gastric ulcer - cgmh...gastric ulcer. • methods the relations of following the factors such as...

胃潰瘍Gastric Ulcer報告者:廖苡琁

指導老師:李秋月

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Barry J. Marshall

諾貝爾生理學或醫學獎（2005年）

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Epidemiological

• Objective To study the relationship of Helicobacter pylori infection to gastric ulcer.

• Methods The relations of following the factors such as site, age, gender were analyzed. Histologic stain and Hp detection was made to

the specimen from the ulcer border. Ascertaining index such as

maximum diameter and the position of ulcer diagnosed by endoscopy.

• Results The 923 patients were inspected with gastric ulcer. In the group of 673 Hp positive patients, 81% of ulcer occurred in angle and

antrum of stomach.

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• Ulcer of stomach angle was more in man than woman. Incidence of ulcer in 31-60 years was the highest (59%).

• Both the size of ulcer and the proportion of multiple ulcers increased with the age.

• The proportion of Hp infection was high under 60 years. Both the size of ulcer and age of patient in Hp positive group were

lower than those in Hp negative group.

• Conclusion The Hp infection of gastric mucosa is the main factorcontributing to gastric ulcer. The Infection was prior to the

middle age people

Epidemiological

Outline:

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1. symptom

2. Mechanism and risk factors

3. Diagnosis

4. Treatment goals

5. Drugs

a) H2 – blockers

b) Proton Pump Inhibitor ( PPI )

c) Misoprostol

d) Sucrafate

e) Antibiotic combinations

f) Antacid

1. Gastric ulcer’s symptom

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� Hiccups

� Bloating

� Upper abdominal pain

� Don’t have appetite

� Dyspepsia

� Nausea

� Vomiting

� Bloody stool

2. Mechanism and risk factors

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1. NSAID

2. Helicobacter pylori

3. Coffeine and alcohol

4. Stress

5. Smoking

6. Abuse of steroids

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Risk of stomach ulcerRisk of stomach ulcer------ Abuse of steroidAbuse of steroid

3.Diagnosis

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1. Barium X –ray

A thickwhite liquid (barium) that you drink helps

the stomatch and small intestine show up on X-ray .

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2. endoscopy

A thin , lighted tube is stomach to look for

the presence of an ulcer.

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3. Tissue sections

A piece of stomach tissue is removed so it can

be analyzed.

4. Treatment goals

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Treatment goals :

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Gastric Ulcer Classification of Esophagitis

•Grade A:One or more mucosal break,each≦5mm long,confined to the mucosal folds

•Grade B:One or more mucosal break > 5mm long, confined to the mucosal folds but not continuous between the tops of two mucosal

folds

•Grade C:One or more mucosal break continuous between the tops of two or more mucosal folds but which involve less than 75% of the

esophageal circumference

•Grade D:Mucosal breaks which involve less than 75% of the esophageal circumference

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Gastric Ulcer健保給付規範:

Grade A或Grade B者，欲使用消化性潰瘍用藥，其使用期間以四個月為限，申報費用時需檢附四個月內有效之上消化道內視鏡檢查或上消化道Ｘ光攝影報告，其針劑限使用於消化道出血不能口服之病人急性期替代療法。

Grade C或Grade D者，得經消化系專科醫師之確認後可長期使用消化性潰瘍用藥一年。

5. Drugs

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H2 – blockers

H2受體拮抗劑:藉由阻斷胃內的組織胺H2受體來抑制胃酸分泌

H2 – blockers

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H2 – blockers

• Cimetidine200mg/tab

200mg/amp

• Cimetin治潰淨錠(強生)

• PO:300mg QID400-600mg BID

• Indictation:gastric ulter、duodenum ulter

• Side effect:Diarrhea、男性女乳樣症

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H2 – blockers

• Famotidine20mg/tab

20mg/amp

• Welizen胃利贊膜衣錠

• Indictation:gastric ulter、duodenum ulter

• Side effect:Diarrhea、dizziness、rash

• PO:20mg BID

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H2 – blockers

• Ranitidine

• 20mg/tab20mg／amp

• Trade name : RADIN (景德)

• Adult dosing : 300mg BID

• Nizatidine

• 150mg/cap300mg/cap

• Trade name : TAZAC (禮來)

• Adult dosing : 300mg QD or 150mg BID

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H2 – blockers

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Proton Pump Inhibitor ( PPI )

NOTICE: pregnant ( grade B )

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• Dexlansoprazole

• Trade name : Dexilant

• 30 mg daily or 30 mg twice daily

• Indictation :diffuse ulter 、gastric ulter

• Side effect : headach、diaharrea

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Esomeprazole

•Trade name : Nexium

•30 mg daily or 30 mg twice daily

•Indictation :diffuse ulter 、gastric ulter

Side effect : headach、diaharrea

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• Lansoprazole

• Trade name : Taquidine


• Indictation :diffuse ulter 、gastric ulter、

• Side effect : headach、diaharrea、bloating

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• Omeprazole

• Trade name : Zegerid




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• Pantoprazole

• Trade name : Gastroloc




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• Rabeprazole

• Trade name : Zegerid




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Drug Dose (adult)

Dexlansoprazole 30 mg daily or 30 mg twice daily

Esomeprazole 20 or 40 mg daily

Lansoprazole 30 mg daily or 30 mg twice daily

Omeprazole 20 to 40 mg daily or20 mg twice daily

Pantoprazole 40 mg daily or 40 mg twice daily

Rabeprazole 20 mg daily or 20 mg twice daily

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• 需使用NSAIDs而曾經上消化道內視鏡或Ｘ光攝影證實有過潰瘍，得於使用NSAIDs期間內，經消化系專科醫師之確認後可使用消化性潰瘍用藥。

健保給付規範 :

• 嚴重外傷、大手術、腦手術、嚴重燙傷、休克、嚴重胰臟炎及急性腦中風者為預防壓力性潰瘍，得使用消化性潰瘍藥品。此類藥物之針劑限使用於不能口服之前述病患短期替代療法。

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Misoprostol• Brand Names: Cytotec

• Adult Dosing: Oral 200 mg QD

• Second – line to cure stomatch ulter .

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Misoprostol

• 禁忌： pregnancy ( X級 )

• 引起子宮收縮、流產、早產、胎兒死亡、出生缺陷(第六和第七腦神經麻痺)

• 健保給付規範:

下列病患若因長期服用NSAIDs而需使用前列腺素劑(如misoprostol)，得免附胃鏡報告：

Ⅰ紅斑性狼瘡。Ⅱ五十歲以上罹患類風濕性關節炎或僵直性脊椎炎之病患。

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Misoprostol

機轉:•為analogue of prostaglandin E1 (PGE1衍生物)•產生cyclic adenosine monophosphate(環磷酸腺苷)•並選擇性的減少胃壁細胞分泌，以抑制胃酸•維持腸胃血流

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Sucrafate

Brand Names: Carafate

Adult Dosing:

Initial : 1 g 4 times daily on an empty stomach for 4-8 weeks

Maintenance: 1 g twice daily

Sucralfate also binds to the injured tissue, thereby delivering growth

factors and reducing access to pepsin and acid.

(硫糖鋁也結合到受傷組織，從而提供生長因子和減少胃蛋白酶和胃酸)

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H. pylori (幽門螺旋桿菌幽門螺旋桿菌幽門螺旋桿菌幽門螺旋桿菌)的一線治療的一線治療的一線治療的一線治療

情況情況情況情況建議用藥建議用藥建議用藥建議用藥

無penicillin 過敏

尚未接觸過巨還類抗生素

標準劑量PPI 每天兩次或esomeprazole 40 mg每天一次+clarithromycin 500 mg 每天兩次 +amoxicillin 1000 mg 每天兩次(持續10-14 天)

Penicillin 過敏

尚未接觸過metronidazole或bismuth

標準劑量PPI 每天兩次+clarithromycin 500 mg 每天兩次+metronidazole 500 mg 每天兩次(持續10-14 天)

Penicillin 過敏

對H. pylori 治療失敗

標準劑量PPI 每天兩次+Bismuth subsalicylate 525 mg 每天四次 +metronidazole 250 mg 每天四次 +tetracycline 500 mg 每天四次(持續10-14 天)

所謂的標準劑量PPI為: Lansoprazole 30 mg twice daily

omeprazole 20 mg twice daily

pantoprazole 40 mg twice daily

rabeprazole 20 mg twice daily.

Antibiotic combinations

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• 消化性潰瘍病患得進行初次幽門螺旋桿菌消除治療，使用時需檢附上消化道內視鏡檢查或上消化道Ｘ光攝影報告並註明初次治療。

• 幽門螺旋桿菌之消除治療療程以二週為原則，特殊病例需延長治療或再次治療，需檢附相關檢驗報告說明理由。


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Antacid

• Aluminum hydroxide300 mg/tab

• Magnesium hydroxide324/350mg /tab

70mg／1ml /suspension5～10ml 或 600mg飯後1～3小時及睡前

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• 消化性潰瘍及逆流性食道炎符合洛杉磯食道炎分級表（The Los Angeles Classification of Esophagitis※備註）Grade A或Grade B者，欲使用消化性潰瘍用藥，其使用期間以四個月為限，申報費用時需檢附四個月內有效之上消化道內視鏡檢查或上消化道Ｘ光攝影報告，其針劑限使用於消化道出血不能口服之病人急性期替代療法。

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• 經上消化道內視鏡檢查，診斷為重度逆流性食道炎，且符合洛杉磯食道炎分級表（The Los Angeles Classification of Esophagitis※備註）Grade C或Grade D者，得經消化系專科醫師之確認後可長期使用消化性潰瘍用藥一年。

• 另外，下列病患得比照辦理：Ⅰ.胃切除手術縫接處產生之潰瘍。Ⅱ.經消化系專科醫師重覆多次（三次以上）上消化道內視鏡檢查確認屬難治癒性之潰瘍。經診斷確定為Zollinger-Ellision症候群之病患，得長期使用氫離子幫浦阻斷劑而不受一年之限制。

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SUMMARY• Treatment goal :

remove Helicobacter pylori、NSAID

• Aspirin – induced ulters H2-blocker

• NSAID – induced ulters PPI 、 Misoprostol有效

• Misoprostol can not cure stomatch ulter .

• Antacid、sucralfate can not cure stomatch ulter .

• Hybird therapy : Antibiotic combinations

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資料來源 :1.UP TODATE

2.華藝線上圖書館3.國家網路藥典4.長庚藥物處方集5.全球華人藥物資訊網

圖片來源:1.長庚藥物處方集2.Google圖片

gastric ulcer - cgmh...gastric ulcer. • methods the relations of following the factors such as...

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