Peptic Ulcer Disease Peptic Ulcer Disease (PUD)(PUD)Zhong LiangZhong Liang Hua Shan HospitalHua Shan HospitalDefinitionDefinitionA circumscribed ulceration of the A circumscribed ulceration of the gastrointestinal mucosa occurring in gastrointestinal mucosa occurring in areas exposed to acid and pepsin and areas exposed to acid and pepsin and most often caused by Helicobacter most often caused by Helicobacter pylori infection.pylori infection. (Uphold Prevalence of H. pylori: 80% in developing area; 20-50% in developed area20-50% in developed arean nThe rate of H. pylori infection is declining in The rate of H. pylori infection is declining in developed countrydeveloped countryn nTransmission:Transmission:oral oral oral oralfecal oral fecal oralHelicobactor pyloriHelicobactor pylorin nIt is possible that the different disease It is possible that the different disease related to H. pylori infection can be related to H. pylori infection can be attribute to different strains of attribute to different strains of organism with distinct pathogenic organism with distinct pathogenic featuresfeaturesHelicobactor pyloriHelicobactor pyloriHelicobactor pyloriHelicobactor pyloriNSAIDNSAIDn nNSAIDCOX PGNSAIDCOX PG n nThe form of NSAIDs have no relation to The form of NSAIDs have no relation to their damage on GI mucosa ! their damage on GI mucosa ! NSAIDNSAIDRisk factor:Risk factor:n nAdvanced ageAdvanced agen nHistory of ulcerHistory of ulcern nConcomitant use of glucocorticoidsConcomitant use of glucocorticoidsn nConcomitant use of anticogulantsConcomitant use of anticogulantsn nSerious or multi-system diseaseSerious or multi-system diseasen nH. pylori infectionH. pylori infectionn nCigarette and/or alcohol consumptionCigarette and/or alcohol consumptionSubjective DataSubjective Datan nPainPain”gnawinggnawing” ”, , “ “achingaching” ”, or , or “ “burningburning” ”n nDuodenal ulcers: occurs 1-3 hours after a meal and may Duodenal ulcers: occurs 1-3 hours after a meal and may awaken patient from sleep. Pain is relieved by food, antacids, awaken patient from sleep. Pain is relieved by food, antacids, or vomiting. or vomiting. n nGastric ulcers: food may exacerbate the pain while vomiting Gastric ulcers: food may exacerbate the pain while vomiting relieves it.relieves it.n nNausea, vomiting, belching, dyspepsia, bloating, Nausea, vomiting, belching, dyspepsia, bloating, chest discomfort, anorexia, hematemesis, &/or chest discomfort, anorexia, hematemesis, &/or melena may also occur.melena may also occur.n nnausea, vomiting, & weight loss more common with Gastric nausea, vomiting, & weight loss more common with Gastric ulcersulcersObjective DataObjective Datan nEpigastric tendernessEpigastric tendernessn nGuaic-positive stoolGuaic-positive stool resulting from occult blood loss resulting from occult blood lossn nSuccussion splashSuccussion splash resulting from scaring or edema due to resulting from scaring or edema due to partial or complete gastric outlet obstructionpartial or complete gastric outlet obstructionn nA succussion splash describes the sound obtained by shaking an 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 individual who has free fluid and air or gas in a hollow organ or body cavity. cavity. n nUsually elicited to confirm intestinal or pyloric obstruction. Usually elicited to confirm intestinal or pyloric obstruction. n nDone by gently shaking the abdomen by holding either side of the pelvis. 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 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 without a stethoscope. It is not valid if the pt has eaten or drunk fluid within the last three hours.within the last three hours.ComplicationsComplicationsn nPerforation & PenetrationPerforation & Penetrationinto pancreas, liver into pancreas, liver and retroperitoneal space and retroperitoneal space n nPeritonitisPeritonitisn nBowel obstruction, Gastric outflow obstruction, Bowel obstruction, Gastric outflow obstruction, & Pyloric stenosis & Pyloric stenosis n nBleeding-occurs in 25% to 33% of cases and Bleeding-occurs in 25% to 33% of cases and accounts for 25% of ulcer deaths. accounts for 25% of ulcer deaths. n nGastric CAGastric CAActive bleedingn n胃角溃疡出血录像胃角溃疡出血录像.avi.aviGastric CAPeptic ulcerPeptic ulcer special special n nSilent ulcerSilent ulcern nPeptic ulcer in advanced agePeptic ulcer in advanced agen nPeptic ulcer on posterior bulbPeptic ulcer on posterior bulbn nPeptic ulcer on pylorus tubePeptic ulcer on pylorus tuben nGiant peptic ulcerGiant peptic ulcerDiagnostic PlanDiagnostic Plann nStool for fecal occult bloodStool for fecal occult bloodn nLabs: CBC (