内科学消化性溃疡钟良.ppt

Peptic Ulcer Disease(PUD)Zhong LiangHua Shan HospitalDefinition 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 DuodenalPUD Demographicsn nHigher prevalence in developing countriesHigher prevalence in developing countries n nH.Pylori is sometimes associated with socioeconomic status H.Pylori is sometimes associated with socioeconomic status and poor hygieneand poor hygienen 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 Comparing Duodenal And Gastric UlcersEpidemiology(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 yearspeak 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%up to 95%n nSmoking is twice as commonSmoking is twice as commonGastric 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 about 80%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 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,are mucus,bicarbonate,mucosal blood flow,prostaglandins,hydrophobic layer,mucosal blood flow,prostaglandins,hydrophobic layer,and epithelial renewal.and epithelial renewal.n nIncreased risk when older than 50 d/t decrease Increased risk when older than 50 d/t decrease protectionprotectionn nWhen an imbalance occurs,PUD might develop.When an imbalance occurs,PUD might develop.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 oralHelicobactor pylorinIt is possible that the different disease related to H.pylori infection can be attribute to different strains of organism with distinct pathogenic featuresHelicobactor pyloriHelicobactor pyloriNSAIDn nNSAIDCOX PGn nThe form of NSAIDs have no relation to their damage on GI mucosa!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 Subjective Datan nPain”gnawing”,“aching”,or“burning”n nDuodenal ulcers:occurs 1-3 hours after a meal and may Duodenal ulcers:occurs 1-3 hours after a meal and may awaken patient from sleep.Pain is relieved by food,antacids,awaken patient from sleep.Pain is relieved by food,antacids,or vomiting.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 ulcersulcersObjective 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 resulting from scaring or edema due to partial or complete gastric outlet obstructionpartial or complete gastric outlet obstructionn nA succussion splash describes the sound obtained by shaking an 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 individual who has free fluid and air or gas in a hollow organ or body cavity.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.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 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 without a stethoscope.It is not valid if the pt has eaten or drunk fluid within the last three hours.within the last three hours.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 CAActive bleedingn n胃角溃疡出血录像.aviGastric CAPeptic ulcer special n nSilent ulcern nPeptic ulcer in advanced agen nPeptic ulcer on posterior bulbn nPeptic ulcer on pylorus tuben nGiant peptic ulcerDiagnostic 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 mealDiagnostic 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 Preferred diagnostic test b/c its highly sensitive for dx of ulcers and allows for biopsy to rule out dx of ulcers and allows for biopsy to rule out malignancy and rapid urease tests for testing for H.malignancy and rapid urease tests for testing for H.Pylori.Pylori.Gastric ulcerDuodenal ulcerDifferential 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 painTreatment-antacidnMixture of aluminum hydroxide and magnesium hydroxidenTalcid Treatment acid secretion inhabitornProton Pump Inhibitors PPI:Prilosec,Prevacid,Nexium,Protonix,or Aciphex for 4-8 weeksnH2 receptor antagonists HRA:Tagament,Pepcid,Axid,or Zantac for up to 8 weeks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+Treatment H.pylori eradicationn nTriple therapyTriple therapy for 14 days is considered the treatment for 14 days is considered the treatment of of choice.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.Treatment H.pylori eradicationn nQuadruple therapy for the infection of resistant for the infection of resistant organismorganism 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 Goal:complete elimination of H.Pylori.Once achieved re-infection rates are low.re-infection rates are low.Compliance!Treatment NSAID related PUDPrevention!H2RA PPI Misoprostol Selective COX-2 inhibitors H.pylori eradicationTreatment cytoprotective agentsn nSucralfaten nBismuth-Containing Preparationsn nProstaglandin AnaloguesGU active to healedDU active to healedLifestyle 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 No dietary restrictions unless certain foods are associated with problems.associated 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 reductionPreventionn nConsider prophylactic therapy for the following Consider prophylactic therapy for the following patients: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 Pts taking steroids or anticoagulants or patients with significant comorbid medical illnessesmedical illnessesn nProphylactic regimens that have been shown to Prophylactic regimens that have been shown to dramatically reduce the risk of NSAID-induced gastric dramatically reduce the risk of NSAID-induced gastric and duodenal ulcers include the use of a prostaglandin and duodenal ulcers include the use of a prostaglandin analogue or a proton pump inhibitor.analogue or a proton pump 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 daySurgeryn nPeople who do not respond to medication,or who develop complications:n nVagotomyVagotomy-cutting the vagus nerve to interrupt -cutting the vagus nerve to interrupt messages sent from the brain to the stomach to messages sent from the brain to the stomach to reducing acid secretion.reducing acid secretion.n nAntrectomyAntrectomy -remove the lower part of the stomach-remove the lower part of the stomach(antrum),which produces a hormone that stimulates(antrum),which produces a hormone that stimulates the stomach to secrete digestive juices.A vagotomy the stomach to secrete digestive juices.A vagotomy is usually done in conjunction with an antrectomy.is usually done in conjunction with an antrectomy.n nPyloroplastyPyloroplasty-the opening into the duodenum and -the opening into the duodenum and small intestine(pylorus)are enlarged,enabling small intestine(pylorus)are enlarged,enabling contents to pass more freely from the stomach.May contents to pass more freely from the stomach.May be performed along with a vagotomy.be performed along with a vagotomy.Evaluation/Follow-up/Referralsn nH.Pylori Positive:retesting for tx efficacyn nUrea breath testUrea breath testno sooner than 4 weeks after therapy to no sooner than 4 weeks after therapy to avoid false negative resultsavoid 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.