Peptic Ulcer( 消化性溃疡 )

XinJie ChenDepartment of

GastroenterologyZhuJiang Hospital

Useful words

Duodenum( 十二指肠 ) Duodenal ulcer( 十二指肠溃疡 ) Gastric ulcer( 胃溃疡 ) Helicobacter pylori ( 幽门螺杆菌 ) Muscularis mucosa ( 粘膜肌层 ) Cyclooxygenase ( 环氧合酶 ) Upper gastrointestinal hemorrhage( 上消化

道出血 ) Perforation ( 穿孔 ) Pyloric obstruction( 幽门梗阻 ) Canceration （癌变）

Structure of stomach and duodenum

Fundus

Cardiac region

Gastric body

Gastric antrum

Duodenum bulb

Pyloric orifice

Descending part of duodenum

Esophagus

DefinitionChronic ulcers extend through muscularis mucosa ( 粘膜肌层 )of stomach or duodenum

Ulcer and gastritis

An ulcer at the anterior wall of

duodenal bulb with a minor

signs of recent bleeding

Erosive gastritis

Epidemiology

• In all age groups• Incidence( 发病率 )

– Gastric ulcer(GU) < Duodenal ulcer(DU)

– male > female– DU young people– GU Middle age/old people

Etiology and Pathogenesis

• Mucus & bicarbonate – ( 粘液和碳酸氢盐 )

• Epithelium– ( 上皮细胞 )

• Capillary network – ( 毛细血管网 )

• Prostaglandin E– ( 前列腺素 E)

• Epidermal growth factor– ( 表皮生长因子 )

Defense and repairing system of

gastric and duodenal mucosa

Prof. Barry J. Marshall & Prof. J. Robin Warren

Etiology and Pathogenesis

• Helicobacter pylori infection★– Peptic ulcer > control group– Clearance Recurrence rate( 复发率 )– Mechanism Not clear

• Nonsteroidal anti-inflammatory drugs(NSAID)

• Gastric acid and Pepsin ( 胃蛋白酶 )– No acid, no ulcer + No HP, no ulcer

Etiology and Pathogenesis

Helicobacter pylori infection demonstrated o

gastric antral biopsy

Helicobacter pylori infection demonstrated

with electronmicroscope

Etiology and Pathogenesis

NSAID

Cyclooxygenase-1(COX-1)

Cyclooxygenase-2(COX-2)

Prostaglandin E

Secretion of mucus and

bicarbonate ions

Mucosal blood flow

Epithelial defense against

cytotoxic injury

Etiology and Pathogenesis

• Other factors– Smoking– Genetics– Stress– Abnormal motility of gastro &

duodenum

Clinical manifestation

• Cardinal symptoms( 主要症状 )– Epigastric pain( 上腹痛 )

•Chronic •Periodic•Rhythmic• “Hunger-like” DU

– Belching( 嗳气 ),nausea,anoresia,etc

• Physical Examination– Localized epigastric tenderness

Special Types of Peptic Ulcer

• Complex ulcers( 复合溃疡 ) Gastric + Duodenal− Pyloric obstruction

• Ulcers of pyloric canal( 幽门管溃疡 )– Effects of drugs – Complications

• Postbulbar ulcer( 十二指肠球后溃疡 ) Bleeding• Giant ulcer diameter > 2cm Malignant?• Peptic ulcer in old people • Asymptomatic ulcer( 无症状溃疡 )

Laboratory Tests and Imaging studies

• Upper endoscopy + biopsy Preferred

• Barium studies( 钡餐检查 ) Optional

• Testing for Helicobacter pylori– Enzyme-linked immunosorbent assay

(ELISA)– Stool antigen testing ★– 13C-urea or 14C-urea breath test– Invasive methods

Antral ulcer( 胃窦溃疡 )

Antral ulcer scars with fold

convergency

Gastric ulcers with flat pigmented spots as a sign

of previous bleeding

Kissing ulcers of duodenal bulb

Ulcer of duodenal bulb

Diagnosis• Epigastric pain( 上腹痛 )

– Chronic – Periodic– Rhythmic

• Upper endoscopy + biopsy The Key!

• Barium studies

Differential Diagnosis( 鉴别诊断 )

• Chronic diseases – Liver,gallbladder,pancreas,etc– Functional dyspepsia( 功能性消化不良 )

• Gastric cancer – Endoscopic signs + biopsy

• Gastrin adenoma (Zollinger-Ellison syndrome)– BAO,MAO– BAO/MAO >60%– Serum gastrin >200pg/ml

Complications( 并发症 )

• Upper gastrointestinal bleeding • Perforation ( 穿孔 )• Pyloric obstruction( 幽门梗阻 )

– Duodenal ulcer or ulcer of pyloric canal

• Canceration （癌变）

Remaining blood (coffee ground like)

in the stomach

Active bleeding ulcer with a visible blood jet

in duodenal bulb

Plain Film Radiography of upright views of the

abdomen shows free air under the diaphragm

Gastric outlet obstruction with

prepyloric deformity and a stenotic pyloric

channel

Gastric cancer

Treatment

• General treatment• Acid-inhibitory drugs ( 抑酸药 )

– Proton pump inhibitors(PPI)

– H2-receptor antagonists (H2RA)

• Agents enhancing mucosal defenses– Bismuth Potassium Citrate – Prostaglandin analogs ( 前列腺素类似物 )– Sucralfate( 硫糖铝 )– Antacids( 抗酸药 )

Treatment

• Helicobacter pylori eradication therapy– Clarithromycin ( 克拉霉素 )– Metronidazole （甲硝唑） ???– Amoxicillin （阿莫西林）– Levofloxacin （左氧氟沙星） – Tetracycline （四环素）– Proton pump inhibitors （质子泵抑制剂）– Bismuth Potassium Citrate （枸橼酸铋钾）

PPI 或 Bismuth Antibiotics PPI (double doses/d) Clarithromycin

1.0g/dBismuth Potassium

Citrate Amoxicillin 2.0g/d

480mg/d Metronidazole 0.8g/d (one of above) (two of above)

Eradication therapy of HP

Bid ， time of therapy: 7 -14days

Rescue therapy after HP eradication failure

• Time of therapy: 10-14days• PPI+ Bismuth Potassium Citrate + two kinds

of antibacterial Recommended

• Selection of antibiotic – Results of drug sensitive test

Treatment

• Treatment of NSAID-associated ulcer– Stop taking NSAID !!– Selective COX-2 inhibitor– PPI– H.pylori (+) Eradication therapy

• Prevention of NSAID-associated ulcer – High risk group PPI

Treatment

• Prevention of recurrence of ulcer– Recurrence of H.pylori infection

Eradication– Taking NSAID PPI– Ulcer associated with H.pylori

H2RA(1/2)

– H.pylori (-) H2RA(1/2)

• Surgical treatment – Upper gastrointestinal bleeding

Medical treatment failed

Treatment

– Perforation – Cicatricial pyloric obstruction( 瘢痕性

幽门梗阻 ) – Canceration– Telephium ( 顽固性溃疡 )

•Drug therapy failed