內(nèi)科學(xué) 消化性潰瘍鐘良

PepticUlcerDisease(PUD)ZhongLiangHuaShanHospital1DefinitionAcircumscribedulcerationofthegastrointestinalmucosaoccurringinareasexposedtoacidandpepsinandmostoftencausedbyHelicobacterpyloriinfection.(Uphold&Graham,2003)2Pepticulcers:

GastricandDuodenal3PUDDemographicsHigherprevalenceindevelopingcountries

H.PyloriissometimesassociatedwithsocioeconomicstatusandpoorhygieneIntheUS:

Lifetimeprevalenceis~10%.PUDaffects~4.5millionannually.Hospitalizationrateis~30ptsper100,000cases.Mortalityratehasdecreaseddramaticallyinthepast20yearsapproximately1deathper100,000cases

4ComparingDuodenal

AndGastricUlcers5Epidemiology(DU)Duodenalsitesare4xascommonasgastricsitesMostcommoninmiddleagepeak30-50yearsMaletofemaleratio—4:1Geneticlink:3xmorecommonin1stdegreerelativesMorecommoninpatientswithbloodgroupOAssociatedwithincreasedserumpepsinogenH.pyloriinfectioncommonupto95%Smokingistwiceascommon6GastricUlcersCommoninlatemiddleageincidenceincreaseswithageMaletofemaleratio—2:1MorecommoninpatientswithbloodgroupAUseofNSAIDs-associatedwithathree-tofour-foldincreaseinriskofgastriculcerLessrelatedtoH.pylorithanduodenalulcers–about80%10-20%ofpatientswithagastriculcerhaveaconcomitantduodenalulcer7EtiologyApepticulcerisamucosalbreak,3mmorgreater,thatcaninvolvethestomachorduodenum.ThemostimportantcontributingfactorsareHpylori,NSAIDs,acid,andpepsin.Additionalaggressivefactorsincludesmoking,ethanol,bileacids,aspirin,steroids,andstress.Importantprotectivefactorsaremucus,bicarbonate,mucosalbloodflow,prostaglandins,hydrophobiclayer,andepithelialrenewal.Increasedriskwhenolderthan50d/tdecreaseprotectionWhenanimbalanceoccurs,PUDmightdevelop.89HelicobactorpyloriH.pylori→

?→ulcerationPrevalenceofH.pylori:80%indevelopingarea;20-50%indevelopedareaTherateofH.pyloriinfectionisdecliningindevelopedcountryTransmission:oral→oralfecal→oral10HelicobactorpyloriItispossiblethatthedifferentdiseaserelatedtoH.pyloriinfectioncanbeattributetodifferentstrainsoforganismwithdistinctpathogenicfeatures11Helicobactorpylori12Helicobactorpylori13NSAIDNSAID→COX→PG↓TheformofNSAIDshavenorelationtotheirdamageonGImucosa!!14NSAIDRiskfactor:AdvancedageHistoryofulcerConcomitantuseofglucocorticoidsConcomitantuseofanticogulantsSeriousormulti-systemdiseaseH.pyloriinfectionCigaretteand/oralcoholconsumption

15SubjectiveDataPain—”gnawing”,“aching”,or“burning”Duodenalulcers:occurs1-3hoursafteramealandmayawakenpatientfromsleep.Painisrelievedbyfood,antacids,orvomiting.Gastriculcers:foodmayexacerbatethepainwhilevomitingrelievesit.Nausea,vomiting,belching,dyspepsia,bloating,chestdiscomfort,anorexia,hematemesis,&/ormelenamayalsooccur.

nausea,vomiting,&weightlossmorecommonwithGastriculcers16ObjectiveDataEpigastrictendernessGuaic-positivestoolresultingfromoccultbloodlossSuccussionsplashresultingfromscaringoredemaduetopartialorcompletegastricoutletobstructionAsuccussionsplashdescribesthesoundobtainedbyshakinganindividualwhohasfreefluidandairorgasinaholloworganorbodycavity.Usuallyelicitedtoconfirmintestinalorpyloricobstruction.Donebygentlyshakingtheabdomenbyholdingeithersideofthepelvis.Apositivetestoccurswhenasplashingnoiseisheard,eitherwithorwithoutastethoscope.Itisnotvalidifthepthaseatenordrunkfluidwithinthelastthreehours.17ComplicationsPerforation&Penetration—intopancreas,liverandretroperitonealspacePeritonitisBowelobstruction,Gastricoutflowobstruction,&PyloricstenosisBleeding--occursin25%to33%ofcasesandaccountsfor25%ofulcerdeaths.GastricCA18Activebleeding19胃角潰瘍出血錄像.avi20GastricCA21Pepticulcer–specialSilentulcerPepticulcerinadvancedagePepticulceronposteriorbulbPepticulceronpylorustubeGiantpepticulcer22DiagnosticPlanStoolforfecaloccultbloodLabs:CBC(R/Obleeding),liverfunctiontest,amylase,andlipase.H.Pyloricanbediagnosedbyureabreathtest,bloodtest,stoolantigenassays,&rapidureasetestonabiopsysample.Bariummeal23DiagnosticPlanUpperGIEndoscopy:Anypt>50ywithnewonsetofsymptomsorthosewithalarmmarkingsincludinganemia,weightloss,orGIbleeding.Preferreddiagnostictestb/citshighlysensitivefordxofulcersandallowsforbiopsytoruleoutmalignancyandrapidureasetestsfortestingforH.Pylori.24Gastriculcer25Duodenalulcer26DifferentialDiagnosisNeoplasmofthestomachPancreatitisPancreaticcancerDiverticulitisNonulcerdyspepsia(alsocalledfunctionaldyspepsia)CholecystitisGastritisGERDMI—nottobemissedifhavingchestpain27Treatment--antacidMixtureofaluminumhydroxideandmagnesiumhydroxideTalcid

28Treatment—acidsecretioninhabitorProtonPumpInhibitorsPPI:Prilosec,Prevacid,Nexium,Protonix,orAciphexfor4-8weeksH2

receptorantagonistsHRA:Tagament,Pepcid,Axid,orZantacforupto8weeks29不同抑酸劑的作用機(jī)理丙谷胺雷尼替丁哌侖西平GH2MPPhe+H+K+壁細(xì)胞PPI

H+30Treatment–H.pylorieradicationTripletherapyfor14daysisconsideredthetreatmentofchoice.

ProtonPumpInhibitor+clarithromycinandamoxicillinOmeprazole(Prilosec):20mgPObidfor14dor

Lansoprazole(Prevacid):30mgPObidfor14dor

Rabeprazole(Aciphex):20mgPObidfor14dor

Esomeprazole(Nexium):40mgPOqdfor14dplus

Clarithromycin(Biaxin):500mgPObidfor14and

Amoxicillin(Amoxil):1gPObidfor14dCansubstituteFlagyl500mgPObidfor14difallergictoPCNInthesettingofanactiveulcer,continueqdprotonpumpinhibitortherapyforadditional2weeks.31Treatment–H.pylorieradicationQuadrupletherapyfortheinfectionofresistantorganism

Omeprazole20mgqdBismuthsubsalicylate2tabletsqidMetronidazole250mgqidTetracycline500mgqidGoal:completeeliminationofH.Pylori.Onceachievedre-infectionratesarelow.Compliance!32Treatment—NSAIDrelatedPUDPrevention!H2RAPPIMisoprostolSelectiveCOX-2inhibitorsH.pylorieradication33Treatment–cytoprotectiveagentsSucralfateBismuth-ContainingPreparationsProstaglandinAnalogues34GUactivetohealed35DUactivetohealed36LifestyleChangesDiscontinueNSAIDsanduseAcetaminophenforpaincontrolifpossible.Acidsuppression--AntacidsSmokingcessationNodietaryrestrictionsunlesscertainfoodsareassociatedwithproblems.AlcoholinmoderationMenunder65:2drinks/dayMenover65andallwomen:1drink/dayStressreduction37PreventionConsiderprophylactictherapyforthefollowingpatients:PtswithNSAID-inducedulcerswhorequiredailyNSAIDtherapyPtsolderthan60yearsPtswithahistoryofPUDoracomplicationsuchasGIbleedingPtstakingsteroidsoranticoagulantsorpatientswithsignificantcomorbidmedicalillnessesProphylacticregimensthathavebeenshowntodramaticallyreducetheriskofNSAID-inducedgastricandduodenalulcersincludetheuseofaprostaglandinanalogueoraprotonpumpinhibitor.Misoprostol(Cytotec)100-200mcgPO4timesperdayOmeprazole(Prilosec)20-40mgPOeverydayLansoprazole(Prevacid)15-30mgPOeveryday38SurgeryPeoplewhodonotrespondtomedication,orwhodevelopcomplications:Vagotomy-cuttingthevagusnervetointerruptmessagessentfromthebraintot