医学消化系统类课件：PEPTIC ULCER

1、PEPTIC ULCER 1 Definition Hole caused by the aggression of gastric acid and pepsin, extending through the mucosa into the muscularis mucosae of the esophagus, stomach (GU), or duodenum (DU ). Vulnerable sites Duodenal bulb and stomach. 2 3 Peptic ulcer Common used for gastric ulcer Duodenal ulcer bo

2、th Any portion GERD Meckes diverticulum 4 Acid and pepsin Sufficient concentration and duration Peptic ulcer Peptic ulcer Peptic ulcer Common used for gastric ulcer Duodenal ulcer both Any portion GERD Meckes diverticulum 5 6 ulcer! why? inflammationinflammation Weak Weak DefensDefens acidacid keywo

3、rds： normal Pathophysiology Defense mechanisms Helicobacter pylori NSAIDs Abnormalities in gastric acid secretion, gastroduodenal motility other HCI pH：0.9-1.5 why does the gastric acid not digest itself？ First : the mucus of the mucosal surface Second : the mucosal epithelium Three : mucosal microc

4、irculation Four: mucosal repair itself Four defensive factors for gastric mucosa Attack factors Defensive factors Defense mechanisms 11 H.Pylori infection can be associated with abnormalities in mucus and duodenal bicarbonate secretion. Too much acid Increase of parietal cells Genetic factors, long-

5、term stimulation of gastrin Increased sensitivity of parietal cells HP Increased sensitivity of vagus nerve No HP, no ulcer! The second revolutionary view on peptic ulcer Warren & Marshall获获2005年诺贝尔医学奖年诺贝尔医学奖 HP is everything!HP is everything! HP is the root cause of the defensive-barrier injury Hel

6、icobacter pylori (HP) defensive-barrier injury to mucosa Helicobacter pylori is the most important factor for induction of neutrophil infiltration. 粘液中有大量粘液中有大量HP 粘膜上皮层粘膜上皮层 vDU 90%100% GU 80%90% vThe eradication of HP can promote ulcer healing and reduce recurrence rate of peptic ulcer to 10% 1 yea

7、r. Helicobacter pylori (HP) 15 NSAIDs Common used for angiocardiopathy, and RA, SLE 15%-45% NSAIDs user -peptic ulcer 1% NSAIDs user 1 year-experience serious GI complication Cyclooxygenase inhibition环氧化酶抑制剂 COX-1 protective factor COX-2 impair factor-specific inhibitors Lipid-soluble, un-ionized di

8、ffuse across gastric mucosal epithelial cell membrance 16 Risk Factors for NSAID-Induced Ulcers Definite Prior peptic ulcer disease Prior NSAID-induced gastrointestinal complication Advanced age Concomitant use of glucocorticoids Concomitant use of anticoagulants High doses or combinations of NSAIDs

9、, including low-dose aspirin Comorbid diseases Ethanol use Possible Helicobacter pylori Infection Smoking 17 Other drugs A number of drugs other than NSAIDs appear to peptic injury. Cancer chemotherapy Solid preparation of potassium chloride Crak cocaine 18 Gastric acid and pepsin Non-acid-secreting

10、 epithelium is suspected to ulcer Gastric antrum: columnar epithelium, not secret acid Gastric body and fundus: parietal cell, secret acid H.Pylori -atrophy and intestinal metaplasia-non- acid-secreting epithelium extending to proximal stomach-ulcer 19 胃体胃体 胃窦胃窦 胃底胃底 贲门贲门 Antrum region （20） Cardiac

11、region （5） Gastric fundus and body region （75） Where gastric acid produced? Abnormal gastroduodenal motility Stress and psychological factor Smoking, drinking, spicy food 21 vRhythmicity vPeriodicity Clinical Manifestation belching, abdominal bloating, heartburn vMild, localized epigastric tendernes

12、s to deep palpation 22 vNo symptoms vMay complicated by bleeding, perforation, and obstruction Clinical Manifestation How to diagnose peptic ulcer? 1 History and symptoms 2 signs 3 laboratory tests 4 Imaging 5 pathology upper abdominal pain vomiting, melena chronic Rhythmicity Periodicity acid reflu

13、x belching bloating GU: postprandial Pain DU: preprandial Pain Enderness on Upper abdomen 上腹部局限性轻压痛，球溃压痛点常偏 右 1 History and symptoms 2 signs 3 laboratory tests 4 Imaging 5 pathology How to diagnose peptic ulcer? FOB (+) Blood regular test：anemia HP (+) q尿素酶试验:HP感染时,产生的尿素酶分解尿素产氨, pH值升高,试剂变粉红色 q13C-尿素

14、呼气试验: 口服标记尿素,若胃内HP感染, 尿素酶水解成标记的CO2, q组织学检测: 吉姆萨,甲苯胺蓝或Warthin-Starry染色 q血清学检测: 用ELISA法检测抗H.pylori抗体 q分子生物学检测:PCR扩增HP尿素酶基 因片段或HP16SrRNA基因片段 q细菌培养 5%氧气(微需氧)和37,含动物血的培养基 1 History and symptoms 2 signs 3 laboratory tests 4 Imaging 5 pathology How to diagnose peptic ulcer? gasroscopy barium meal test EUS

15、CT How to diagnose peptic ulcer? 1 History and symptoms 2 signs 3 laboratory tests 4 Imaging 5 pathology Active stage: A1: Accompanied by bleeding or blood scab A2: no bleeding Healing stage: H1: Folds centralized phenomenon H2: Obvious folds centralized phenomenon Scarring stage: S1: red scar S2: w

16、hite scar 对吻溃疡对吻溃疡 线状溃疡线状溃疡 Kissing ulcer Liner ulcer gasroscopy barium meal test EUS CT 1 History and symptoms 2 signs 3 laboratory tests 4 Imaging 5 pathology How to diagnose peptic ulcer? How to diagnose peptic ulcer? gasroscopy barium meal test EUS CT 1 History and symptoms 2 signs 3 laboratory

17、tests 4 Imaging 5 pathology gasroscopy barium meal test EUS CT 1 History and symptoms 2 signs 3 laboratory tests 4 Imaging 5 pathology How to diagnose peptic ulcer? gold standard assess precancerous lesions distinguish between benign and malignant ulcers 1 History and symptoms 2 signs 3 laboratory t

18、ests 4 Imaging 5 pathology GU DU 34 vBleeding （25%） vomiting blood, bloody or dark stools, anaemia vPerforation (5%） a sudden extreme abdominal pain that is worsened by any type of movement. vPyloric stenosis（5%） increasing abdominal pain, repeated vomiting and a feeling of fullness or bloating. vGa

19、stric carcinoma（2%4% ） Complication 35 36 Bleeding Perforation 37 subdiaphragmatic free air 38 Peptic Ulcer Pyloric Obstruction Gastric carcinoma 2%4% 39 lifestyle change drug treatment relapse prevention surgical treatment Treatment 40 Lifestyle changes Quit smoking Receive treatment for alcohol ab

20、use Cut down on coffee Relieve mental stress Avoid NSAID and spicy foods 41 42 43 Antisecretory Drugs Antisecretory Drugs-H2-RAs, proton-pump inhibitors(PPIs) 44 PPI can: p increase the antibacterial effect p relieve pain p stop bleeding Omeprazole-1989 Lansoprazole-1994 Pantoprazole-1996 Lebeiprazo

21、le- 1998 Isoprazole-2000 Mucosal protective agents Bismuth compounds, Hydrotalcite, Sucralfate, Misoprostol 45 Blocking HP mucosal barrier injury Block NSAIDs on gastric mucosal injury Blocking alcohol-related gastritis Improve the quality of ulcer healing 46 Treatment for complicaiton: bleeding Inj

22、ection Hemostasis 1:10,000 adrenalin 47 Argon plasma coagulation，APC 48 hemoclip 49 50 Interventional treatment selective angiography hemostasis by embolizing gastroduodenal artery 51 Surgical treatment Indications Massive bleeding treated ineffectively with medical treatment Acute perforation Organ

23、ic pyloric stenosis Treatment-resistant peptic ulcers Gastric ulcers suspected to be caused by malignant tumors Types of surgery antrectomy and pyloroplasty 52 summary Peptic ulcer is a defect of gastroduodenal tract with inflammatory deep to submucosa. Helicobacter pylori is the main cause of damage and relapse clinical feature: Chronic process, periodic episodes and