PepticUlcerDisease(PUD),ZhongLiangHuaShanHospital,Definition,AcircumscribedulcerationofthegastrointestinalmucosaoccurringinareasexposedtoacidandpepsinandmostoftencausedbyHelicobacterpyloriinfection.(Uphold20-50%indevelopedareaTherateofH.pyloriinfectionisdecliningindevelopedcountryTransmission:oraloralfecaloral,Helicobactorpylori,ItispossiblethatthedifferentdiseaserelatedtoH.pyloriinfectioncanbeattributetodifferentstrainsoforganismwithdistinctpathogenicfeatures,Helicobactorpylori,Helicobactorpylori,NSAID,NSAIDCOXPGTheformofNSAIDshavenorelationtotheirdamageonGImucosa!,NSAID,Riskfactor:AdvancedageHistoryofulcerConcomitantuseofglucocorticoidsConcomitantuseofanticogulantsSeriousormulti-systemdiseaseH.pyloriinfectionCigaretteand/oralcoholconsumption,SubjectiveData,Pain”gnawing”,“aching”,or“burning”Duodenalulcers:occurs1-3hoursafteramealandmayawakenpatientfromsleep.Painisrelievedbyfood,antacids,orvomiting.Gastriculcers:foodmayexacerbatethepainwhilevomitingrelievesit.Nausea,vomiting,belching,dyspepsia,bloating,chestdiscomfort,anorexia,hematemesis,&/ormelenamayalsooccur.nausea,vomiting,&weightlossmorecommonwithGastriculcers,ObjectiveData,EpigastrictendernessGuaic-positivestoolresultingfromoccultbloodlossSuccussionsplashresultingfromscaringoredemaduetopartialorcompletegastricoutletobstructionAsuccussionsplashdescribesthesoundobtainedbyshakinganindividualwhohasfreefluidandairorgasinaholloworganorbodycavity.Usuallyelicitedtoconfirmintestinalorpyloricobstruction.Donebygentlyshakingtheabdomenbyholdingeithersideofthepelvis.Apositivetestoccurswhenasplashingnoiseisheard,eitherwithorwithoutastethoscope.Itisnotvalidifthepthaseatenordrunkfluidwithinthelastthreehours.,Complications,Perforation&Penetrationintopancreas,liverandretroperitonealspacePeritonitisBowelobstruction,Gastricoutflowobstruction,&PyloricstenosisBleeding-occursin25%to33%ofcasesandaccountsfor25%ofulcerdeaths.GastricCA,Activebleeding,胃角潰瘍出血錄像.avi,GastricCA,Pepticulcerspecial,SilentulcerPepticulcerinadvancedagePepticulceronposteriorbulbPepticulceronpylorustubeGiantpepticulcer,DiagnosticPlan,StoolforfecaloccultbloodLabs:CBC(R/Obleeding),liverfunctiontest,amylase,andlipase.H.Pyloricanbediagnosedbyureabreathtest,bloodtest,stoolantigenassays,&rapidureasetestonabiopsysample.Bariummeal,DiagnosticPlan,UpperGIEndoscopy:Anypt50ywithnewonsetofsymptomsorthosewithalarmmarkingsincludinganemia,weightloss,orGIbleeding.Preferreddiagnostictestb/citshighlysensitivefordxofulcersandallowsforbiopsytoruleoutmalignancyandrapidureasetestsfortestingforH.Pylori.,Gastriculcer,Duodenalulcer,DifferentialDiagnosis,NeoplasmofthestomachPancreatitisPancreaticcancerDiverticulitisNonulcerdyspepsia(alsocalledfunctionaldyspepsia)CholecystitisGastritisGERDMInottobemissedifhavingchestpain,Treatment-antacid,MixtureofaluminumhydroxideandmagnesiumhydroxideTalcid,Treatmentacidsecretioninhabitor,ProtonPumpInhibitorsPPI:Prilosec,Prevacid,Nexium,Protonix,orAciphexfor4-8weeksH2receptorantagonistsHRA:Tagament,Pepcid,Axid,orZantacforupto8weeks,不同抑酸劑的作用機理,丙谷胺,雷尼替丁,哌侖西平,G,H2,M,PP,he+H+,K+,壁細胞,PPI,H+,TreatmentH.pylorieradication,Tripletherapyfor14daysisconsideredthetreatmentofchoice.ProtonPumpInhibitor+clarithromycinandamoxicillinOmeprazole(Prilosec):20mgPObidfor14dorLansoprazole(Prevacid):30mgPObidfor14dorRabeprazole(Aciphex):20mgPObidfor14dorEsomeprazole(Nexium):40mgPOqdfor14dplusClarithromycin(Biaxin):500mgPObidfor14andAmoxicillin(Amoxil):1gPObidfor14dCansubstituteFlagyl500mgPObidfor14difallergictoPCNInthesettingofanactiveulcer,continueqdprotonpumpinhibitortherapyforadditional2weeks.,TreatmentH.pylorieradication,QuadrupletherapyfortheinfectionofresistantorganismOmeprazole20mgqdBismuthsubsalicylate2tabletsqidMetronidazole250mgqidTetracycline500mgqidGoal:completeeliminationofH.Pylori.Onceachievedre-infectionratesarelow.Compliance!,TreatmentNSAIDrelatedPUD,Prevention!H2RAPPIMisoprostolSelectiveCOX-2inhibitorsH.pylorieradication,Treatmentcytoprotectiveagents,SucralfateBismuth-ContainingPreparationsProstaglandinAnalogues,GUactivetohealed,DUactivetohealed,LifestyleChanges,DiscontinueNSAIDsanduseAcetaminophenforpaincontrolifpossible.Acidsuppression-AntacidsSmokingcessationNodietaryrestrictionsunlesscertainfoodsareassociatedwithproblems.AlcoholinmoderationMenunder65:2drinks/dayMenover65andallwomen:1drink/dayStressreduction,Prevention,Considerprophylactictherapyforthefollowingpatients:PtswithNSAID-inducedulcerswhorequiredailyNSAIDtherapyPtsolderthan60yearsPtswithahistoryofPUDoracomplicationsuchasGIbleedingPtstakingsteroidsoranticoagulantsorpatientswithsignificantcomorbidmedicalillnessesProphylacticregimensthathavebeenshowntodramaticallyreducetheriskofNSAID-inducedgastricandduodenalulcersincludetheuseofaprostaglandinanalogueoraprotonpumpinhibitor.Misoprostol(Cytotec)100-200mcgPO4timesperdayOmeprazole(Prilosec)20-40mgPOeverydayLansoprazole(Prevacid)15-30mgPOeveryday,Surgery,Peoplewhodonotrespondtomedication,orwhodevelopcomplications:Vagotomy-cuttingthevagusnervetointerruptmessagessentfromthebraintothestomachtoreducingacidsecretion.Antrectomy-removethelowerpartofthestomach(antrum),whichproducesahormonethatstimulatesthestomachtosecretedigestivejuices.Avagotomyisusuallydoneinconjunctionwithanantrectomy.Pyloroplasty-theopeningintotheduodenumandsmallintestine(pylorus)areenlarged,enablingcontentstopassmorefreelyfromthestomach.Maybeperformedalongwithavagotomy.,Evaluation/Follow-up/Referrals,H.PyloriPositive:retestingfortxefficacyUreabreathtestnoso