內(nèi)科學 消化性潰瘍鐘良

內(nèi)科學消化性潰瘍鐘良第一頁，共四十一頁，編輯于2023年，星期日Definition

AcircumscribedulcerationofthegastrointestinalmucosaoccurringinareasexposedtoacidandpepsinandmostoftencausedbyHelicobacterpyloriinfection.(Uphold&Graham,2003)第二頁，共四十一頁，編輯于2023年，星期日Pepticulcers:

GastricandDuodenal第三頁，共四十一頁，編輯于2023年，星期日PUDDemographicsHigherprevalenceindevelopingcountries

H.PyloriissometimesassociatedwithsocioeconomicstatusandpoorhygieneIntheUS:

Lifetimeprevalenceis~10%.PUDaffects~4.5millionannually.Hospitalizationrateis~30ptsper100,000cases.Mortalityratehasdecreaseddramaticallyinthepast20yearsapproximately1deathper100,000cases

第四頁，共四十一頁，編輯于2023年，星期日ComparingDuodenal

AndGastricUlcers第五頁，共四十一頁，編輯于2023年，星期日Epidemiology(DU)Duodenalsitesare4xascommonasgastricsitesMostcommoninmiddleagepeak30-50yearsMaletofemaleratio—4:1Geneticlink:3xmorecommonin1stdegreerelativesMorecommoninpatientswithbloodgroupOAssociatedwithincreasedserumpepsinogenH.pyloriinfectioncommonupto95%Smokingistwiceascommon第六頁，共四十一頁，編輯于2023年，星期日GastricUlcersCommoninlatemiddleageincidenceincreaseswithageMaletofemaleratio—2:1MorecommoninpatientswithbloodgroupAUseofNSAIDs-associatedwithathree-tofour-foldincreaseinriskofgastriculcerLessrelatedtoH.pylorithanduodenalulcers–about80%10-20%ofpatientswithagastriculcerhaveaconcomitantduodenalulcer第七頁，共四十一頁，編輯于2023年，星期日EtiologyApepticulcerisamucosalbreak,3mmorgreater,thatcaninvolvethestomachorduodenum.ThemostimportantcontributingfactorsareHpylori,NSAIDs,acid,andpepsin.Additionalaggressivefactorsincludesmoking,ethanol,bileacids,aspirin,steroids,andstress.Importantprotectivefactorsaremucus,bicarbonate,mucosalbloodflow,prostaglandins,hydrophobiclayer,andepithelialrenewal.Increasedriskwhenolderthan50d/tdecreaseprotectionWhenanimbalanceoccurs,PUDmightdevelop.第八頁，共四十一頁，編輯于2023年，星期日第九頁，共四十一頁，編輯于2023年，星期日HelicobactorpyloriH.pylori→

?→ulcerationPrevalenceofH.pylori:80%indevelopingarea;20-50%indevelopedareaTherateofH.pyloriinfectionisdecliningindevelopedcountryTransmission:oral→oralfecal→oral第十頁，共四十一頁，編輯于2023年，星期日HelicobactorpyloriItispossiblethatthedifferentdiseaserelatedtoH.pyloriinfectioncanbeattributetodifferentstrainsoforganismwithdistinctpathogenicfeatures第十一頁，共四十一頁，編輯于2023年，星期日Helicobactorpylori第十二頁，共四十一頁，編輯于2023年，星期日Helicobactorpylori第十三頁，共四十一頁，編輯于2023年，星期日NSAIDNSAID→COX→PG↓TheformofNSAIDshavenorelationtotheirdamageonGImucosa!!第十四頁，共四十一頁，編輯于2023年，星期日NSAIDRiskfactor:AdvancedageHistoryofulcerConcomitantuseofglucocorticoidsConcomitantuseofanticogulantsSeriousormulti-systemdiseaseH.pyloriinfectionCigaretteand/oralcoholconsumption

第十五頁，共四十一頁，編輯于2023年，星期日SubjectiveDataPain—”gnawing”,“aching”,or“burning”Duodenalulcers:occurs1-3hoursafteramealandmayawakenpatientfromsleep.Painisrelievedbyfood,antacids,orvomiting.Gastriculcers:foodmayexacerbatethepainwhilevomitingrelievesit.Nausea,vomiting,belching,dyspepsia,bloating,chestdiscomfort,anorexia,hematemesis,&/ormelenamayalsooccur.

nausea,vomiting,&weightlossmorecommonwithGastriculcers第十六頁，共四十一頁，編輯于2023年，星期日ObjectiveDataEpigastrictendernessGuaic-positivestoolresultingfromoccultbloodlossSuccussionsplashresultingfromscaringoredemaduetopartialorcompletegastricoutletobstructionAsuccussionsplashdescribesthesoundobtainedbyshakinganindividualwhohasfreefluidandairorgasinaholloworganorbodycavity.Usuallyelicitedtoconfirmintestinalorpyloricobstruction.Donebygentlyshakingtheabdomenbyholdingeithersideofthepelvis.Apositivetestoccurswhenasplashingnoiseisheard,eitherwithorwithoutastethoscope.Itisnotvalidifthepthaseatenordrunkfluidwithinthelastthreehours.第十七頁，共四十一頁，編輯于2023年，星期日ComplicationsPerforation&Penetration—intopancreas,liverandretroperitonealspacePeritonitisBowelobstruction,Gastricoutflowobstruction,&PyloricstenosisBleeding--occursin25%to33%ofcasesandaccountsfor25%ofulcerdeaths.GastricCA第十八頁，共四十一頁，編輯于2023年，星期日Activebleeding第十九頁，共四十一頁，編輯于2023年，星期日胃角潰瘍出血錄像.avi第二十頁，共四十一頁，編輯于2023年，星期日GastricCA第二十一頁，共四十一頁，編輯于2023年，星期日Pepticulcer–specialSilentulcerPepticulcerinadvancedagePepticulceronposteriorbulbPepticulceronpylorustubeGiantpepticulcer第二十二頁，共四十一頁，編輯于2023年，星期日DiagnosticPlanStoolforfecaloccultbloodLabs:CBC(R/Obleeding),liverfunctiontest,amylase,andlipase.H.Pyloricanbediagnosedbyureabreathtest,bloodtest,stoolantigenassays,&rapidureasetestonabiopsysample.Bariummeal第二十三頁，共四十一頁，編輯于2023年，星期日DiagnosticPlanUpperGIEndoscopy:Anypt>50ywithnewonsetofsymptomsorthosewithalarmmarkingsincludinganemia,weightloss,orGIbleeding.Preferreddiagnostictestb/citshighlysensitivefordxofulcersandallowsforbiopsytoruleoutmalignancyandrapidureasetestsfortestingforH.Pylori.第二十四頁，共四十一頁，編輯于2023年，星期日Gastriculcer第二十五頁，共四十一頁，編輯于2023年，星期日Duodenalulcer第二十六頁，共四十一頁，編輯于2023年，星期日DifferentialDiagnosisNeoplasmofthestomachPancreatitisPancreaticcancerDiverticulitisNonulcerdyspepsia(alsocalledfunctionaldyspepsia)CholecystitisGastritisGERDMI—nottobemissedifhavingchestpain第二十七頁，共四十一頁，編輯于2023年，星期日Treatment--antacidMixtureofaluminumhydroxideandmagnesiumhydroxideTalcid

第二十八頁，共四十一頁，編輯于2023年，星期日Treatment—

acidsecretioninhabitorProtonPumpInhibitorsPPI:Prilosec,Prevacid,Nexium,Protonix,orAciphexfor4-8weeksH2

receptorantagonistsHRA:Tagament,Pepcid,Axid,orZantacforupto8weeks第二十九頁，共四十一頁，編輯于2023年，星期日不同抑酸劑的作用機理丙谷胺雷尼替丁哌侖西平GH2MPPhe+H+K+壁細胞PPI

H+第三十頁，共四十一頁，編輯于2023年，星期日Treatment–

H.pylorieradicationTripletherapyfor14daysisconsideredthetreatmentofchoice.

ProtonPumpInhibitor+clarithromycinandamoxicillinOmeprazole(Prilosec):20mgPObidfor14dor

Lansoprazole(Prevacid):30mgPObidfor14dor

Rabeprazole(Aciphex):20mgPObidfor14dor

Esomeprazole(Nexium):40mgPOqdfor14dplus

Clarithromycin(Biaxin):500mgPObidfor14and

Amoxicillin(Amoxil):1gPObidfor14dCansubstituteFlagyl500mgPObidfor14difallergictoPCNInthesettingofanactiveulcer,continueqdprotonpumpinhibitortherapyforadditional2weeks.第三十一頁，共四十一頁，編輯于2023年，星期日Treatment–

H.pylorieradicationQuadrupletherapyfortheinfectionofresistantorganism

Omeprazole20mgqdBismuthsubsalicylate2tabletsqidMetronidazole250mgqidTetracycline500mgqidGoal:completeeliminationofH.Pylori.Onceachievedre-infectionratesarelow.Compliance!第三十二頁，共四十一頁，編輯于2023年，星期日Treatment—

NSAIDrelatedPUDPrevention!H2RAPPIMisoprostolSelectiveCOX-2inhibitorsH.pylorieradication第三十三頁，共四十一頁，編輯于2023年，星期日Treatment–

cytoprotectiveagentsSucralfateBismuth-ContainingPreparationsProstaglandinAnalogues第三十四頁，共四十一頁，編輯于2023年，星期日GUactivetohealed第三十五頁，共四十一頁，編輯于2023年，星期日DUactivetohealed第三十六頁，共四十一頁，編輯于2023年，星期日LifestyleChangesDiscontinueNSAIDsanduseAcetaminophenforpaincontrolifpossible.Acidsuppression--AntacidsSmokingcessationNodietaryrestrictionsunlesscertainfoodsareassociatedwithproblems.AlcoholinmoderationMenunder65:2drinks/dayMenover65andallwomen:1drink/dayStressreduction第三十七頁，共四十一頁，編輯于2023年，星期日PreventionConsiderprophylactictherapyforthefollowingpatients:PtswithNSAID-inducedulcerswhorequiredailyNSAIDtherapyPtsolderthan60yearsPtswithahistoryofPUDoracomplicationsuchasGIbleedingPtstakingsteroidsoranticoagulantsorpatientswithsignificantcomorbidmedicalillnessesProphylacticregimensthathavebeenshowntodramaticallyreducetheriskofNSAID-inducedgastricandduodenalulcersincludetheuseofaprostaglandinanalogueoraprotonpumpinhibitor.Misoprostol(Cytotec)100-200mcgPO4timesperdayOmeprazole(Prilosec)20-40mgPOeverydayLansoprazole(Prevacid)15-30mgPOeveryday第三十八頁，共四十一頁，編輯于2023年，星期日SurgeryPeoplewhodonotrespondtomedication,orwhodevelopcomplications:Vagotomy-cuttingthevagusnervetointerruptmessagessentf