内科学消化性溃疡钟良课件

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

GastricandDuodenalComparingDuodenal

AndGastricUlcersEpidemiology(DU)Duodenalsitesare4xascommonasgastricsitesMostcommoninmiddleagepeak30-50yearsMaletofemaleratio—4:1Geneticlink:3xmorecommonin1stdegreerelativesMorecommoninpatientswithbloodgroupOAssociatedwithincreasedserumpepsinogenH.pyloriinfectioncommonupto95%SmokingistwiceascommonGastricUlcersCommoninlatemiddleageincidenceincreaseswithageMaletofemaleratio—2:1MorecommoninpatientswithbloodgroupAUseofNSAIDs-associatedwithathree-tofour-foldincreaseinriskofgastriculcerLessrelatedtoH.pylorithanduodenalulcers–about80%10-20%ofpatientswithagastriculcerhaveaconcomitantduodenalulcerHelicobactorpyloriH.pylori→

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

ObjectiveDataEpigastrictendernessGuaic-positivestoolresultingfromoccultbloodlossSuccussionsplashresultingfromscaringoredemaduetopartialorcompletegastricoutletobstructionAsuccussionsplashdescribesthesoundobtainedbyshakinganindividualwhohasfreefluidandairorgasinaholloworganorbodycavity.Usuallyelicitedtoconfirmintestinalorpyloricobstruction.Donebygentlyshakingtheabdomenbyholdingeithersideofthepelvis.Apositivetestoccurswhenasplashingnoiseisheard,eitherwithorwithoutastethoscope.Itisnotvalidifthepthaseatenordrunkfluidwithinthelastthreehours.ComplicationsPerforation&Penetration—intopancreas,liverandretroperitonealspacePeritonitisBowelobstruction,Gastricoutflowobstruction,&PyloricstenosisBleeding--occursin25%to33%ofcasesandaccountsfor25%ofulcerdeaths.GastricCAActivebleedingGastricCAPepticulcer–specialSilentulcerPepticulcerinadvancedagePepticulceronposteriorbulbPepticulceronpylorustubeGiantpepticulcerDiagnosticPlanStoolforfecaloccultbloodLabs:CBC(R/Obleeding),liverfunctiontest,amylase,andlipase.H.Pyloricanbediagnosedbyureabreathtest,bloodtest,stoolantigenassays,&rapidureasetestonabiopsysample.BariummealGastriculcerDuodenalulcerTreatment—

acidsecretioninhabitorProtonPumpInhibitorsPPI:Prilosec,Prevacid,Nexium,Protonix,orAciphexfor4-8weeksH2

receptorantagonistsHRA:Tagament,Pepcid,Axid,orZantacforupto8weeks不同抑酸剂的作用机理丙谷胺雷尼替丁哌仑西平GH2MPPhe+H+K+壁细胞PPI

H+Treatment–

H.pylorieradicationTripletherapyfor14daysisconsideredthetreatmentofchoice.

ProtonPumpInhibitor+clarithromycinandamoxicillinOmeprazole(Prilosec):20mgPObidfor14dor

Lansoprazole(Prevacid):30mgPObidfor14dor

Rabeprazole(Aciphex):20mgPObidfor14dor

Esomeprazole(Nexium):40mgPOqdfor14dplus

Clarithromycin(Biaxin):500mgPObidfor14and

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

H.pylorieradicationQuadrupletherapyfortheinfectionofresistantorganism

Omeprazole20mgqdBismuthsubsalicylate2tabletsqidMetronidazole250mgqidTetracycline500mgqidGoal:completeeliminationofH.Pylori.Onceachievedre-infectionratesarelow.Compliance!Treatment—

NSAIDrelatedPUDPrevention!H2RAPPIMisoprostolSelectiveCOX-2inhibitorsH.pylorieradicationTreatment–

cytoprotectiveagentsSucralfateBismuth-ContainingPreparationsProstaglandinAnaloguesGUactivetohealedDUactivetohealedLifestyleChangesDiscontinueNSAIDsanduseAcetaminophenforpaincontrolifpossible.Acidsuppression--AntacidsSmokingcessationNodietaryrestrictionsunlesscertainfoodsareassociatedwithproblems.AlcoholinmoderationMenunder65:2drinks/dayMenover65andallwomen:1drink/dayStressreductionPreventionConsiderprophylactictherapyforthefollowingpatients:PtswithNSAID-inducedulcerswhorequiredailyNSAIDtherapyPtsolderthan60yearsPtswithahistoryofPUDoracomplicationsuchasGIbleedingPtstakingsteroidsoranticoagulantsorpatientswithsignificantcomorbidmedicalillnessesProphylacticregimensthathavebeenshowntodramaticallyreducetheriskofNSAID-inducedgastricandduodenalulcersincludetheuseofaprostaglandinanalogueoraprotonpumpinhibitor.Misoprostol(Cytotec)100-200mcgPO4timesperdayOmeprazole(Prilosec)20-40mgPOeverydayLansoprazole(Prevacid)15-30mgPOeverydaySurgeryPeoplewhodonotrespondtomedication,orwhodevelopcomplications:Vagotomy-cuttingthevagusnervetointerruptmessagessentfromthebraintothestomachtoreducingacidsecretion.Antrectomy

-removethelowerpartofthestomach(antrum),whichproducesahormonethatstimulatesthestomachtosecretedigestivejuices.Avagotomyisusuall