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1、Definition,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 Duodenal,PUD Demographics,Higher prevalence in developing countries H. Pylori
2、is sometimes associated with socioeconomic status and poor hygiene In the US: Lifetime prevalence is 10%. PUD affects 4.5 million annually. Hospitalization rate is 30 pts per 100,000 cases. Mortality rate has decreased dramatically in the past 20 years approximately 1 death per 100,000 cases,Compari
3、ng Duodenal And Gastric Ulcers,Epidemiology (DU),Duodenal sites are 4x as common as gastric sites Most common in middle age peak 30-50 years Male to female ratio4:1 Genetic link: 3x more common in 1st degree relatives More common in patients with blood group O Associated with increased serum pepsino
4、gen H. pylori infection common up to 95% Smoking is twice as common,Gastric Ulcers,Common in late middle age incidence increases with age Male to female ratio2:1 More common in patients with blood group A Use of NSAIDs - associated with a three- to four-fold increase in risk of gastric ulcer Less re
5、lated to H. pylori than duodenal ulcers about 80% 10 - 20% of patients with a gastric ulcer have a concomitant duodenal ulcer,Etiology,A peptic ulcer is a mucosal break, 3 mm or greater, that can involve the stomach or duodenum. The most important contributing factors are H pylori, NSAIDs, acid, and
6、 pepsin. Additional aggressive factors include smoking, ethanol, bile acids, aspirin, steroids, and stress. Important protective factors are mucus, bicarbonate, mucosal blood flow, prostaglandins, hydrophobic layer, and epithelial renewal. Increased risk when older than 50 d/t decrease protection Wh
7、en an imbalance occurs, PUD might develop.,Helicobactor pylori,H. pylori ? ulceration Prevalence of H. pylori: 80% in developing area; 20-50% in developed area The rate of H. pylori infection is declining in developed country Transmission: oral oral fecal oral,Helicobactor pylori,It is possible that
8、 the different disease related to H. pylori infection can be attribute to different strains of organism with distinct pathogenic features,Helicobactor pylori,Helicobactor pylori,NSAID,NSAIDCOX PG The form of NSAIDs have no relation to their damage on GI mucosa !,NSAID,Risk factor: Advanced age Histo
9、ry of ulcer Concomitant use of glucocorticoids Concomitant use of anticogulants Serious or multi-system disease H. pylori infection Cigarette and/or alcohol consumption,Subjective Data,Pain”gnawing”, “aching”, or “burning” Duodenal ulcers: occurs 1-3 hours after a meal and may awaken patient from sl
10、eep. Pain is relieved by food, antacids, or vomiting. Gastric ulcers: food may exacerbate the pain while vomiting relieves it. Nausea, vomiting, belching, dyspepsia, bloating, chest discomfort, anorexia, hematemesis, &/or melena may also occur. nausea, vomiting, & weight loss more common with Gastri
11、c ulcers,Objective Data,Epigastric tenderness Guaic-positive stool resulting from occult blood loss Succussion splash resulting from scaring or edema due to partial or complete gastric outlet obstruction A succussion splash describes the sound obtained by shaking an individual who has free fluid and
12、 air or gas in a hollow organ or body cavity. Usually elicited to confirm intestinal or pyloric obstruction. 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 without a stethoscope. It is not valid if the p
13、t has eaten or drunk fluid within the last three hours.,Complications,Perforation & Penetrationinto pancreas, liver and retroperitoneal space Peritonitis Bowel obstruction, Gastric outflow obstruction, & Pyloric stenosis Bleeding-occurs in 25% to 33% of cases and accounts for 25% of ulcer deaths. Ga
14、stric CA,Active bleeding,胃角溃疡出血录像.avi,Gastric CA,Peptic ulcer special,Silent ulcer Peptic ulcer in advanced age Peptic ulcer on posterior bulb Peptic ulcer on pylorus tube Giant peptic ulcer,Diagnostic Plan,Stool for fecal occult blood Labs: CBC (R/O bleeding), liver function test, amylase, and lipa
15、se. H. Pylori can be diagnosed by urea breath test, blood test, stool antigen assays, & rapid urease test on a biopsy sample. Barium meal,Diagnostic Plan,Upper GI Endoscopy: Any pt 50y with new onset of symptoms or those with alarm markings including anemia, weight loss, or GI bleeding. Preferred di
16、agnostic test b/c its highly sensitive for dx of ulcers and allows for biopsy to rule out malignancy and rapid urease tests for testing for H. Pylori.,Gastric ulcer,Duodenal ulcer,Differential Diagnosis,Neoplasm of the stomach Pancreatitis Pancreatic cancer Diverticulitis Nonulcer dyspepsia (also ca
17、lled functional dyspepsia) Cholecystitis Gastritis GERD MInot to be missed if having chest pain,Treatment- antacid,Mixture of aluminum hydroxide and magnesium hydroxide Talcid,Treatment acid secretion inhabitor,Proton Pump Inhibitors PPI: Prilosec, Prevacid, Nexium, Protonix, or Aciphex for 4-8 week
18、s H2 receptor antagonists HRA: Tagament, Pepcid, Axid, or Zantac for up to 8 weeks,不同抑酸剂的作用机理,丙谷胺,雷尼替丁,哌仑西平,G,H2,M,PP,he+H+,K+,壁细胞,PPI,H+,Treatment H. pylori eradication,Triple therapy for 14 days is considered the treatment of choice. Proton Pump Inhibitor + clarithromycin and amoxicillin Omeprazol
19、e (Prilosec): 20 mg PO bid for 14 d or Lansoprazole (Prevacid): 30 mg PO bid for 14 d or Rabeprazole (Aciphex): 20 mg PO bid for 14 d or Esomeprazole (Nexium): 40 mg PO qd for 14 d plus Clarithromycin (Biaxin): 500 mg PO bid for 14 and Amoxicillin (Amoxil): 1 g PO bid for 14 d Can substitute Flagyl
20、500 mg PO bid for 14 d if allergic to PCN In the setting of an active ulcer, continue qd proton pump inhibitor therapy for additional 2 weeks.,Treatment H. pylori eradication,Quadruple therapy for the infection of resistant organism Omeprazole 20mg qd Bismuth subsalicylate 2 tablets qid Metronidazol
21、e 250mg qid Tetracycline 500mg qid Goal: complete elimination of H. Pylori. Once achieved re-infection rates are low. Compliance!,Treatment NSAID related PUD,Prevention! H2RA PPI Misoprostol Selective COX-2 inhibitors H. pylori eradication,Treatment cytoprotective agents,Sucralfate Bismuth-Containin
22、g Preparations Prostaglandin Analogues,GU active to healed,DU active to healed,Lifestyle Changes,Discontinue NSAIDs and use Acetaminophen for pain control if possible. Acid suppression-Antacids Smoking cessation No dietary restrictions unless certain foods are associated with problems. Alcohol in mo
23、deration Men under 65: 2 drinks/day Men over 65 and all women: 1 drink/day Stress reduction,Prevention,Consider prophylactic therapy for the following patients: Pts with NSAID-induced ulcers who require daily NSAID therapy Pts older than 60 years Pts with a history of PUD or a complication such as G
24、I bleeding Pts taking steroids or anticoagulants or patients with significant comorbid medical illnesses Prophylactic regimens that have been shown to dramatically reduce the risk of NSAID-induced gastric and duodenal ulcers include the use of a prostaglandin analogue or a proton pump inhibitor. Mis
25、oprostol (Cytotec) 100-200 mcg PO 4 times per day Omeprazole (Prilosec) 20-40 mg PO every day Lansoprazole (Prevacid) 15-30 mg PO every day,Surgery,People who do not respond to medication, or who develop complications: Vagotomy - cutting the vagus nerve to interrupt messages sent from the brain to t
26、he stomach to reducing acid secretion. Antrectomy - remove the lower part of the stomach (antrum), which produces a hormone that stimulates the stomach to secrete digestive juices. A vagotomy is usually done in conjunction with an antrectomy. Pyloroplasty - the opening into the duodenum and small in
27、testine (pylorus) are enlarged, enabling contents to pass more freely from the stomach. May be performed along with a vagotomy.,Evaluation/Follow-up/Referrals,H. Pylori Positive: retesting for tx efficacy Urea breath testno sooner than 4 weeks after therapy to avoid false negative results Stool antigen testan 8 week interval must be allowed after therapy. H. Pylori Negative: evaluate symptoms after one month. Patients who are controlled should cont. 2-4 more weeks. If symptoms persist then refer to specialist for additional diagnostic testing.,Thank you!,
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