peptic ulcer ( 消化性溃疡 )
DESCRIPTION
Peptic Ulcer ( 消化性溃疡 ). XinJie Chen Department of Gastroenterology ZhuJiang Hospital. Useful words. Duodenum( 十二指肠 ) Duodenal ulcer( 十二指肠溃疡 ) Gastric ulcer( 胃溃疡 ) Helicobacter pylori ( 幽门螺杆菌 ) Muscularis mucosa ( 粘膜肌层 ) Cyclooxygenase ( 环氧合酶 ) - PowerPoint PPT PresentationTRANSCRIPT
Peptic Ulcer( 消化性溃疡 )
XinJie ChenDepartment of
GastroenterologyZhuJiang Hospital
Useful words
Duodenum( 十二指肠 ) Duodenal ulcer( 十二指肠溃疡 ) Gastric ulcer( 胃溃疡 ) Helicobacter pylori ( 幽门螺杆菌 ) Muscularis mucosa ( 粘膜肌层 ) Cyclooxygenase ( 环氧合酶 ) Upper gastrointestinal hemorrhage( 上消化
道出血 ) Perforation ( 穿孔 ) Pyloric obstruction( 幽门梗阻 ) Canceration (癌变)
Structure of stomach and duodenum
Fundus
Cardiac region
Gastric body
Gastric antrum
Duodenum bulb
Pyloric orifice
Descending part of duodenum
Esophagus
DefinitionChronic ulcers extend through muscularis mucosa ( 粘膜肌层 )of stomach or duodenum
Ulcer and gastritis
An ulcer at the anterior wall of
duodenal bulb with a minor
signs of recent bleeding
Erosive gastritis
Epidemiology
• In all age groups• Incidence( 发病率 )
– Gastric ulcer(GU) < Duodenal ulcer(DU)
– male > female– DU young people– GU Middle age/old people
Etiology and Pathogenesis
• Mucus & bicarbonate – ( 粘液和碳酸氢盐 )
• Epithelium– ( 上皮细胞 )
• Capillary network – ( 毛细血管网 )
• Prostaglandin E– ( 前列腺素 E)
• Epidermal growth factor– ( 表皮生长因子 )
Defense and repairing system of
gastric and duodenal mucosa
Prof. Barry J. Marshall & Prof. J. Robin Warren
Etiology and Pathogenesis
• Helicobacter pylori infection★– Peptic ulcer > control group– Clearance Recurrence rate( 复发率 )– Mechanism Not clear
• Nonsteroidal anti-inflammatory drugs(NSAID)
• Gastric acid and Pepsin ( 胃蛋白酶 )– No acid, no ulcer + No HP, no ulcer
Etiology and Pathogenesis
Helicobacter pylori infection demonstrated o
gastric antral biopsy
Helicobacter pylori infection demonstrated
with electronmicroscope
Etiology and Pathogenesis
NSAID
Cyclooxygenase-1(COX-1)
Cyclooxygenase-2(COX-2)
Prostaglandin E
Secretion of mucus and
bicarbonate ions
Mucosal blood flow
Epithelial defense against
cytotoxic injury
Etiology and Pathogenesis
• Other factors– Smoking– Genetics– Stress– Abnormal motility of gastro &
duodenum
Clinical manifestation
• Cardinal symptoms( 主要症状 )– Epigastric pain( 上腹痛 )
•Chronic •Periodic•Rhythmic• “Hunger-like” DU
– Belching( 嗳气 ),nausea,anoresia,etc
• Physical Examination– Localized epigastric tenderness
Special Types of Peptic Ulcer
• Complex ulcers( 复合溃疡 ) Gastric + Duodenal− Pyloric obstruction
• Ulcers of pyloric canal( 幽门管溃疡 )– Effects of drugs – Complications
• Postbulbar ulcer( 十二指肠球后溃疡 ) Bleeding• Giant ulcer diameter > 2cm Malignant?• Peptic ulcer in old people • Asymptomatic ulcer( 无症状溃疡 )
Laboratory Tests and Imaging studies
• Upper endoscopy + biopsy Preferred
• Barium studies( 钡餐检查 ) Optional
• Testing for Helicobacter pylori– Enzyme-linked immunosorbent assay
(ELISA)– Stool antigen testing ★– 13C-urea or 14C-urea breath test– Invasive methods
Antral ulcer( 胃窦溃疡 )
Antral ulcer scars with fold
convergency
Gastric ulcers with flat pigmented spots as a sign
of previous bleeding
Kissing ulcers of duodenal bulb
Ulcer of duodenal bulb
Diagnosis• Epigastric pain( 上腹痛 )
– Chronic – Periodic– Rhythmic
• Upper endoscopy + biopsy The Key!
• Barium studies
Differential Diagnosis( 鉴别诊断 )
• Chronic diseases – Liver,gallbladder,pancreas,etc– Functional dyspepsia( 功能性消化不良 )
• Gastric cancer – Endoscopic signs + biopsy
• Gastrin adenoma (Zollinger-Ellison syndrome)– BAO,MAO– BAO/MAO >60%– Serum gastrin >200pg/ml
Complications( 并发症 )
• Upper gastrointestinal bleeding • Perforation ( 穿孔 )• Pyloric obstruction( 幽门梗阻 )
– Duodenal ulcer or ulcer of pyloric canal
• Canceration (癌变)
Remaining blood (coffee ground like)
in the stomach
Active bleeding ulcer with a visible blood jet
in duodenal bulb
Plain Film Radiography of upright views of the
abdomen shows free air under the diaphragm
Gastric outlet obstruction with
prepyloric deformity and a stenotic pyloric
channel
Gastric cancer
Treatment
• General treatment• Acid-inhibitory drugs ( 抑酸药 )
– Proton pump inhibitors(PPI)
– H2-receptor antagonists (H2RA)
• Agents enhancing mucosal defenses– Bismuth Potassium Citrate – Prostaglandin analogs ( 前列腺素类似物 )– Sucralfate( 硫糖铝 )– Antacids( 抗酸药 )
Treatment
• Helicobacter pylori eradication therapy– Clarithromycin ( 克拉霉素 )– Metronidazole (甲硝唑) ???– Amoxicillin (阿莫西林)– Levofloxacin (左氧氟沙星) – Tetracycline (四环素)– Proton pump inhibitors (质子泵抑制剂)– Bismuth Potassium Citrate (枸橼酸铋钾)
PPI 或 Bismuth Antibiotics PPI (double doses/d) Clarithromycin
1.0g/dBismuth Potassium
Citrate Amoxicillin 2.0g/d
480mg/d Metronidazole 0.8g/d (one of above) (two of above)
Eradication therapy of HP
Bid , time of therapy: 7 -14days
Rescue therapy after HP eradication failure
• Time of therapy: 10-14days• PPI+ Bismuth Potassium Citrate + two kinds
of antibacterial Recommended
• Selection of antibiotic – Results of drug sensitive test
Treatment
• Treatment of NSAID-associated ulcer– Stop taking NSAID !!– Selective COX-2 inhibitor– PPI– H.pylori (+) Eradication therapy
• Prevention of NSAID-associated ulcer – High risk group PPI
Treatment
• Prevention of recurrence of ulcer– Recurrence of H.pylori infection
Eradication– Taking NSAID PPI– Ulcer associated with H.pylori
H2RA(1/2)
– H.pylori (-) H2RA(1/2)
• Surgical treatment – Upper gastrointestinal bleeding
Medical treatment failed
Treatment
– Perforation – Cicatricial pyloric obstruction( 瘢痕性
幽门梗阻 ) – Canceration– Telephium ( 顽固性溃疡 )
•Drug therapy failed