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1、Peptic Ulcer Disease (PUD)Zhong LiangHua Shan Hospital内科学消化性溃疡钟良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)内科学消化性溃疡钟良Peptic ulcers:Gastric and Duodena
2、l内科学消化性溃疡钟良PUD Demographicsn nHigher prevalence in developing countriesHigher prevalence in developing countries n nH. Pylori is sometimes associated with socioeconomic H. Pylori is sometimes associated with socioeconomic status and poor hygienestatus and poor hygienen nIn the USIn the US: : n nLife
3、time prevalence is 10%. Lifetime prevalence is 10%. n nPUD affects 4.5 million annually. PUD affects 4.5 million annually. n nHospitalization rate is 30 pts per 100,000 cases.Hospitalization rate is 30 pts per 100,000 cases.n nMortality rate has decreased dramatically in the past 20 Mortality rate h
4、as decreased dramatically in the past 20 years years n napproximately 1 death per 100,000 casesapproximately 1 death per 100,000 cases 内科学消化性溃疡钟良Comparing Duodenal And Gastric Ulcers内科学消化性溃疡钟良Epidemiology (DU)n nDuodenal sites are 4x as common as gastric sites Duodenal sites are 4x as common as gast
5、ric sites n nMost common in middle age Most common in middle age n npeak 30-50 yearspeak 30-50 yearsn nMale to female ratioMale to female ratio4:1 4:1 n nGenetic link: 3x more common in 1Genetic link: 3x more common in 1st st degree relatives degree relativesn nMore common in patients with blood gro
6、up O More common in patients with blood group O n nAssociated with increased serum pepsinogenAssociated with increased serum pepsinogenn nH. pylori infection common H. pylori infection common n nup to 95%up to 95%n nSmoking is twice as commonSmoking is twice as common内科学消化性溃疡钟良Gastric Ulcersn nCommo
7、n in late middle ageCommon in late middle agen nincidence increases with age incidence increases with age n nMale to female ratioMale to female ratio2:1 2:1 n nMore common in patients with blood group A More common in patients with blood group A n nUse of NSAIDs - associated with a three- to four-fo
8、ld Use of NSAIDs - associated with a three- to four-fold increase in risk of gastric ulcer increase in risk of gastric ulcer n nLess related to H. pylori than duodenal ulcers Less related to H. pylori than duodenal ulcers about about 80%80%n n10 - 20% of patients with a gastric ulcer have a 10 - 20%
9、 of patients with a gastric ulcer have a concomitant duodenal ulcer concomitant duodenal ulcer 内科学消化性溃疡钟良Etiologyn nA peptic ulcer is a mucosal break, 3 mm or greater, A peptic ulcer is a mucosal break, 3 mm or greater, that can involve the stomach or duodenum. that can involve the stomach or duoden
10、um. n nThe most important The most important contributing factorscontributing factors are H pylori, are H pylori, NSAIDs, acid, and pepsin. NSAIDs, acid, and pepsin. n nAdditional Additional aggressive factorsaggressive factors include smoking, include smoking, ethanol, bile acids, aspirin, steroids
11、, and stress.ethanol, bile acids, aspirin, steroids, and stress.n nImportant Important protective factorsprotective factors are mucus, bicarbonate, are mucus, bicarbonate, mucosal blood flow, prostaglandins, hydrophobic mucosal blood flow, prostaglandins, hydrophobic layer, and epithelial renewal. l
12、ayer, and epithelial renewal. n nIncreased risk when older than 50 d/t decrease Increased risk when older than 50 d/t decrease protectionprotectionn nWhen an imbalance occurs, PUD might develop.When an imbalance occurs, PUD might develop.内科学消化性溃疡钟良内科学消化性溃疡钟良Helicobactor pylorin nH. pylori ? ulcerati
13、onn nPrevalence of H. pylori: 80% in developing area; 20-50% in developed arean nThe rate of H. pylori infection is declining in developed countryn nTransmission: oral oral fecal oral内科学消化性溃疡钟良Helicobactor pylorinIt is possible that the different disease related to H. pylori infection can be attribu
14、te to different strains of organism with distinct pathogenic features内科学消化性溃疡钟良Helicobactor pylori内科学消化性溃疡钟良Helicobactor pylori内科学消化性溃疡钟良NSAIDn nNSAIDCOX PGn nThe form of NSAIDs have no relation to their damage on GI mucosa ! 内科学消化性溃疡钟良NSAIDRisk factor:n nAdvanced agen nHistory of ulcern nConcomitan
15、t use of glucocorticoidsn nConcomitant use of anticogulantsn nSerious or multi-system diseasen nH. pylori infectionn nCigarette and/or alcohol consumption 内科学消化性溃疡钟良Subjective Datan nPain”gnawing”, “aching”, or “burning”n nDuodenal ulcers: occurs 1-3 hours after a meal and may Duodenal ulcers: occur
16、s 1-3 hours after a meal and may awaken patient from sleep. Pain is relieved by food, awaken patient from sleep. Pain is relieved by food, antacids, or vomiting. antacids, or vomiting. n nGastric ulcers: food may exacerbate the pain while Gastric ulcers: food may exacerbate the pain while vomiting r
17、elieves it.vomiting relieves it.n nNausea, vomiting, belching, dyspepsia, bloating, chest discomfort, anorexia, hematemesis, &/or melena may also occur. n nnausea, vomiting, & weight loss more common with nausea, vomiting, & weight loss more common with Gastric ulcersGastric ulcers内科学消化性溃疡钟良Objectiv
18、e Datan nEpigastric tendernessEpigastric tendernessn nGuaic-positive stoolGuaic-positive stool resulting from occult blood loss resulting from occult blood lossn nSuccussion splashSuccussion splash resulting from scaring or edema due to resulting from scaring or edema due to partial or complete gast
19、ric outlet obstructionpartial or complete gastric outlet obstructionn nA succussion splash describes the sound obtained by shaking an A succussion splash describes the sound obtained by shaking an individual who has free fluid and air or gas in a hollow organ or body individual who has free fluid an
20、d air or gas in a hollow organ or body cavity. cavity. n nUsually elicited to confirm intestinal or pyloric obstruction. Usually elicited to confirm intestinal or pyloric obstruction. n nDone by gently shaking the abdomen by holding either side of the Done by gently shaking the abdomen by holding ei
21、ther side of the pelvis. A positive test occurs when a splashing noise is heard, either pelvis. A positive test occurs when a splashing noise is heard, either with or without a stethoscope. It is not valid if the pt has eaten or drunk with or without a stethoscope. It is not valid if the pt has eate
22、n or drunk fluid within the last three hours.fluid within the last three hours.内科学消化性溃疡钟良Complicationsn nPerforation & Penetrationinto pancreas, liver and retroperitoneal space n nPeritonitisn nBowel obstruction, Gastric outflow obstruction, & Pyloric stenosis n nBleeding-occurs in 25% to 33% of cas
23、es and accounts for 25% of ulcer deaths. n nGastric CA内科学消化性溃疡钟良Active bleeding内科学消化性溃疡钟良n n胃角溃疡出血录像.avi内科学消化性溃疡钟良Gastric CA内科学消化性溃疡钟良Peptic ulcer special n nSilent ulcern nPeptic ulcer in advanced agen nPeptic ulcer on posterior bulbn nPeptic ulcer on pylorus tuben nGiant peptic ulcer内科学消化性溃疡钟良Diag
24、nostic Plann nStool for fecal occult bloodn nLabs: CBC (R/O bleeding), liver function test, amylase, and lipase.n nH. Pylori can be diagnosed by urea breath test, blood test, stool antigen assays, & rapid urease test on a biopsy sample.n nBarium meal内科学消化性溃疡钟良Diagnostic Plann nUpper GI Endoscopy: An
25、y pt 50y with new onset of symptoms or those with alarm markings including anemia, weight loss, or GI bleeding.n nPreferred diagnostic test b/c its highly sensitive for Preferred diagnostic test b/c its highly sensitive for dx of ulcers and allows for biopsy to rule out dx of ulcers and allows for b
26、iopsy to rule out malignancy and rapid urease tests for testing for H. malignancy and rapid urease tests for testing for H. Pylori. Pylori. 内科学消化性溃疡钟良Gastric ulcer内科学消化性溃疡钟良Duodenal ulcer内科学消化性溃疡钟良Differential Diagnosisn nNeoplasm of the stomachNeoplasm of the stomachn nPancreatitisPancreatitisn nPa
27、ncreatic cancerPancreatic cancern nDiverticulitisDiverticulitisn nNonulcer dyspepsia (also called functional dyspepsia)Nonulcer dyspepsia (also called functional dyspepsia)n nCholecystitisCholecystitisn nGastritis Gastritis n nGERDGERDn nMIMInot to be missed if having chest painnot to be missed if h
28、aving chest pain内科学消化性溃疡钟良Treatment- antacidnMixture of aluminum hydroxide and magnesium hydroxidenTalcid 内科学消化性溃疡钟良Treatment acid secretion inhabitornProton Pump Inhibitors PPI: Prilosec, Prevacid, Nexium, Protonix, or Aciphex for 4-8 weeksnH2 receptor antagonists HRA: Tagament, Pepcid, Axid, or Za
29、ntac for up to 8 weeks内科学消化性溃疡钟良不同抑酸剂的作用机理不同抑酸剂的作用机理丙谷胺丙谷胺雷尼替丁雷尼替丁哌仑西平哌仑西平GH2MPPhe+H+K+壁壁细细胞胞PPIPPI H+内科学消化性溃疡钟良Treatment H. pylori eradicationn nTriple therapyTriple therapy for 14 days is considered the treatment for 14 days is considered the treatment of of choice.choice. n nProton Pump Inhibitor
30、 + clarithromycin and amoxicillin Proton Pump Inhibitor + clarithromycin and amoxicillin n nOmeprazole (Prilosec): 20 mg PO bid for 14 d Omeprazole (Prilosec): 20 mg PO bid for 14 d ororLansoprazole (Prevacid): 30 mg PO bid for 14 d Lansoprazole (Prevacid): 30 mg PO bid for 14 d ororRabeprazole (Aci
31、phex): 20 mg PO bid for 14 d Rabeprazole (Aciphex): 20 mg PO bid for 14 d ororEsomeprazole (Nexium): 40 mg PO qd for 14 d Esomeprazole (Nexium): 40 mg PO qd for 14 d plusplusClarithromycin (Biaxin): 500 mg PO bid for 14 Clarithromycin (Biaxin): 500 mg PO bid for 14 andandAmoxicillin (Amoxil): 1 g PO
32、 bid for 14 dAmoxicillin (Amoxil): 1 g PO bid for 14 dn nCan substitute Flagyl 500 mg PO bid for 14 d if allergic to PCNCan substitute Flagyl 500 mg PO bid for 14 d if allergic to PCNn nIn the setting of an active ulcer, continue qd proton pump In the setting of an active ulcer, continue qd proton p
33、ump inhibitor therapy for additional 2 weeks.inhibitor therapy for additional 2 weeks.内科学消化性溃疡钟良Treatment H. pylori eradicationn nQuadruple therapy for the infection of resistant for the infection of resistant organismorganism Omeprazole 20mg qdOmeprazole 20mg qd Bismuth subsalicylate 2 tablets qid
34、Bismuth subsalicylate 2 tablets qid Metronidazole 250mg qid Metronidazole 250mg qid Tetracycline 500mg qid Tetracycline 500mg qidn nGoal: complete elimination of H. Pylori. Once Goal: complete elimination of H. Pylori. Once achieved re-infection rates are low. achieved re-infection rates are low. Co
35、mpliance!内科学消化性溃疡钟良Treatment NSAID related PUDPrevention! H2RA PPI Misoprostol Selective COX-2 inhibitors H. pylori eradication内科学消化性溃疡钟良Treatment cytoprotective agentsn nSucralfaten nBismuth-Containing Preparationsn nProstaglandin Analogues内科学消化性溃疡钟良GU active to healed内科学消化性溃疡钟良DU active to healed内
36、科学消化性溃疡钟良Lifestyle Changesn nDiscontinue NSAIDs and use Acetaminophen for Discontinue NSAIDs and use Acetaminophen for pain control if possible.pain control if possible.n nAcid suppression-AntacidsAcid suppression-Antacidsn nSmoking cessationSmoking cessationn nNo dietary restrictions unless certain
37、 foods are No dietary restrictions unless certain foods are associated with problems.associated with problems.n nAlcohol in moderationAlcohol in moderationn nMen under 65: 2 drinks/dayMen under 65: 2 drinks/dayn nMen over 65 and all women: 1 drink/dayMen over 65 and all women: 1 drink/dayn nStress r
38、eductionStress reduction内科学消化性溃疡钟良Preventionn nConsider prophylactic therapy for the following Consider prophylactic therapy for the following patients:patients:n nPts with NSAID-induced ulcers who require daily NSAID therapyPts with NSAID-induced ulcers who require daily NSAID therapyn nPts older t
39、han 60 yearsPts older than 60 yearsn nPts with a history of PUD or a complication such as GI bleeding Pts with a history of PUD or a complication such as GI bleeding n nPts taking steroids or anticoagulants or patients with significant Pts taking steroids or anticoagulants or patients with significa
40、nt comorbid medical illnessescomorbid medical illnessesn nProphylactic regimens that have been shown to Prophylactic regimens that have been shown to dramatically reduce the risk of NSAID-induced dramatically reduce the risk of NSAID-induced gastric and duodenal ulcers include the use of a gastric a
41、nd duodenal ulcers include the use of a prostaglandin analogue or a proton pump inhibitor.prostaglandin analogue or a proton pump inhibitor.n nMisoprostol (Cytotec) 100-200 mcg PO 4 times per day Misoprostol (Cytotec) 100-200 mcg PO 4 times per day n nOmeprazole (Prilosec) 20-40 mg PO every day Omep
42、razole (Prilosec) 20-40 mg PO every day n nLansoprazole (Prevacid) 15-30 mg PO every dayLansoprazole (Prevacid) 15-30 mg PO every day内科学消化性溃疡钟良Surgeryn nPeople who do not respond to medication, or who develop complications:n nVagotomyVagotomy - cutting the vagus nerve to interrupt - cutting the vagu
43、s nerve to interrupt messages sent from the brain to the stomach to messages sent from the brain to the stomach to reducing acid secretion. reducing acid secretion. n nAntrectomyAntrectomy - remove the lower part of the - remove the lower part of the stomach (antrum), which produces a hormone that s
44、tomach (antrum), which produces a hormone that stimulates the stomach to secrete digestive juices. stimulates the stomach to secrete digestive juices. A vagotomy is usually done in conjunction with an A vagotomy is usually done in conjunction with an antrectomy. antrectomy. n nPyloroplastyPyloroplas
45、ty - the opening into the duodenum and - the opening into the duodenum and small intestine (pylorus) are enlarged, enabling small intestine (pylorus) are enlarged, enabling contents to pass more freely from the stomach. contents to pass more freely from the stomach. May be performed along with a vag
46、otomy.May be performed along with a vagotomy.内科学消化性溃疡钟良Evaluation/Follow-up/Referralsn nH. Pylori Positive: retesting for tx efficacyn nUrea breath testUrea breath testno sooner than 4 weeks after therapy no sooner than 4 weeks after therapy to avoid false negative resultsto avoid false negative res
47、ultsn nStool antigen testStool antigen testan 8 week interval must be allowed an 8 week interval must be allowed after therapy.after therapy.n nH. Pylori Negative: evaluate symptoms after one month. Patients who are controlled should cont. 2-4 more weeks.n nIf symptoms persist then refer to specialist for additional diagnostic testing.内科学消化性溃疡钟良内科学消化性溃疡钟良
