1、Peptic Ulcer Disease(PUD)Zhong LiangHua Shan HospitalDefinitionA circumscribed ulceration of the gastrointestinal mucosa occurring in areas exposed to acid and pepsin and most often caused by Helicobacter pylori infection.(Uphold&Graham,2019)Peptic ulcers:Gastric and DuodenalPUD Demographics?Higher
2、prevalence in developing countries?H.Pylori is sometimes associated with socioeconomic status and poor hygieneLifetime 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 de
3、ath per 100,000 cases?In the US:?Comparing Duodenal And Gastric UlcersEpidemiology(DU)?Duodenal sites are 4x as common as gastric sites Most common in middle age?peak 30-50 yearsMale to female ratio4:1 Genetic link:3x more common in 1stdegree relativesMore common in patients with blood group O Assoc
4、iated with increased serum pepsinogenH.pylori infection common?up to 95%Smoking is twice as commonGastric 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 ri
5、sk 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 important contributing factors are H pylori
6、,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.?Increased risk when older than 50 d/t decrease protectio
7、nWhen an imbalance occurs,PUD might develop.Helicobactor pylori?H.pylori?ulcerationPrevalence of H.pylori:80%in developing area;20-50%in developed areaThe rate of H.pylori infection is declining in developed countryTransmission:oral oralfecal oralHelicobactor pylori?It is possible that the different
8、 disease related to H.pylori infection can be attribute to different strains of organism with distinct pathogenic featuresHelicobactor pyloriHelicobactor pyloriNSAID?NSAIDCOX PG?The form of NSAIDs have no relation to their damage on GI mucosa!NSAIDRisk factor:?Advanced ageHistory of ulcerConcomitant
9、 use of glucocorticoidsConcomitant use of anticogulantsSerious or multi-system diseaseH.pylori infectionCigarette and/or alcohol consumptionSubjective Data?Pain”gnawing”,“aching”,or“burning”?Duodenal ulcers:occurs 1-3 hours after a meal and may awaken patient from sleep.Pain is relieved by food,anta
10、cids,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 Gastric ulcersObjective Data?Epigastric tendernessGuaic
11、-positive stoolresulting from occult blood lossSuccussion splashresulting 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 air or gas in a hollow organ or body cavity.Usually e
12、licited 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 pt has eaten or drunk fluid within the last three hours.Comp
13、lications?Perforation&Penetrationinto pancreas,liver and retroperitoneal space PeritonitisBowel obstruction,Gastric outflow obstruction,&Pyloric stenosis Bleeding-occurs in 25%to 33%of cases and accounts for 25%of ulcer deaths.Gastric CAActive bleeding?胃角溃疡出血录像.aviGastric CAPeptic ulcer special Sile
14、nt 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 bloodLabs:CBC(R/O bleeding),liver function test,amylase,and lipase.H.Pylori can be diagnosed by urea breath test,blood test,stool antigen assays
15、,&rapid urease test on a biopsy sample.Barium mealDiagnostic 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 diagnostic test b/c its highly sensitive for dx of ulcers and allows for biopsy to rule out m
16、alignancy and rapid urease tests for testing for H.Pylori.Gastric ulcerDuodenal ulcerDifferential Diagnosis?Neoplasm of the stomachPancreatitisPancreatic cancerDiverticulitisNonulcer dyspepsia(also called functional dyspepsia)CholecystitisGastritis GERDMInot to be missed if having chest painTreatmen
17、t-antacid?Mixture of aluminum hydroxide and magnesium hydroxide?TalcidTreatmentacid secretion inhabitor?Proton Pump InhibitorsPPI:Prilosec,Prevacid,Nexium,Protonix,or Aciphex for 4-8 weeks?H2receptor antagonists HRA:Tagament,Pepcid,Axid,or Zantac for up to 8 weeks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
18、西平哌仑西平GH2MK+壁壁细细胞胞PPIPPIPP+he+HHTreatmentH.pylori eradication?Triple therapyfor 14 days is considered the treatment of choice.?Proton Pump Inhibitor+clarithromycin and amoxicillin?Omeprazole(Prilosec):20 mg PO bid for 14 d orLansoprazole(Prevacid):30 mg PO bid for 14 d orRabeprazole(Aciphex):20 mg P
19、O bid for 14 d orEsomeprazole(Nexium):40 mg PO qd for 14 d Clarithromycin(Biaxin):500 mg PO bid for 14 Amoxicillin(Amoxil):1 g PO bid for 14 dCan substitute Flagyl 500 mg PO bid for 14 d if allergic to PCNplusand?In the setting of an active ulcer,continue qd proton pump inhibitor therapy for additio
20、nal 2 weeks.TreatmentH.pylori eradication?Quadruple therapyfor the infection of resistant organismOmeprazole 20mg qdBismuth subsalicylate 2 tablets qidMetronidazole 250mg qidTetracycline 500mg qid?Goal:complete elimination of H.Pylori.Once achieved re-infection rates are low.Compliance!TreatmentNSAI
21、D related PUDPrevention!H2RA PPIMisoprostolSelective COX-2 inhibitorsH.pylori eradicationTreatmentcytoprotective agents?SucralfateBismuth-Containing PreparationsProstaglandin Analogues?GU active to healedDU active to healedLifestyle Changes?Discontinue NSAIDs and use Acetaminophen for pain control i
22、f possible.Acid suppression-AntacidsSmoking cessationNo dietary restrictions unless certain foods are associated with problems.Alcohol in moderation?Men under 65:2 drinks/dayMen over 65 and all women:1 drink/day?Stress reductionPrevention?Consider prophylactic therapy for the following patients:?Pts
23、 with NSAID-induced ulcers who require daily NSAID therapyPts older than 60 yearsPts with a history of PUD or a complication such as GI bleeding Pts taking steroids or anticoagulants or patients with significant comorbid medical illnesses?Prophylactic regimens that have been shown to dramatically re
24、duce the risk of NSAID-induced gastric and duodenal ulcers include the use of a prostaglandin analogue or a proton pump inhibitor.?Misoprostol (Cytotec)100-200 mcg PO 4 times per day Omeprazole(Prilosec)20-40 mg PO every day Lansoprazole(Prevacid)15-30 mg PO every daySurgery?People who do not respon
25、d to medication,or who develop complications:Vagotomy-cutting the vagus nerve to interrupt messages sent from the brain to the 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.
26、A vagotomy is usually done in conjunction with an antrectomy.?Pyloroplasty-the opening into the duodenum and small intestine(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
27、for tx efficacyUrea 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.
