Peptic Ulcer Disease (PUD),Zhong Liang Hua Shan Hospital,Definition,A circumscribed ulceration of the gastrointestinal mucosa occurring in areas exposed to acid and pepsin and most often caused by Helicobacter pylori infection. (Uphold 20-50% in developed area The rate of H. pylori infection is declining in developed country Transmission: oral oral fecal oral,Helicobactor pylori,It is possible that the different disease related to H. pylori infection can be attribute to different strains of organism with distinct pathogenic features,Helicobactor pylori,Helicobactor pylori,NSAID,NSAIDCOX PG The form of NSAIDs have no relation to their damage on GI mucosa !,NSAID,Risk factor: Advanced age History of ulcer Concomitant use of glucocorticoids Concomitant use of anticogulants Serious or multi-system disease H. pylori infection Cigarette and/or alcohol consumption,Subjective Data,Pain”gnawing”, “aching”, or “burning” Duodenal ulcers: occurs 1-3 hours after a meal and may awaken patient from sleep. Pain is relieved by food, antacids, or vomiting. Gastric ulcers: food may exacerbate the pain while vomiting relieves it. Nausea, vomiting, belching, dyspepsia, bloating, chest discomfort, anorexia, hematemesis, &/or melena may also occur. nausea, vomiting, & weight loss more common with Gastric ulcers,Objective Data,Epigastric tenderness Guaic-positive stool resulting from occult blood loss Succussion splash resulting from scaring or edema due to partial or complete gastric outlet obstruction A succussion splash describes the sound obtained by shaking an individual who has free fluid and air or gas in a hollow organ or body cavity. Usually elicited to confirm intestinal or pyloric obstruction. Done by gently shaking the abdomen by holding either side of the pelvis. A positive test occurs when a splashing noise is heard, either with or without a stethoscope. It is not valid if the pt has eaten or drunk fluid within the last three hours.,Complications,Perforation & Penetrationinto pancreas, liver and retroperitoneal space Peritonitis Bowel obstruction, Gastric outflow obstruction, & Pyloric stenosis Bleeding-occurs in 25% to 33% of cases and accounts for 25% of ulcer deaths. Gastric CA,Active bleeding,胃角溃疡出血录像.avi,Gastric CA,Peptic ulcer special,Silent ulcer Peptic ulcer in advanced age Peptic ulcer on posterior bulb Peptic ulcer on pylorus tube Giant peptic ulcer,Diagnostic Plan,Stool for fecal occult blood Labs: CBC (R/O bleeding), liver function test, amylase, and lipase. H. Pylori can be diagnosed by urea breath test, blood test, stool antigen assays, & rapid urease test on a biopsy sample. Barium meal,Diagnostic Plan,Upper GI Endoscopy: Any pt 50y with new onset of symptoms or those with alarm markings including anemia, weight loss, or GI bleeding. Preferred diagnostic test b/c its highly sensitive for dx of ulcers and allows for biopsy to rule out malignancy and rapid urease tests for testing for H. Pylori.,Gastric ulcer,Duodenal ulcer,Differential Diagnosis,Neoplasm of the stomach Pancreatitis Pancreatic cancer Diverticulitis Nonulcer dyspepsia (also called functional dyspepsia) Cholecystitis Gastritis GERD MInot to be missed if having chest pain,Treatment- antacid,Mixture of aluminum hydroxide and magnesium hydroxide Talcid,Treatment acid secretion inhabitor,Proton Pump Inhibitors PPI: Prilosec, Prevacid, Nexium, Protonix, or Aciphex for 4-8 weeks H2 receptor antagonists HRA: Tagament, Pepcid, Axid, or Zantac for up to 8 weeks,不同抑酸剂的作用机理,丙谷胺,雷尼替丁,哌仑西平,G,H2,M,PP,he+H+,K+,壁细胞,PPI,H+,Treatment H. pylori eradication,Triple therapy for 14 days is considered the treatment of choice. Proton Pump Inhibitor + clarithromycin and amoxicillin Omeprazole (Prilosec): 20 mg PO bid for 14 d orLansoprazole (Prevacid): 30 mg PO bid for 14 d orRabeprazole (Aciphex): 20 mg PO bid for 14 d orEsomeprazole (Nexium): 40 mg PO qd for 14 d plusClarithromycin (Biaxin): 500 mg PO bid for 14 andAmoxicillin (Amoxil): 1 g PO bid for 14 d Can substitute Flagyl 500 mg PO bid for 14 d if allergic to PCN In the setting of an active ulcer, continue qd proton pump inhibitor therapy for additional 2 weeks.,Treatment H. pylori eradication,Quadruple therapy for the infection of resistant organism Omeprazole 20mg qd Bismuth subsalicylate 2 tablets qid Metronidazole 250mg qid Tetracycline 500mg qid Goal: complete elimination of H. Pylori. Once achieved re-infection rates are low. Compliance!,Treatment NSAID related PUD,Prevention! H2RA PPI Misoprostol Selective COX-2 inhibitors H. pylori eradication,Treatment cytoprotective agents,Sucralfate Bismuth-Containing Preparations Prostaglandin Analogues,GU active to healed,DU active to healed,Lifestyle Changes,Discontinue NSAIDs and use Acetaminophen for pain control if possible. Acid suppression-Antacids Smoking cessation No dietary restrictions unless certain foods are associated with problems. Alcohol in moderation Men under 65: 2 drinks/day Men over 65 and all wome