaglandins,hydrophobic layer,and epithelial blood flow,prostaglandins,hydrophobic layer,and epithelial renewal.renewal.n nIncreased risk when older than 50 d/t decrease protectionn nWhen an imbalance occurs,PUD might develop.When an imbalance occurs,PUD might develop.第8页，共41页，编辑于2022年，星期五第9页，共41页，编辑于2022年，星期五Helicobactor pylorin nH.pylori?ulcerationn nPrevalence of H.pylori:80%in developing area;20-50%in developed arean nThe rate of H.pylori infection is declining in developed countryn nTransmission:oral oral fecal oral第10页，共41页，编辑于2022年，星期五Helicobactor pylorin nIt is possible that the different disease related to H.pylori infection can be attribute to different strains of organism with distinct pathogenic features第11页，共41页，编辑于2022年，星期五Helicobactor pylori第12页，共41页，编辑于2022年，星期五Helicobactor pylori第13页，共41页，编辑于2022年，星期五NSAIDn nNSAIDCOX PGn nThe form of NSAIDs have no relation to their damage on GI mucosa!第14页，共41页，编辑于2022年，星期五NSAIDRisk factor:n nAdvanced agen nHistory of ulcern nConcomitant use of glucocorticoidsn nConcomitant use of anticogulantsn nSerious or multi-system diseasen nH.pylori infectionn nCigarette and/or alcohol consumption 第15页，共41页，编辑于2022年，星期五Subjective Datan nPain”gnawing”,“aching”,or“burning”n nDuodenal ulcers:occurs 1-3 hours after a meal and may awaken patient Duodenal ulcers:occurs 1-3 hours after a meal and may awaken patient from sleep.Pain is relieved by food,antacids,or vomiting.from sleep.Pain is relieved by food,antacids,or vomiting.n nGastric ulcers:food may exacerbate the pain while vomiting Gastric ulcers:food may exacerbate the pain while vomiting relieves it.relieves it.n nNausea,vomiting,belching,dyspepsia,bloating,chest discomfort,anorexia,hematemesis,&/or melena may also occur.n nnausea,vomiting,&weight loss more common with Gastric nausea,vomiting,&weight loss more common with Gastric ulcersulcers第16页，共41页，编辑于2022年，星期五Objective Datan nEpigastric tendernessEpigastric tendernessn nGuaic-positive stoolGuaic-positive stool resulting from occult blood loss resulting from occult blood lossn nSuccussion splashSuccussion splash resulting from scaring or edema due to partial or resulting from scaring or edema due to partial or complete gastric outlet obstructioncomplete gastric outlet obstructionn nA succussion splash describes the sound obtained by shaking an individual who has 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.free fluid and air or gas in a hollow organ or body cavity.n nUsually elicited to confirm intestinal or pyloric obstruction.Usually elicited to confirm intestinal or pyloric obstruction.n nDone by gently shaking the abdomen by holding either side of the pelvis.A 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 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 stethoscope.It is not valid if the pt has eaten or drunk fluid within the last three hours.three hours.第17页，共41页，编辑于2022年，星期五Complicationsn nPerforation&Penetrationinto pancreas,liver and retroperitoneal space n nPeritonitisn nBowel obstruction,Gastric outflow obstruction,&Pyloric stenosis n nBleeding-occurs in 25%to 33%of cases and accounts for 25%of ulcer deaths.n nGastric CA第18页，共41页，编辑于2022年，星期五Active bleeding第19页，共41页，编辑于2022年，星期五n n胃角溃疡出血录像.avi第20页，共41页，编辑于2022年，星期五Gastric CA第21页，共41页，编辑于2022年，星期五Peptic ulcer special n nSilent ulcern nPeptic ulcer in advanced agen nPeptic ulcer on posterior bulbn nPeptic ulcer on pylorus tuben nGiant peptic ulcer第22页，共41页，编辑于2022年，星期五Diagnostic Plann nStool for fecal occult bloodn nLabs:CBC(R/O bleeding),liver function test,amylase,and lipase.n nH.Pylori can be diagnosed by urea breath test,blood test,stool antigen assays,&rapid urease test on a biopsy sample.n nBarium meal第23页，共41页，编辑于2022年，星期五Diagnostic Plann nUpper GI Endoscopy:Any pt 50y with new onset of symptoms or those with alarm markings including anemia,weight loss,or GI bleeding.n nPreferred 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.第24页，共41页，编辑于2022年，星期五Gastric ulcer第25页，共41页，编辑于2022年，星期五Duodenal ulcer第26页，共41页，编辑于2022年，星期五Differential Diagnosisn nNeoplasm of the stomachNeoplasm of the stomachn nPancreatitisPancreatitisn nPancreatic cancerPancreatic cancern nDiverticulitisDiverticulitisn nNonulcer dyspepsia(also called functional dyspepsia)Nonulcer dyspepsia(also called functional dyspepsia)n nCholecystitisCholecystitisn nGastritis Gastritis n nGERDGERDn nMIMInot to be missed if having chest painnot to be missed if having chest pain第27页，共41页，编辑于2022年，星期五Treatment-antacidn nMixture of aluminum hydroxide and magnesium hydroxiden nTalcid 第28页，共41页，编辑于2022年，星期五Treatment acid secretion inhabitorn nProton Pump Inhibitors PPI:Prilosec,Prevacid,Nexium,Protonix,or Aciphex for 4-8 weeksn nH2 receptor antagonists HRA:Tagament,Pepcid,Axid,or Zantac for up to 8 weeks第29页，共41页，编辑于2022年，星期五不同抑酸剂的作用机理不同抑酸剂的作用机理丙谷胺丙谷胺雷尼替丁雷尼替丁哌仑西平哌仑西平GH2MPPhe+H+K+壁壁细细胞胞PPIPPI H+第30页，共41页，编辑于2022年，星期五Treatment H.pylori eradicationn nTriple therapyTriple therapy for 14 days is considered the treatment for 14 days is considered the treatment of choice.of choice.n nProton Pump Inhibitor+clarithromycin and amoxicillin Proton Pump Inhibitor+clarithromycin and amoxicillin n nOmeprazole(Prilosec):20 mg PO bid for 14 d Omeprazole(Prilosec):20 mg PO bid for 14 d ororLansoprazole(Prevacid):30 mg PO bid for 14 d Lansoprazole(Prevacid):30 mg PO bid for 14 d ororRabeprazole(Aciphex):20 mg PO bid for 14 d Rabeprazole(Aciphex):20 mg PO bid for 14 d ororEsomeprazole(Nexium):40 mg PO qd for 14 d Esomeprazole(Nexium):40 mg PO qd for 14 d plusplusClarithromycin(Biaxin):500 mg PO bid for 14 Clarithromycin(Biaxin):500 mg PO bid for 14 andandAmoxicillin(Amoxil):1 g PO bid for 14 dAmoxicillin(Amoxil):1 g PO bid for 14 dn nCan substitute Flagyl 500 mg PO bid for 14 d if allergic to PCNCan substitute Flagyl 500 mg PO bid for 14 d if allergic to PCNn nIn the setting of an active ulcer,continue qd proton pump In the setting of an active ulcer,continue qd proton pump inhibitor therapy for additional 2 weeks.inhibitor therapy for additional 2 weeks.第31页，共41页，编辑于2022年，星期五Treatment H.pylori eradicationn nQuadruple therapy for the infection of resistant organism for the infection of resistant organism Omeprazole 20mg qdOmeprazole 20mg qd Bismuth subsalicylate 2 tablets qid Bismuth subsalicylate 2 tablets qid Metronidazole 250mg qid Metronidazole 250mg qid Tetracycline 500mg qid Tetracycline 500mg qidn nGoal:complete elimination of H.Pylori.Once achieved re-Goal:complete elimination of H.Pylori.Once achieved re-infection rates are low.infection rates are low.Compliance!第32页，共41页，编辑于2022年，星期五Treatment NSAID related PUDPrevention!n nH2RA n nPPIn nMisoprostoln nSelective COX-2 inhibitorsn nH.pylori eradication第33页，共41页，编辑于2022年，星期五Treatment cytoprotective agentsn nSucralfaten nBismuth-Containing Preparationsn nProstaglandin Analogues第34页，共41页，编辑于2022年，星期五GU active to healed第35页，共41页，编辑于2022年，星期五DU active to healed第36页，共41页，编辑于2022年，星期五Lifestyle Changesn nDiscontinue NSAIDs and use Acetaminophen for pain Discontinue NSAIDs and use Acetaminophen for pain control if possible.control if possible.n nAcid suppression-AntacidsAcid suppression-Antacidsn nSmoking cessationSmoking cessationn nNo dietary restrictions unless certain foods are associated No dietary restrictions unless certain foods are associated with problems.with problems.n nAlcohol in moderationAlcohol in moderationn nMen under 65:2 drinks/dayMen under 65:2 drinks/dayn nMen over 65 and all women:1 drink/dayMen over 65 and all women:1 drink/dayn nStress reductionStress reduction第37页，共41页，编辑于2022年，星期五Preventionn nConsider prophylactic therapy for the following patients:Consider prophylactic therapy for the following patients:n nPts with NSAID-induced ulcers who require daily NSAID therapyPts with NSAID-induced ulcers who require daily NSAID therapyn nPts older than 60 yearsPts older than 60 yearsn nPts with a history of PUD or a complication such as GI bleeding Pts with a history of PUD or a complication such as GI bleeding n nPts taking steroids or anticoagulants or patients with significant comorbid medical illnessesPts taking steroids or anticoagulants or patients with significant comorbid medical illnessesn nProphylactic regimens that have been shown to dramatically Prophylactic regimens that have been shown to dramatically reduce the risk of NSAID-induced gastric and duodenal ulcers reduce the risk of NSAID-induced gastric and duodenal ulcers include the use of a prostaglandin analogue or a proton pump include the use of a prostaglandin analogue or a proton pump inhibitor.inhibitor.n nMisoprostol (Cytotec)100-200 mcg PO 4 times per day Misoprostol (Cytotec)100-200 mcg PO 4 times per day n nOmeprazole(Prilosec)20-40 mg PO every day Omeprazole(Prilosec)20-40 mg PO every day n nLansoprazole(Prevacid)15-30 mg PO every dayLansoprazole(Prevacid)15-30 mg PO every day第38页，共41页，编辑于2022年，星期五Surgeryn nPeople who do not respond to medication,or who develop complications:n nVagotomy-cutting the vagus nerve to interrupt messages sent from the brain to the stomach to reducing acid secretion.n nAntrectomy-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.n nPyloroplasty-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.第39页，共41页，编辑于2022年，星期五Evaluation/Follow-up/Referralsn nH.Pylori Positive:retesting for tx efficacyn nUrea breath testUrea breath testno sooner than 4 weeks after therapy no sooner than 4 weeks after therapy to avoid false negative resultsto avoid false negative resultsn nStool antigen testStool antigen testan 8 week interval must be allowed an 8 week interval must be allowed after therapy.after therapy.n nH.Pylori Negative:evaluate symptoms after one month.Patients who are controlled should cont.2-4 more weeks.n nIf symptoms persist then refer to specialist for additional diagnostic testing.第40页，共41页，编辑于2022年，星期五Thank you!第41页，共41页，编辑于2022年，星期五