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18 peptic ulcer

18 peptic ulcer






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    18 peptic ulcer 18 peptic ulcer Presentation Transcript

    • Peptic ulcer Chen Jie Department of gastroenterology, The first affiliated hospital of Sun Yat-sen university
    • Ulcer Erosion Definition Chronic ulcer occur in stomach and duodenum (Pathologically, ulcer is a lesion extending deeper into submucosa)
      • Epidemiology
      • A common disease in digestive system
      • No data are available about the exact incidence of peptic ulcer
      • worldwide
    • Ideograph of gastric mucosa barrier PGE ( prostaglandin e) EGF( epidermal growth factor) Gastric acid and pepsin Pathogenesis CO 2 +H 2 O  HCO 3  HCO 3  HCO 3  HCO 3  pH 2 pH 3 pH 4 pH 5 pH 6 pH 7 H + H + H + H + Mucus Bicarbonate Epithelial cell Bllod flow Capillary Artery of submucosa Gastral cavity
    • Pathogenesis
    • Helicobacter pylori, Hp ( transmission electron microscope ) Hp is an important etiological factor of peptic ulcer
    • Evidences Detection rate of Hp in PU patients 1
    • Recurence rate of PU after successful eradication of Hp 2
    • Cyclo-oxygenase (COX) ( rate-limiting enzyme in PG synthesis) Arachidonic acid COX-1 Tissue type COX-2 Induced type NSAIDs Prostaglandin NSAIDs(non-steroidal anti-inflammatory drugs) is another important etiological factor of PU (-) (-) Prostaglandin Gastrointestinal tract Physiological function Inflammation Inflammatory reaction
      • “ No acid, no ulcer ”
      • --- Key role of gastric acid in the formation of peptic ulcer
      • Because the activation of pepsin is pH-dependent (pH<4)
      Gastric acid and pepsin
    • Diagnosis and differential diagnosis
      • Symptom is the most important clue for clinical diagnosis
      • Typical upper abdominal pain:
      • Chronic, periodic and rhythmical pain
      • Relieve after food eating or antacid using
      • (Attention: Symptomless or un-typical ulcer)
      • Complex ulcer:
      • --ulcers occur in both gastric and duodenal mucosa
      • Ulcer of pyloric canal:
      • -- usually cause pyloric obstruction
      • Postbulbar ulcer
      • Macrosis ulcer:
      • --size>2cm
      • Peptic ulcer in elderly people
      • Symptomless ulcer
      • --half of the NSAIDS-related ulcers are symptomless
      Special type of peptic ulcer
      • Definite diagnosis of peptic ulcer depends on endoscopy examination:
      • --- may observe ulcer, take biopsy and
      • detect HP infection
      • Niche sign observed by X-ray barium meal examination may also provide evidence for definite diagnosis of peptic ulcer
      • ---not as accurate as endoscopy detection
    • Pictures of PU under endoscopy DU GU
    • X-ray barium meal examination --- Niche sign (direct sign of ulcer)
      • Virulence (biopsy specimen of gastric mucosa)
      • Histological examination
      • Hp culture
      • Rapid urease test
      • Non-virulence
      • 13 C or 14 C urea breath test
      • Hp antigen detection in stool
      • Serologic examination of Hp antibody
      Hp detection (routine)
    • Steiner silver stain of gastric mucosa, showing abundantly microorganisms scattered within mucus (dark arrow indicated)
    • Culture Very small and translucent colony on the plate
    • Rapid Urease Test : urea in the reagent was broken down by Hp urease, then the PH value of the reagent changed, finally the yellow color of the reagent changed to read color
    • 13C Urea Breath Test (UBT)
    • Differential diagnosis
      • Peptic ulcer need to be differentiated from diseases with chronic upper abdominal pain
      • Diseases of liver, gallbladder and pancreas, functional dyspepsia
      • After the ulcer has been detected by endoscopy examination
      • The differential diagnosis of benign and malignant gastric ulcer is very important
    • ---larger size, dirty moss, swollen and stiff surrounding mucosa---cancer --- Definite diagnosis must depend on biopsy and pathohistological examination!! Gatric ulcer Gatric cancer Benign and malignant gastric ulcer
    • Complications
      • Bleeding
      • The most common complication
      • The most common cause of massive hemorrhage of gastrointestinal tract
      • Perforation
      • Pyloric obstruction
      • Canceration (GU, 1%)
    • Pyloric obstruction (DU 、 pyloric canal ulcer)
      • Temporary obstruction (caused by pyloric dropsy or pylorospasm during the active stage of ulcer)
      • Chronic obstruction (cicatricial pyloric obstruction) (caused by shrink of scar during the healing stage of ulcer)
      • Symptoms (abdominal pain, nausea, vomit, et al)
      • Confirmed by gastroscope or X-ray barium meal examination
    • Treatment
      • Principles
      • Eliminate etiological factors (Hp eradication, stop using NSAIDs)
      • Relieve symptoms, facilitate ulcer healing (antiulcer drugs)
      • Prevent ulcer recurrence, and prevent or treat complications
      • General treatment
      • --- Stop smoking, stop drinking ,regular food-intake, et al
      • 2. Anti-ulcer treatment
      • Types Commonly used drugs Recommend dosage
      • Acid inhibition drugs
      • Antacid Algeldrate, hydrotalcite et al
      • H 2 RA Cimetidine 800mg qN or 400mg bid
      • Ranitidine 300mg qN or 150mg bid
      • Famotidine 40mg qN or 20mg bid
      • PPI Omeprazole 20mg qd
      • Lansoprazole 30mg qd
      • Rabeprazole 10mg qd
      • Gastric mucosa protection drugs
      • Sucralfate Sucralfate 1g qid
      • Prostaglandins Misoprostol 200  g qid
      • Bismuth compound Colloidal bismuth subcitrate 120mg qid
      Anti-ulcer drugs H2RA :Histamine H2 receptor antagonist; PPI :proton pump inhibitor
      • 3. Hp eradication treatment
      • Hp must be eradicated in all
      • Hp-positive peptic ulcer!!
    • Proton pump inhibitor (PPI) Two antibiotics Colloidal Bismuth Subcitrate Amoxicillin , Clarithromycin , Tetracycline , Metronidazole , Furaltadone … + (1) Hp eradication regimen Or
      • Omeprazole 20mg b.i.d
      • +
      • Clarithromycin 500mg b.i.d
      • +
      • Amoxicillin 1000mg b.i.d
      • ×
      • 7days
      A trigeminy regimen of Hp eradication This is a widely used first-line Hp eradication regimem.
      • Ulcer patient with complications
      • Patient with large ulcer or recurrent ulcer
      • Symptom cannot be relieved after Hp eradication
      • Above patients need to use PPI or H2RA for 2-8weeks
      (2)Anti-ulcer treatment after Hp eradication
    • (3) Detect Hp after eradication treatment
      • 4 weeks after eradication treatment
      • ---- to avoid false negative result
      • 13 C or 14 C-UBT is the first choice
      • Detect Hp infection by gastroscope is necessary in DU patients with complications, or in GU patients with or without complications
    • 4. Treatment and Prevention of NSAID-related ulcer
      • Treatment
      • Stop using NSAIDs , routinely give H 2 RA or PPI for treatment
      • For patients who can not stop using NSAIDs, give PPI, and maintain long term anti-ulcer treatment after ulcer healing
      • For patients with Hp infection , Hp eradication is also needed
      • (NSAID and Hp are two independent ulcerogenic factors )
      • Prevention
      • Following patients need routine prevention treatment :
      • Patients with a history of peptic ulcer
      • Elderly patients
      • Patients using glucocorticosteroid or decoagulant (including low-dosage asprin) together with NSAIDs
      • Prevention method:
      • PPI , routine dosage
    • 5. Prevention of peptic ulcer recurrence
      • 2. Following patients need to maintain long term anti-ulcer treatment to prevent ulcer recurrence :
      • Patient who can not stop using NSAIDs
      • Hp can not be eradicated
      • Ulcer recurrence after Hp eradication
      • Non-Hp and non-NSAIDs ulcer
      • Elderly patients
      • Patients with serious concomitant disease
      • 3. Prevention method:
      • PPI or H 2 RA, routine dosage
      1.Hp eradication and stop using NSAID may prevent peptic ulcer recurrence
    • 6. Indication for surgery
      • Hemorrhea, medical treatment is ineffective
      • Acute perforation
      • Cicatricial pyloric obstruction
      • Gastric ulcer with canceration
      • Telephium, medical treatment is ineffective
    • What is the etiopathogenisis of PU?
    • How to diagnose PU?
      • Chronic, periodic and rhythmical upper abdominal pain
      • Endoscopy (or X-ray barium meal ) examination for definite diagnosis
      • Routinely detect Hp
    • Common complications of PU?
      • Bleeding
      • Perforation
      • Pyloric obstruction
      • Canceration (GU, 1%)
    • Case one: How to treat a young patient with DU, upper gastrointestinal bleeding and Hp infection?
      • Hp eradication (for example, PPI+Amo+Cla, 1w)
      • Continue to treat with anti-ulcer drug (for example, omeprazole 20mg qd, 2w)
      • Take endoscopy examination
      • 4w after eradication, take 13 C or 14 C urea breath test
    • Case two: How to treat a patient with gastric ulcer and Hp infection who needs to use NSAID for a long term?
      • Hp eradication (for example, PPI+Amo+Cla, 1w)
      • Continue to treat with PPI (for example, omeprazole 20mg qd, 4w)
      • Take endoscopy examination
      • Continue long term maintenance treatment with PPI to prevent recurrence (for example, omeprazole 20mg qd)
    • Thank you!