消化性溃疡.ppt

（PU）,Peptic ulcer,definition: Peptic ulcer (PU) refers to a chronic ulcer that occurs in the stomach and duodenum. It is named after the formation of ulcers related to the digestion of gastric acid/pepsin. Generally refers to the ulcer caused by digestion of the digestive juice (self-digestion) under certain conditions, which may occur in the esophagus, stomach, duodenum, or in the vicinity of the gastric-jejunal anastomosis, and contains the stomach. Mucosal Meckel憩 indoor. However, stomach and duodenal ulcers are the most common, so the so-called peptic ulcers generally refer to stomach and duodenal ulcers.,2,Ulcer: refers to mucosal defects beyond the mucosal muscle layer. Erosion: It means that the mucosal defect does not exceed the mucosal layer. PU includes: gastric ulcer (GU) Duodenal ulcer (DU) DU and GU are two separate diseases.,3,Epidemiological data 1. Incidence rate: 10-20%, South North; 2. City Rural; 3.DU:GU, ratio 3:1; 4. Male and female ratio GU 3.64.7:1; DU 4.46.8:1. 5.DU is good for young adults, and the elderly in GU are more common, about ten years later; 6. Autumn and winter, good fortune in winter and spring; 7. In recent years, the incidence rate of the elderly has increased, and the symptoms are not typical.,5,etiology and pathogenesis,6,The disease is a multi-pathogenic disease, and its pathogenesis is not fully understood. However, gastric acid is too high, HP infection and weakening of gastric mucosal protective factors are the most important factors in the production of PU.,7,Leaky roof theory,Mucosal barrier: roof Gastric acid, pepsin: acid rain Leaky roof - not too much acid rain Normal roof - too strong acid rain,8,Balance theory,9,NO acid NO ulcer,10,Gastric acid is the determinant of ulceration As early as 1910, some people put forward that there is no ulcer without acid. This is a classic summary of the struggle between man and PU in the past 97 years. Gastric acid is secreted by parietal cells. About 1 billion parietal cells secrete 23-25 mmol/h of hydrochloric acid and pH of gastric juice is 1.3-1.8. Pepsin is a pepsinogen secreted by the main cell transformed by the activation of hydrochloric acid. Its biological activity depends on the pH of the gastric juice. When the pH is raised to 4, the pepsin is inactivated.,11,In the more than a decade since Australian scholars Warren and Marshall successfully cultivated and isolated HP in 1983, a large number of studies have fully demonstrated that HP infection is one of the main causes of PU. Many scholars have suggested that there is no PU without HP.,12,NO HP NO ulcer,13,(1) The pathogenic role of HP HP is a microaerobic bacteria, and the human gastric mucosa is its natural colonization site. It has a highly active urease that decomposes urea to produce ammonia and forms a protective layer around the cells. Once HP enters the stomach, it adheres to the mucus layer, and the phytohemagglutinin through its outer layer selectively binds to the carbohydrate layer of the mucus layer and epithelial cell membrane.,14,Some possible pathogenic factors have been discovered: urease, vacuolating toxin protein, cytotoxin-related gene protein, lipopolysaccharide endotoxin, protease, lipase and phospholipase A2. As a relevant medium, they stimulate the release of cytokines, produce toxic oxygen free radicals, and destroy the integrity of cell membranes. Some of HPs component antigens are similar to certain cellular components of the gastric mucosa, stimulating the body to produce antibodies that cause damage to the gastric mucosal cells.,15,(B) the etiology and pathogenesis of each person have different causes, DU, GU have differences A clear cause: 1. Helicobacter pylori (HP) infection - the most common, primary cause 2. Taking non-steroidal anti-inflammatory drugs (NSAID) - common 3. Excessive gastric acid-DU, GU-protection factor weakened 4. Genetic factors 5. Abnormal gastroduodenal movement 6. Stress and psychological factors 7. Other risk factors: smoking, diet, viral infection,(3) Disease Features: 1, quantity: generally single, multiple rare; 2. Shape: round or elliptical; 3, size: diameter DU 1cm; GU2.5cm; 4, depth: mucosal muscle layer, smooth edges, clean and flat bottom, with gray or gray yellow moss; 5, good hair parts: GU - good in the stomach angle, small antrum of the stomach; DUmore in the ball department; 6, 12 refers to the intestinal descending ulcer should be alert to the possibility of Zhuo-Ai syndrome.,(D) clinical manifestations: can be asymptomatic or complications Features: chronic periodic rhythmic upper abdominal pain Location: Middle of the upper abdomen, left or right under the xiphoid Post-balloon ulcer can appear in the right upper abdomen Back pain in the stomach or the posterior wall of the ball Nature: dull pain, burning pain, pain, even pain Sustained, can be antacid, eating relieved Generally not emitting radiation, Scope: more limited, such as the size of the palm,1 chronic Chronic menstruation Medical history for several years or ten years,2 rhythm GU Postprandial pain: eating-pain-relieving DU hunger pain, night pain, pain before meals, fasting pain, relief after eating Pain-meal-relief,3 periodicity - episodes and relief alternating Pain lasts for days, weeks, months After several months, several years of relief and then relapse More than the incidence of autumn and winter and winter and spring Other symptoms: fullness, belching, acid reflux, heartburn Nausea, vomiting, etc.,体征 剑突下局限而固定的压痛点 少数因贫血出现面色苍白、 心率加快,消化性溃疡的特殊类型 1.巨大溃疡 DU：d2cm；GU：d3cm 特点：易穿透 2.球后溃疡5%-10% 特点： 易出血 3.幽门管溃疡 特点：易并发幽门梗阻、出血、穿孔,球后溃疡 Postbulbar ulcer,24,幽门管溃疡 Pyloric channel ulcer,25,DU: kissing ulcer,26,Duodenal ulcer,27,检 查,1.HP检测 同慢性胃炎 2.X-ray 气钡双重造影能更好 显示粘膜象 直接征象龛影，钡剂轮廓之外 良、恶性溃疡区别 确诊价值 间接征象局部压痛，大弯痉挛切迹 球部激惹及畸形 无确诊价值,胃溃疡,30,3.胃镜检查和粘膜活检 有确诊价值 是最重要的检查方法 表现 : 活动期- 圆形或椭圆形,边光滑 底覆灰黄或白苔 周边粘膜充血肿胀 愈合期- 皱襞向溃疡集中、溃疡变浅变小 瘢痕期- 红色、白色瘢痕 DU不作常规活检；GU应作常规活检,4.胃液分析 GU: 正常或低于正常 DU:1/4-3/4分泌过高 促胃液素瘤的辅助诊断： BAO15mmol/h, MAO60mmol/h BAO/MAO60%, 可能为促胃液素瘤,5.血清促胃液素测定 促胃液素值与胃酸分泌成反比 如同时升高可诊断促胃液素瘤 空腹血清促胃液素200pg/ml 6.粪隐血试验 持续阳性应怀疑 癌的可能,诊断 1、 慢性周期性节律性上腹痛 注意：症状溃疡 2、 X-ray 龛影可确诊 3、胃镜+活检 可确诊,鉴别诊断,一、功能性消化不良（FD ） 有消化不良症状无溃疡及其他器质性疾病 特点：1.多见于年轻妇女 2.餐后上腹饱胀、嗳气、反酸、 恶心、食欲减退 3.x线、胃镜等（-）,二、胃癌 有时难区分 恶性溃疡 X 线：龛影位于胃腔之内、边缘不整 胃 壁僵直、粘膜中断 胃镜：形状不规则、苔污秽、边缘呈 结节状隆起（堤围） 注意：1.疑恶性溃疡一次活检（-）再复查 2.强抑酸药治疗可影响判断,胃癌 gastric cancer,进展期胃癌（型）：胃角类圆形溃疡，基底不平结节状，病变向周边浸润。,39,进展期胃癌（型）：胃角类圆形溃疡，基底不平结节状，病变向周边浸润。,40,三、促胃液素瘤（Zollinger-Ellison综合症） 少见、胰腺非细胞瘤 1.溃疡发生在不典型部位：胃、十二指肠、食管、空肠等，且为多发性溃疡 2.难治性溃疡 3.高胃酸与高促胃液素并存：高胃酸是正常的6倍以上，血清胃泌素 500pg/ml 四、胆石症和胆囊炎,并 发 症 出血 -15-25%：最常见 穿孔1-5%;最重 梗阻2-4% 癌变1%,一、出血 PU是上消化道出血最常见病因 治疗首选PPI。 二、穿孔 穿孔的三种类型： 1.急性穿孔：胃内容物流入腹腔-急性腹膜炎 2.亚急性穿孔：穿孔较小,引起局限性腹膜炎 3.慢性穿孔：后壁穿孔时,易与邻近组织器官粘连，胃内容物不致流入腹腔，不引起腹膜炎 4、对穿孔诊断最有价值的体征是肝浊音界减少或消失，首选的辅助检查是立位腹部X线平片。,PU 动脉出血,44,三、幽门梗阻 1.发病率：2%-4% 2.原因：DU或幽门管溃疡引起 暂时性-炎症水肿和幽门平滑肌痉挛 持久性-瘢痕收缩 3.症状 ： 胃排空延迟，上腹胀满，餐后加重 恶心、呕吐（最典型）发酵酸性隔离宿食（不含胆汁），吐后缓解 严重呕吐可失水和低氯低钾性碱中毒（最早的酸碱失衡） 营养不良和体重减轻 4.查体 胃型、蠕动波，空腹检查胃内有震水声插胃管抽液