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1、Peptic Ulcer Disease (PUD),Zhong Liang Hua Shan Hospital,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 Demograp
2、hics,Higher prevalence in developing countries H. Pylori 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
3、 20 years approximately 1 death per 100,000 cases,Comparing 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 w
4、ith blood group O Associated with increased serum pepsinogen 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 thre
5、e- to four-fold increase in risk of gastric ulcer Less related 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 impor
6、tant contributing factors are H pylori, NSAIDs, acid, and 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. Inc
7、reased risk when older than 50 d/t decrease protection When 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: ora
8、l oral fecal oral,Helicobactor pylori,It is possible that 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 da
9、mage on GI mucosa !,NSAID,Risk factor: Advanced age History 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: occ
10、urs 1-3 hours after a meal and may awaken patient from sleep. 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
11、. nausea, vomiting, & weight loss more common with Gastric 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
12、 obtained by shaking an individual who has free fluid and 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, eithe
13、r with or without a stethoscope. It is not valid if the pt 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%
14、 to 33% of cases and accounts for 25% of ulcer deaths. Gastric 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: C
15、BC (R/O bleeding), liver function test, amylase, and lipase. 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 in
16、cluding anemia, weight loss, or GI bleeding. Preferred diagnostic 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 called functional dyspepsia) Cholecystitis Gastritis GERD MInot to be missed if having chest pain,Treatment- antacid
