24 peptic ulcer
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24 peptic ulcer Document Transcript

  • 1. • Peptic ulcer disease. • 2007 • Peptic ulcer disease – ulceration of the gastroduodenal mucosa typically extending through the muscularis mucosa. Ulcers occur within the stomach and/or duodenum and are often chronic in nature. • Etiology of PU • Local infection - H. pylori; • Hypersecretion of HCl (ZOLLINGER-ELLISON SYNDROME); • NSAID-induced injury • Pathogenesis of PU. Factors of agression and defence. • Balance Shay (H.Shay, 1968) • Classification of PU • Gastric ulcer • Duodenal ulcer • Gastroduodenal ulcers • Classification of PU Localization of ulcer Duodenum А: • Bulbus duodeni, • Postbulbar part. • Anterior wall, • Posterior wall, • Lesser curvature, • Greater curvature. Б:
  • 2. • Classification of PU Localization of ulcer Stomach А: • Cardial part, • Subcardial part, • Body of the stomach, • Antrum, • Pyloric part. • Anterior wall, Б: Posterior wall, • • • Lesser curvature, Greater curvature Classification of PU Clinical form • Acute (revealed for the first time) • Chronic • Classification of PU Course Latent • Mild (rarely relapsing) • Moderate ( 1-2 timesyear relapsing) • Severe (relapsing more than 3 timesyear ), with complications • Classification of PU Phase • Exacerbation (relapse)
  • 3. • Damping exacerbation (incomplete remission) • Remission • Classification of PU Morphological characteristic of ulcer Ulcers’ size • small (less than 0,5 сm) • middle (0,5 – 1 сm ) • large (1,1 – 3 сm ) • giant (more than 3 сm) • Classification of PU Functional characteristic of gastroduodenal system • With increased secretion • With normal secretion • With reduced secretion • Classification of PU Complications • Perforation; • gastrointestinal bleeding; • gastric outlet obstruction; • malignancy; • Penetration ; • Clinical picture of PU • Clinical picture Abdominal pain, classically epigastric with severity relating to mealtimes • Early pains • Late pains • Fasting pains 30 - 60 min after meals 1,5 - 2 hours at night
  • 4. Gastric dyspepsia • nausea • vomitting • heartburn Intestinal dyspepsia constipation Astheno-vegetative syndrome • Instrumental diagnostics • Evaluation of gastric secretion pH metry of stomach and duodenun • Severe hyperacidity (рН 0,9-1,2) • Hyperacidity (рН 1,3-1,5) • Normacidity (рН 1,6-2,2) • Mild hypoacidity (рН 2,5-3,5) • Severe hypoacidity (рН 3,6-6,0) • Achlorhydria (рН > 6,5) • Methods for diagnosing Helicobacter Pylori • Invasive methods 1. Bacteriologic test 2. Hystologic method 3. Quick urease test 4. Polymerase chain reaction 5. Phase contrast microscopy • Non-invasive methods • 1. Serologic method • 2. Polymerase chain reaction • 3. Urea breath test
  • 5. • Radiography Direct signs: • Discrete crater (niche sign) Indirect signs: • Scar deformation • Radiating mucosal folds(convergence of folds) • Functional changes (slow or quick barium passage, duodenal dyskinesia, duodenogastral reflux, local spasms) • Radiography • Esophagogastroduodenoscopy Advantages: 1. Confirmation of the disease 2.Establishment of the benign or malignant character of ulceration 3. Visual and morphologic control of the ulcer healing 4.Revealing the concomitant lesions • of mucosa Complications of PUD: Complications, appearing suddenly and threatens to the patients’ life : • Gastrointestinal bleeding • • Moderate: deficiency CBV 20-30%. Hb<70 g/l hematocrit 0,25-0,30. • Severe: deficiency CBV 30-40%. Hb<50 g/L, hematocrit < 0,20. • • Mild: deficiency CBV(circulating blood volume) < 20%. Hb<100 g/L, hematocrit > 0,30. Very severe: deficiency CBV > 40%. Hb<50 g/L, hematocrit < 0,20. Complications of PUD Complications, appearing suddenly and threatens to the patients’ life : • Perforation • Complications of PUD Complications, developing gradually and of chronic course:
  • 6. • Penetration • Complications of PUD Complications, developing gradually and of chronic course: • Gastric outlet obstruction • • • Organic Functional Complications of PUD Complications, developing gradually and of chronic course: • Malignancy • Treatment of PUD • Management considerations • The goals of ulcer therapy include relief of symptoms, ulcer healing and prevention of recurrence and complications. • influence on the factors of aggression and/or defense; • In PUD, associated with H. pylori – eradication of HP; • Usage of medications, removing dyspeptic andor neurotic symptoms; • Correction of pharmaceutical treatment with taking into account concomitant diseases; • Indications to H. pylori eradication Absolute indications • Peptic ulcer disease (exacerbation, remission, complications) • chronic atrophic gastritis • MALT-lymphoma • Post-gastric cancer resection • Indications to H. pylori eradication Relative indications • Functional non-ulcer dyspepsia • Gastro-esophago –reflux disease in long treatment with omeprazole
  • 7. • After surgical treatment of PU • Latent НР carrier for prophylaxis of MALT lymphoma and gastric cancer (patients’ wishes) • Patients who are first-degree relatives of gastric cancer patients • Requirements to antihelicobacterial therapy • Eradication of H.Pylori minimum in 80% cases in duration of therapy not more than 7-14 days; • Good compliance, low likelihood of adverse events,short duration, ease of administration, relatively low cost; • Patient must not stop taking the drugs himself. • Rules of antihelicobacterial therapy: 1. If usage of one scheme of therapy does not lead to eradication, than no need to repeat it once more. 2. If used scheme did not lead to eradication, that means, that bacteria became resistant to one of the components of therapy (clarithromycin, metronidazole). 3. If one, and than second scheme fails, than you must evaluate sensitivity of the H. pylori strain to all spectrum of antibiotics. 4. Appearance of the bacteria in the organism after a year after treatment must be evaluated as relapse of infection, not reinfection. In relapsing the more effective treatment must be used. • Antihelicobacterial therapy • Antihelicobacterial therapy Bismuth-containing preparations Colloidal bismuth subcitrate (DE-NOL) 240 mg 2 timesday 30 min before meals bismuth subsalicylate • Antihelicobacterial therapy Antisecretory drugs • ranitidine 150 mg 2 timesday • famotidine 40- 80 mgday • omeprazole 20 - 40 mgday, • lansoprazole 15 - 60 mgday , • pantoprazole 40 - 80 mgday
  • 8. • rabeprazole 20 - 40 mgday • Therapy of H.pylori Antibacterial medications • tetracycline 500 mg q.I.d., • amoxicillin 1000 mg b.I.d. , • clarithromycin 500 mg b.I.d , • azithromycin 100 mg b.I.d , • roxithromycin 150 mg b.I.d. , • metronidazole 500 mg b.I.d , • tinidazole 2000 mg/day. • Eradication of Helicobacter pylori (Maastricht Consensus 2005) • Eradication of Helicobacter pylori (Maastricht Consensus 2005) • Control of eradication efficacy • Diagnosis – not earlier than 4-6 weeks after finishing antihelicobacter therapy or treatment with another antibiotic and antisecretory drugs; • Diagnosis – by at least 2 methods (bacteriological, morphological and urease) • Cytologic method is not used for establishing the eradication. • Indications to the surgical treatment of PUD Absolute: • • Massive gastrointestinal bleeding; • Decompensated gastric outlet obstruction; • Suspicion of malignancy; • • Perforation; Penetration ; Indications to the surgical treatment of PUD Relative
  • 9. • Refractory to medical treatment ulcers; • History of recurring bleeding; • Penetrating unhealing ulcers; • Compensated gastric outlet obstruction; • Callous ulcers without scarring for a long time; • frequent exacerbations of PUD, leading to decreased capacity for work and asthenisation of the patient.