1、L/O/G/ODigestive SystemContents Part 1 Introduction Part 2 Peptic ulcer Part 3 Acute PancreatitisAnatomy Anatomically,the digestive system consists of a 30-feet long mucous membrane-line tube beginning with the mouth and ending with the anusThe digestive system is composed of nine main organs:mouth、
2、pharynx、esophagus、stomach、small intestine、large intestine、liver、gallbladder and pancreasMucous 粘液的粘液的Anus 肛门肛门Pharynx 咽部咽部Esophagus 食管食管Pancreas 胰腺胰腺Overview 1 How many organs are there in the digestive system?What are they?The organs of the digestive systemThe primary functions of the digestive sys
3、temIngestion 摄入摄入 DigestionAbsorption 吸收吸收Elimination 排泄排泄 4123Physiology of the major organsCommon Symptoms Loss of appetiteNausea and VomittingAbdominal distension&pain Diarrhea 4123Common Symptoms Hematochezia 便血便血Hematemesis 呕血呕血Constipation 便秘便秘Jaundice 黄疸黄疸8567Epidemiological investigationMorb
4、iditygastrointestinal diseases patientsthe morbidity of chronic gastritis is 3 0%peptic ulcerchronic gastritis120 million peopleaccounted for more than 7 0%the incidence of peptic ulcer is 10%the elderly2012 Chinese cancer registration reportHepatic carcinomaGastric carcinomaEsophageal cancerColon c
5、ancerCancer death rates list04.autoimmunity03.Diet and environmental factors01.Infection with a bacterium called H.Pylori(Hp)02.Use of drugs like nonsteroidal anti-inflammatory drugs(NSAIDs 非甾体抗炎药)EtiologyEtiologyMethods of examinationBiopsy 活检活检 Gastrointestinal dynamics Laparotomy 剖腹探查术剖腹探查术456End
6、oscopy 内窥镜内窥镜Imageological examinationLaboratory inspection:blood and stool routines,C-urea breath test123vocabularyvocabulary-stomy:造口术、吻合术 appendicostomy gastrostomy gastroduodenostomy-tomy:切开术 pancreatomy gastrotomy anatomyPeptic ulceruPeptic ulcer(PU)：Mainly refers to the chronic ulcer occurs in
7、 the stomach and duodenum mucosa(n.解剖 粘膜),namely,gastric ulcer(GU)and duodenal ulcer(DU).uThe basic formation of ulcer is the gastric acid and pepsin(n.医胃蛋白酶)digestion.uClinically DU is more common than GU with the ratio being about 3:1.DU occurs in young adults.The age of onset of GU is generally 1
8、0 years older than DU.Autumn,winter and spring are the seasons of PU.Overview 2uHow many types can the peptic ulcer be classified?What are they?Etiology 1、H.pylori infection:the main cause of peptic ulcer.2、Gastric acid and pepsin：PU is due to gastric acid and pepsin consisting gastric juice caused
9、by their own digestion.3、Drug factors：some NSAIDs,anticancer drugs have damaging effects on gastric and duodenal mucosa,which was most obvious in NSAIDs.NSAIDs in addition to direct effects on the gastric and duodenal mucosa caused the damage,mainly through the inhibition of prostaglandin synthesis.
10、H.Pylori 幽门螺杆菌幽门螺杆菌Pepsin 胃蛋白酶胃蛋白酶Duodenal 十二指肠的十二指肠的Mucosa 粘膜粘膜Prostaglandin 前列腺素前列腺素Synthesis 合成合成4、Other risk factors Cigarette Psychological factors Genetic factors PathologyuLocation:95%of DU is in the duodenal bulb(十二指肠球部).A few occurred in the back of bulb；85%of GU locate in the lesser curvat
11、ure of stomach（胃窦小弯）and the angle of stomach（胃角）.uNumber:most of them are single,a few cases are crinosity（多发).uShape:round or oval（椭圆）uDepth:The shallow ulcer involves mucosal muscular layer（粘膜肌层）,some ulcers reach to muscular layer（肌层）and even serous coat（浆膜层）.A few ulcers leads to perforation（穿孔）
12、.The bottom of ulcer is clean,with smooth edge and ashen or sallow coating（灰白或灰黄苔）.uRecover time:4-8W Clinical Featuresu symptomAbdominal Painu 1、Long term：several years or even decades.u 2、Periodical(周期性的)attack:the attack and relieved stage appear alternately.发作期与缓解期交替出现u 3、Rhythmic epigastric pai
13、n.节律性上腹疼 GU irregular gastric pain after meal Ingestion of food and antacids（制酸剂）can not relieve pain DU Burning pain worse when hungry or at night Ingestion of food and antacids often relieve painuOther symptoms：Belching Abdominal distension Nausea SatietyuSigns：Epigastric tenderness(not specificit
14、y)Belching 打嗝打嗝Nausea 恶心恶心Satiety 早饱早饱Epigastric 上腹部的上腹部的Tenderness 压痛压痛laboratory examination u Barium meal（钡餐）Barium studies of the proximal gastro-intestinal tract are still commonly used as a first test for documenting an ulcer.For a DU,it appears as a well-demarcated crater,often seen in the bu
15、lb.For a GU,it may represent benign or malignant disease.Typically,a benign GU also appears as a discrete crater with radiating mucosal folds originating from the ulcer margin.（GU可能是良性和恶性。典型的良性表现为游离龛影，粘膜皱襞从溃疡边缘向内放射集中）Barium 钡钡proximal 近端的近端的demarcated 界定的界定的crater 龛影龛影discrete 游离的游离的benign 良性的良性的mal
16、ignant 恶性的恶性的uEndoscopy -most sensitive and specificuTest for detection of H.Pylori Invasive:Rapid urine screening test（快速尿素酶实验）,Histology culture（组织学培养）.Non-invasive:Serology，C-Urea breath test（碳呼气试验）.Urine 尿尿Histology 组织学组织学Serology 血清学血清学Urea 尿素尿素 Diagnosis：uThe history and main symptoms can make
17、 a preliminary（初步的）diagnosis.uWhen Barium studies of the proximal gastrointestinal tract(上消化道钡餐)find the ulcer crater,the Peptic Ulcer can be confirmed.uPeptic Ulcer can also be confirmed by Endoscopy and mucosa biopsy.Differential diagnosisDifferential diagnosisChronic gastritis characterized by ep
18、igastric distension,belching,pain after meal,without rhythm.Peptic ulcer is often combined with chronic gastritis.Gastroscopy can distinguish their difference.Cholecystitis often induced by eating greasy（油腻的）things,and characterized with right upper quadrant pain,radiating to the right humeral back,
19、accompanied by fever,jaundice（黄疸）,etc.Ultrasound and gastroscope can help to identify.TreatmentTherapeutic targets:to eliminate the causes,relieve symptoms,heal ulcer,prevent recurrence,avoid complications.（1）General treatment:proper rest,reasonable diet,regular life,less drinking strong tea,coffee,
20、etc.（2）Drug treatment：Inhibition of gastric acid secretion：commonly used drugs like H2RA or PPI。anti-Hp therapy:classic triple therapy:a PPI,or a kind of colloidal bismuth agent combined with 2 kinds of antibiotics below-clarithromycin(or tetracycline),amoxicillin and metronidazole。Recurrence 复发复发Co
21、lloidal 胶体的胶体的Bismuth 铋铋clarithromycin 克拉霉素克拉霉素tetracycline 四环素四环素amoxicillin 阿莫西林阿莫西林 Metronidazole 甲硝唑甲硝唑Overview 3uWhat is the classic triple therapy?（3）Protection of gastric mucosa drugs：Such as aluminium sulphate,bismuth potassium citrate and prostaglandin E,etc.（4）Surgical treatment:If medical
22、 treatment is invalid,acute perforation,cicatricial pyloric obstruction,such as cancer,surgical treatment should be considered.aluminium sulphate 硫糖铝 bismuth potassium citrate 枸橼酸铋钾prostaglandin E 前列腺素EPerforation穿孔 cicatricial pyloric 瘢痕性幽门的Acute pancreatitis Acute pancretitis is an acute inflammat
23、ory process of the pancreas with variable involvement of other regional tissue or organs.sectional anatomy The anatomy of the pancreas and the surroundingn 1、Common CausesnGallstones (30 to 60%)nAlcoholism (15 to 30%)nHyper-triglycerid-emia（高甘油三酯血症）(1.3 to 3.8%)nEtc ETIOLOGYOverview 4nWhich is the m
24、ost common cause in China?2、Unconmom&Rare Causes nVasculitisnConnective tissue（结缔组织）disordersnPancreatomanEtc.nAutodigestion is one pathogenic theory,according to which pancreatitis results when proteolytic enzymes are activated in the pancreas rather than in the intestinal lumen.PATHOLOGYProteolyti
25、c 分解蛋白的 Enzyme 酶Lumen 管腔n-ly 融化，溶化，分解 proteo-ly-tic 分解蛋白的 thrombo-ly-sis 溶栓 sperm-ly-tic 溶精剂Symptoms Abdominal pain severity:mild&toleratable severe,constant&incapacitating location:epigastrium,periumbilicus radiate to the back/chest/flank/lower abdomen intense:supine relief:sitting with the trunk f
26、lexed and knees drawn up Vomit&Nausea Abdominal distention Tachycardia（心动过速）Hypotension&Shock Epi-在之上 epi-gastric 胃上的 epi-thelium 上皮 Sub-在之下 sub-arachnoid 蛛网膜下的 sub-cutaneous 皮下的 Peri-在周围 peri-umbilical 脐周的 peri-cardium 心包Tachy-快速的 tachy-cardia 心动过速 tachy-pnea 呼吸急促 Brady-慢速的 brady-pnea brady-cardia
27、心动过缓Physical Signs Mild Acute Pancreatitis(MAP)merely no signs Severe Acute Pancreatitis(SAP)-muscle rigidity -bowel sound diminished or absent -jaundice -cullens sign/Turners signRigidity 强直Bowel sound 肠鸣音Diminish 减弱 Complications Local Abcess:fever epigastric mass toxicity symptoms Pseudocyst:form
28、 in 3-4 weeks necrotic fluidsAbcess 脓肿Pseudocyst 假性囊肿 Abcess 脓肿 pulmonary abcess 肺脓肿 abcessocentesis 脓肿穿刺术 abcessotomy 脓肿切开术 Pseudo-假的 pseudocyst 假性囊肿 pseudocyesis 假孕Complications Systemic Pulmonary:acute respiratory distress syndrome(ARDS)Cardiovascular:hypotension,hypovolemia,pericadial effusion H
29、ematology:DIC Gastrointestinal hemorrhage Portal vein thrombosis Renal：oliguria,azotemia,acute renal failure(ARF)etcHypovolemia 低血容量Pericardial effusion 心包积液 Hemorrhage 出血Portal vein 门静脉Thrombosis 栓塞Oliguria 少尿Azotemia 氮质血症 Olig-少，低 oliguria 少尿 oligarchy 寡头的 oligomer 低聚物 Azot-氮 azotemia 氮质血症 azotoba
30、cter 固氮菌 azotometer 氮定量计LABORATORY DATA1.Amylase About 75%of patients have an increased level of serum amylase valuing threefold or more above normal in 24 hours.Amylase elevations in serum and urine occur in many conditions other than pancreatitis.But the level will not reach threefold above normal
31、.Theres no definite correlation between the severity of pancreatitis and the degree of serum amylase elevation2.Lipase Serum lipase activity increases in parallel with amylase activity,and this elevation may also have diagnostic value,especially when its 3 times higher than normal.Amylase 淀粉酶Serum 血
32、清Threefold 三倍Lipase 脂肪酶In parallel with 与同步-ase 酶 lip-ase 脂肪酶 amyl-ase 淀粉酶 phospho-lip-ase 磷脂酶 elast-ase 弹性蛋白酶 3.Other biochemistry data Leukocytosis Hyperglycemia Hypocalcemia Hyperbilirubinemia Hypertriglyceridemia Hypoxemia Leuko-cyt-osis 白细胞增多Hyper-glyc-emia 高血糖Hypo-calc-emia 低血钙Hyper-bilirubin-
33、emia 高胆红素血症Hyper-triglycerid-emia 高甘油三酯血症Hyp-ox-emia 低氧血症 Glyc-糖，葡萄糖糖，葡萄糖 glycose 葡萄糖葡萄糖 hyperglycemia 高血糖高血糖 hypoglycemia 低血糖低血糖Glycer(i)-甘油甘油 nitroglycerin 硝酸甘油硝酸甘油 triglyceride 甘油三酯甘油三酯Calc-钙钙 calcium 钙钙 hypocalcemia 低血钙低血钙Bilirubin-胆红素胆红素 hyperbilirubinemia 高胆红素血症高胆红素血症 bilirubinic acid 胆红酸胆红酸Ox
34、-氧氧 hypoxemia 低氧血症低氧血症 carbon dioxide 二氧化碳二氧化碳 hydrogen peroxide 过氧化氢过氧化氢Auxiliary Examination CT scan Electrocardiogram X-rays Sonography（超声图像）DiagnosisPatients with severe and constant abdominal pain,nausea,emesis,fever,tachycardia,and abnormal findings on abdominal examination,and an elevated lev
35、el of serum amylase should be suspected as acute pancreatitis.But not all the features above have to be present for the diagnosis to be established.Differential DiagnosisAcute pancreatitis should be distinguished from these diseases with acute abdominal pain:perforated viscus,especially peptic ulcer
36、 characterized by the disapperance of hepatic dullness.acute cholecystitis and biliary colic can be confirmed by sonography or CT scan.acute intestinal obstruction abdominal x-ray examination is very helpful in diagnosis.Perforated viscus 内脏穿孔Hepatic dullness肝浊音界Biliary colic胆绞痛Treatment Mild Acute
37、Pancreatitis In most cases,it subsides spontenously after receiving proper treatments:-Diet(fasting)-Nasogastric suction -Intravenous fluids&colloids -AnalgesicsNasogastric suction 经鼻胃管抽吸Intravenous 静脉内的Colloid 胶体Analgesic止痛剂 Severe Acute Pancreatitisconventional therapy -close attention vital signs
38、,symptoms,amylase level -diet TPN （total parental nutrition）EN (endointestinal nutrition)general dietTotal Parental Nutritioin 完全肠外营养Endointestinal Nutrition肠内营养Analgesics dolantinPancreatic secretion inhibitor somatostatin/ocreotidePancreatic enzyme inhibitor aprotinin/gabexadeAntibiotics imipenem,
39、quinolones,fungicidesDolantin 度冷丁Somatostatin 生长抑素Ocreotide 奥曲肽Aprotinin 抑肽酶Gabexade 加贝酯Imipenem 亚胺培南Quinolonoes 喹诺酮Fungicide 杀真菌剂-in/-ine 素 adrenaline 肾上腺素 insulin 胰岛素 heparin 肝素 somato-stat-in 生长抑素-tide/peptide 肽 aminopeptide 氨肽 ocreotide 奥曲肽 Surgical therapy -ERCP/choledochotomy -laparotomy with
40、drainage -operations necrectomy pseudocystocentesis abcessocentesisEndoscopic RetrogradeCholangioPancreatography(ERCP)内窥镜下逆行性胆管胰造影术 Choledochotomy 胆总管切开术Drainage 灌洗Necrectomy坏死切除术Pseudocystocentesis假性囊肿穿刺术Abcessocentesis脓肿穿刺术 Choledoch-胆总管 choledochoplasty 胆总管成形术 choledochotomy 胆总管切开术 choledocholith
41、iasis 胆总管结石 Cholang-胆管 cholangography 胆管造影 cholangolithiasis 胆管结石 TCM therapy -coloclysis 灌肠灌肠Prognosis Mild acute pancreatitis -commonly subsides in one week,no sequelas Severe acute pancreatitis -mortality between 20 and 40%-pancreatic insufficiency -turns into chronic pancreatitisSequela 后遗症Mortality 死亡率L/O/G/OThank You!
