消化性溃疡5年制第七版.ppt

Male，30yearsold，complainofrecurrentepigastricpainfor2years.Thepainbecomeworse2-3hoursaftermealandcanberelievedbyfoodandranitidine，usuallyaccompaniedwithbloating.IntheotherhospitalBultrasoundshowedcholecystitis.Whatsthemostlikelydiagnosis？Whichexaminationshouldbedoneforthispatient？Andhowtotreat?,CaseReview,Contentsofclasses,OverviewEtiologyandpathogenesisPathologyClinicalpresentationSpecialtypesofPULaboratoryexaminationDiagnosisandDifferentialdiagnosisComplicationTreatment,Overview,Definition,Gastriculcer,Duodenalulcer,jejunumulceraftergastricresection,Epidemiology,Overview,AgeofGUmiddleageandelder,Etiology&Pathogenesis病因和发病机制,Injuryfactor,Defensivefactor,Normal,Pepticulcer,Defensivefactors(防御因素）,Mucusandbicarbonate(黏液和碳酸氢盐）Mucosabarrier（粘膜屏障）Therichedmucosalbloodflow（丰富的血流）Otherfactors:PGE1,EGFetc.,Otherriskfactorsdrinking,diet,viralinfection,stress,geneticfactor,Injuryfactors（损伤因素）,Hpinfection（幽门螺杆菌）,NSAID（非甾体抗炎药）Non-steroidalanti-inflammatorydrug,GastricacidandPepsin（胃酸和胃蛋白酶）,Hpinfection,Gcellsfunction,Dcellsfunction,Gastrinacid-pepsinDecreasedduodenalbicarbonatesecretionGastricepitheliummetaplasiainduodenum,Directcytotoxicity(Localeffect)COXinhibitor(systematiceffect),COX1,COX2,PathogenesisofNSAID(二）,胃肠道,炎症,GastricacidandPepsin(三）,Theformationofpepticulcereventuallyresultfrominvadingofacid-pepsin(directfactor)BAOMAO(Leakingroofhypothesis),Pathology病理,Location:Thepepticulcerusuallylocatedinantrumandduodenalanteriorwall.Number:oneormoreSize:generallyDU2cmgiantulcer)Complication,Pathology,Clinicalpresentation临床表现,Chronicity,Rhythmicity,FeaturesofPU,Periodicityandrecurrence,abdominalpain-typicalsymptom,LocationQualityRhythmicity,Othersymptoms,epigstricburningsensation（useful)bloatingdyspepsiaepigastricmalaise(notspecial,notdiagnostic)belch,acidrefluxasymptomaticcase,Physicalsign,Withoutcomplication:justmildepigastrictendernessWithcomplication:presentcorrespondingphysicalsign(reboundtenderness,gastricform,splashingsound),SpecialtypesofPU,Compoundulcer(复合溃疡）Pyloricchannelulcer（幽门管溃疡）Postbulbarulcer（球后溃疡）Giantulcer（巨大溃疡）Theagedpepticulcer（老年人消化性溃疡）Asymptomaticulcer（无症状溃疡）,Laboratoryexamination实验室检查,Endoscopy（胃镜）TestingofHP（HP检测）BariumRadiography（钡餐）Gastricjuiceanalysis（胃液分析）Testingofserousgastrin(血清胃泌素）,Laboratoryexamination,Endoscopyisthesensitive,specificandprecisemethodfordiagnosingpepticulcer,allowingdirectinspectionandbiopsy.,Endoscopy,Endoscope,Endoscopy-normalimaging,Gastricfundus,Gastricbody,Gastricangle,Gastricantrum,duodenalbulb,Endoscopy-pyloricchannelulcer,Endoscopy-Bulbarulcer,InvasiveassessmentRapidureasetest（快速尿素酶法）Histologicalexamination（组织学）HPculture（HP培养）PCR,TestingofHP,rapidureasetest,histologicalexamination,TestingforHP（二）,NoninvasiveassessmentUreabreathtesting(呼气试验）Fecalantigenassay（粪便抗原分析）Serologicantibodytesting（血清学分析）,13C-ureabreathtest,Diagnosis诊断,Endoscopy(内镜）Bariumradiography（钡餐）,Diagnosis,Presenthistory,Initialdiagnosis,Finaldiagnosis,Differentialdiagnosis,鉴别诊断,Gastriccarcinoma（胃癌）Zollinger-Ellisionsyndrome（卓艾综合症）,Differentialdiagnosis,GU,GC,Complication,Hemorrhage(出血）Perforation（穿孔）Gastricoutletobstruction（梗阻）Canceration（癌变）,Treatment治疗,Removetheinducement,Drugtherapy,Surgicaltherapy,AntacidsTherapy,Mucosalprotection,Treatment,Hperadication,Removetheinducement,LivingandDietregularly,Mentalstatuswell,Avoidingbadhabit,Protonpumpinhibitors(PPIs)arethemostpotentAntacidagents.omaprazole(20mg)lansoprazole(30mg)pantoprazole(40mg)rebaprazole(10mg)H2-receptorantagonistcimetidine(200mg)ranitidine(150mg)famotidine(20mg)nizatidine,Drugtherapy-AntacidsTherapy,LithiumandMagnesiumCarbonateProstaglandin,Drugtherapy-Mucosalprotectivetherapy,Drugtherapy-Hperadication,PPI+Clarithromycin0.5+Amoxicillin1.0PPI+Furazolidone0.1+Amoxicillin1.0PPI+Amoxicillin1.0+Metronidazole0.4PPI+Clarithromycin0.5+Metronidazole0.4BidX7days,Drugtherapy-Hperadication,Bismuthagent(480mg/d）+twotypesofantibiotics(Clarithromycin、FurazolidoneAmoxicillin、Metronidazole）,FailureofHPeradication,AlteranothertwoantibioticsPPI+Bismuth+othertwoantibiotics,Surgicaltherapy,Indication：massivehemorrhageAcuteperforationObstructioncausedbyscarSuspectedcancerationRefractoryulcer,Male，30yearsold，complainofrecurrentepigastricpainfor2years.Thepainbecomeworse2-3hoursaftermealandcanberelievedbyfoodandranitidine，usuallyaccompaniedwithbloating.IntheotherhospitalBultrasoundshowedcholecystitis.Whatsthemostlikelydiagnosis？Whichexaminationshoul