消化不良(英文)课件

Dyspepsia,PepticUlcerDiseaseandHelicobacterPyloriPharmacology&TherapeuticsFebruary2007Dyspepsia40%ofalladults4%GPconsultations10%furtherinvestigations10-20%NSAIDusersEndoscopyfindings15%DuodenalorGastriculcer15%Oesophagitis=GORD30%Gastritisduodenitisorhiatushernia30%Normal=functionaldyspepsiaGastricacidsecretionHelicobacterPyloriSymptomatictreatmentAntacidsMOA:WeakbasesthatreactwithgastricacidtoformH20+salt.↓pepsinactivityaspepsininactiveatpH>4Symptomrelief,liquids>tabletsE.g.Maalox=Mg(OH)2+Al(OH)3DrugSideeffectMagnesiumsevereosmoticdiarrhoea(thereforecombinedwithAlOH)↓drugabsorptionAluminium↓phosphate,↓absorptionoftetracycline,thyroxine&chlorpromazine,constipationCalcium↑Cainblood&urine(highdoses)AdditionalagentsAntifoamingagent

–Dimethiconetorelieveflatulence(surfactant)Alginates

-formaraftonsurfaceofstomachcontentstoreducerefluxCarbenoxolone

-liquoricederivative?Altersmucins/eH2Oretention↓K+Proton-pumpInhibitors(PPI)

MOA:blockparietalcellH+/K+ATPaseenzymesystem(protonpump)↓secretionofH+ionsintogastriclumenMoreeffectivethanH2-antagonistsorantacidsUsedinantimicrobialregimenstoeradicateH.pyloriSE:n&v,diarrhoea,dizziness,headaches,gynaecomastia&impotence(rare),thrombocytopenia,rashesDiagnosingH.pyloriUreabreathtest95%sensitive&specificStoolantigentest92%

sensitive&specificSerology80%

sensitive&specificEndoscopy–CLOtest98%sensitive&specific(ureaandphenolred,adyethatturnspinkinapHof6.0orgreater)

H.PyloriEradication1stlineeradicationtxforH.pylori2ndlinetxPreferredtx=PPIPO+Clarithromycin500mgBDPO+Amoxicillin1gmBDPOfor7daysIfPenicillinallergic=PPI+Clarithromycin500mgBDPO+Metronidazole400mgBDPOfor7daysE.g.ofPPI:Lansoprazole30mgBDPOPPI+Bismuth120mgQDSPO+Metronidazole500mgTDSPO+Tetracycline500mgQDSPOfor7daysSubsequentfailureshandledonindividualbasiswithadvicefromgastro/microH.Pylorieradication1weektriple-therapyregimenseradicateH.Pyloriin>90%cases.Usuallynoneedforcontinuedantisecretorytxunlessulcercomplicatedbybleeding/perforation2weektriple-therapyofferhighereradicationratescf1weekbutSEcommon&poorcompliance2-weekdual-therapywithPPI&antibacterialproducelowratesofH.pylorieradication¬recommendedH.pylorieradicationTreatmentfailuremaybedueto -Resistancetoantibacterialdrugs -PoorcomplianceDrugSideeffectsBismuthn&v,unpleasanttaste,darkeningoftongue&stools,cautioninrenaldiseaseMetronidazolen&v,unpleasanttaste,↓effectivenessOCP,carewithlithium/warfarinAmoxicillin&tetracyclineGIsideeffects,↓effectivenessOCP,pseudomenbranouscolitisLansoprazole↓effectivenessOCPPracticalManagementofdyspepsiaPUDonendoscopyStopNSAIDsStartfulldosePPIfor2monthsEradicationtreatmentifHPyloripositiveRepeatendoscopyforgastriculcer2%cancerriskGORDonendoscopyLifestyleadviceFulldosePPIfor1-2monthsHPyloriEradicationmaynotbenefitrefluxsymptomsIfrecurrence-lowestdosePPItocontrolsymptomsNSAIDInducedDyspepsia10-20%developendoscopicallyvisiblePUD1-5%perforationormajorbleedingEndogenousprostaglandins(PGE2&I2)contributetoGImucosaintegrityby -stimulationofmucus&bicarbonatesecretion -maintenanceofbloodflow(allowsremovalofluminalH-ions) -preventluminalH-ionsfromdiffusingintothemucosa -↓gastricacidsecretion -helpingtorepairdamagedepitheliumNSAIDInducedDyspepsiaElderly>65yearsHistoryPUDOtherdrugs–egbisphosphonates,SteroidsPPIormisoprostolprotectionforatriskConsiderscreening&eradicatingHPyloriinfectionNonulcerdyspepsiaTreatHpylori(noroutineretesting)SymptomatictreatmentPPI(provenbenefit)Prokineticagentegmetoclopramide