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

2. 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）

3. Structure of stomach and duodenum Fundus Cardiac region Gastric body Gastric antrum Duodenum bulb Pyloric orifice Descending part of duodenum Esophagus

4. Definition Chronic ulcers extend through muscularis mucosa ( 粘膜肌层 )of stomach or duodenum

5. Ulcer and gastritis An ulcer at the anterior wall of duodenal bulb with a minor signs of recent bleeding Erosive gastritis

6. 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

7. 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

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

9. 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

10. Etiology and Pathogenesis Helicobacter pylori infection demonstrated o gastric antral biopsy Helicobacter pylori infection demonstrated with electronmicroscope

11. 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

12. Etiology and Pathogenesis Other factors –Smoking –Genetics –Stress –Abnormal motility of gastro & duodenum

13. 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

14. 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 )

15. 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

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

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

18. Kissing ulcers of duodenal bulbUlcer of duodenal bulb

19. Diagnosis Epigastric pain( 上腹痛 ) –Chronic –Periodic –Rhythmic Upper endoscopy + biopsy The Key! Barium studies

20. 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

21. 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）

22. Remaining blood (coffee gr ound like) in the stomach

23. Active bleeding ulcer with a visible blood jet in duodenal bulb

24. 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

25. Gastric cancer

26. 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 )

27. 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）

28. 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

29. 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

30. 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

31. 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

32. Treatment –Perforation –Cicatricial pyloric obstruction( 瘢痕性幽门梗阻 ) –Canceration –Telephium ( 顽固性溃疡 ) Drug therapy failed