Peptic Ulcer ( 消化性溃疡 ) XinJie Chen Department of Gastroenterology ZhuJiang 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

Definition Chronic 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 r epairing system of gastric and duod enal 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 i ons Mucosal blood flow Epithelial defense against cytotoxic i njury

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 ★ – 13 C-urea or 14 C-urea breath test –Invasive methods

Antral ulcer( 胃窦溃疡 ) Antral ulcer scars with f old convergency

Gastric ulcers with flat pigmented s pots as a sign of previous bleeding

Kissing ulcers of duodenal bulbUlcer 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 gr ound like) in the stomach

Active bleeding ulcer with a visible blood jet in duodenal bulb

Plain Film Radiography of upright vi ews of the abdomen shows free air u nder the diaphragm Gastric outlet obstruction with p repyloric deformity and a ste notic pyloric channel

Gastric cancer

Treatment General treatment Acid-inhibitory drugs ( 抑酸药 ) –Proton pump inhibitors(PPI) –H 2 -receptor antagonists (H 2 RA) 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/d Bismuth 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 o f 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 H 2 RA(1/2) –H.pylori (-) H 2 RA(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