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消化性溃疡Pepticulcar一概述Summary十二指肠溃疡课件_3

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消化性溃疡Pepticulcar一 Summary十二指肠溃疡 Pepticulcar 一 Summary 十二指肠溃疡 消化性溃疡pepticulcar一概述summary十二指肠溃疡课件
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With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 消化性溃疡 Peptic ulcar 一、概述:Summary 十二指肠溃疡 Duodenal ulcer,Du 胃溃疡 Gastric ulcer,Gu With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 病例1 男,24岁,5年来经常于餐后3-4小时出现 上腹部烧灼痛,严重时夜间疼醒,伴返酸烧心, 多于冬秋季复发,每次持续一周左右。自服甲氰 咪胍或进食后症状可缓解。4天前因过劳,上述 症状加重,且伴恶心、呕吐少许当日食物水,无 胆汁。为确诊来院。查体:一般状态佳,巩黄( -),心肺无异常,腹软,肝脾未触及,上腹偏 右压痛(+),无反跳痛,肠鸣音3次/分。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 二、临床表 Clinical manifestation (一) 慢性经过 Chronic phase (二)周期性发作 periodic onset (三)节律性上腹部疼痛:Rhythmic pain inepigastrium 1. 疼痛的性质 Character of pain 2. 疼痛的部位 Site of pain 3. 疼痛的节律性 Rhythmicity of pain (四) 其他症状 Other Symptoms (五)体征:Signs With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society (六) 特殊类型的消化性溃疡 peptic ulcer of special type 1. 球后溃疡 postbulbar ulcer 2. 幽门管溃疡 pyloric channel ulcer 3.穿透性溃疡 penetrating ulcer 4. 老年人消化性溃疡 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 三、并发症 Compl ication (一)上消化道大出血 upper gastrointestinal hemorrhage 食管贲门粘膜撕裂综合征 Mallory-Weiss Syndrome (二) 穿孔 perforation 1.急性穿孔 Acute perforation- Diffuse peritonitis 2.慢性穿孔 Chronic perforation-penetrating ulcer 3. 亚急性穿孔 Subacute perforation-localized peritonstis With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society (三)幽门梗阻:pyloric obstruction (四)癌变:Canceration 四、诊断和鉴别诊断: Diagnosis and Differential Diagnosis (一)诊断:Diagnosis 1.临床表现 2.X线钡餐检查:X-ray barium meal examination With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 3. 胃镜及活组织检查 endoscope and biopsy With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 4.幽门螺杆菌的检测:detection of H.pyior: 5.便隐血试验:Occult blood in stool (二)鉴别诊断:Differential diagnosis 1.癌性溃疡:cancerous ulcer With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 2.胃泌素瘤:Gastrinoma 卓艾氏综合症 Zollinger-Ellison Syndrome 3.慢性胆囊炎和胆石症 4.功能性消化不良:Functional dyspepsia With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 保护因素 粘膜屏障 粘液HCO3- 屏障 前列腺素 细胞更新 粘膜血流 表皮生长因子 损害因素 胃酸-胃蛋白酶 Hp感染 药物 烟酒 胆盐胰酶 五、病因和发病机制:Cause and mechanism With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society (一)损害因素增加:lncrease of damage Cause. 1. H . pylori感染是消化性溃疡的主要病因: 1)“漏屋顶”假说: 胃酸 Hp感染 胃窦炎 胃溃疡 胃蛋白酶 2)六因素假说: 胃酸 高胃泌素血症 胃酸 Hp感染 胃酸 十二指肠粘膜 幽门腺化生 十二指肠炎 十二指肠溃疡 胃蛋白酶 HCO 3- With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 2. 胃酸——胃蛋白酶的作用: Gastric acid—pepsin effect (1)pcM增多: 肥大细胞迷走神经兴奋G细胞 乙酰胆碱 组胺胃泌素 胃泌素受体乙酰胆碱受体 组胺H2受体 壁细胞 炎症 胃窦炎 (Hp感染的Du) With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society (2) 迷走神经持续兴奋: (3)其他因素: 3. 其他因素: (二)保护因素的削弱: Decrease of protective factors 1.粘液—粘膜屏障的损害: Muci-mucosa barrier damage 2.前列腺素减少 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 六、治疗:Treatment (一)一般治疗:General treatment (二)药物治疗:pharmacotherapy 1.减少损害因素的药物: Drug of decrease damage cause 1)根除H·pylori的治疗: With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 一、铋剂+两种抗生素 1.铋剂标准剂量+阿莫西林0.5+甲硝唑0.4 2次/d×2周 2.铋剂标准剂量+四环素0.5+甲硝唑0.4 2次/d×2周 3.铋剂标准剂量+克拉霉素0.25+甲硝唑0.4 2次/d×2周 二、质子泵抑制剂(PPI)+两种抗生素 1.PPI标准剂量+克拉霉素0.5+阿莫西林1.0 2次/d×1周 2.PPI标准剂量+阿莫西林1.0+甲硝唑0.4 2次/d×1周 3. PPI标准剂量+克拉霉素0.25+甲硝唑0.4 2次/d×1周 三、其他方案 1.雷尼替丁枸椽酸铋(RBC)0.4替代推荐方案二中的PPI 2.H2-RA或PPI+推荐方案一,组成四联疗法 应注意的是: 1.方案中甲硝唑0.4g可用替硝唑0.5g代替。 2. Hp对甲硝唑耐药率已较高,影响疗效。呋喃唑酮抗Hp作用 强,Hp不易产生耐药性,可用呋喃唑酮0.1g替代甲硝唑。 3.PPI+铋剂+两种抗生素组成的四联疗法多用于治疗失败者。 根除H·pylori的治疗方案 一、铋剂+两种抗生素 1.铋剂标准剂量+阿莫西林0.5+甲硝唑0.4 2次/d×2周 2.铋剂标准剂量+四环素0.5+甲硝唑0.4 2次/d×2周 3.铋剂标准剂量+克拉霉素0.25+甲硝唑0.4 2次/d×2周 二、质子泵抑制剂(PPI)+两种抗生素 1.PPI标准剂量+克拉霉素0.5+阿莫西林1.0 2次/d×1周 2.PPI标准剂量+阿莫西林1.0+甲硝唑0.4 2次/d×1周 3. PPI标准剂量+克拉霉素0.25+甲硝唑0.4 2次/d×1周 三、其他方案 1.雷尼替丁枸椽酸铋(RBC)0.4替代推荐方案二中的PPI 2.H2-RA或PPI+推荐方案一,组成四联疗法 应注意的是: 一、铋剂+两种抗生素 1.铋剂标准剂量+阿莫西林0.5+甲硝唑0.4 2次/d×2周 2.铋剂标准剂量+四环素0.5+甲硝唑0.4 2次/d×2周 3.铋剂标准剂量+克拉霉素0.25+甲硝唑0.4 2次/d×2周 二、质子泵抑制剂(PPI)+两种抗生素 1.PPI标准剂量+克拉霉素0.5+阿莫西林1.0 2次/d×1周 2.PPI标准剂量+阿莫西林1.0+甲硝唑0.4 2次/d×1周 3. PPI标准剂量+克拉霉素0.25+甲硝唑0.4 2次/d×1周 三、其他方案 1.雷尼替丁枸椽酸铋(RBC)0.4替代推荐方案二中的PPI 2.H2-RA或PPI+推荐方案一,组成四联疗法 应注意的是: With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 2)抑制和中和胃酸的药物治疗: 制酸剂 HCl With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 抑制和中和胃酸的药物一览表 主要 作用 药药 物作用机制副作用备备 注 抑 制 胃 酸 分 泌 H2受体拮抗剂剂 西咪替丁Cimetidine 雷尼替丁Ranitidine 法莫替丁famotidine 尼刹替丁nicatidine 罗罗沙替丁Roxatidine 与壁细细胞膜上 的H2受体结结 合,抑制胃酸 和胃蛋白酶的 分泌 肝肾损肾损 害, ALT↑ CR↑, 药药疹,药热药热 粒细细胞↓ 男性女乳, 乏力,头头疼 嗜睡,腹泻 DU首选选4-6 周,GU6-8 周 质质子泵泵阻断剂剂 奥美拉唑唑omeprazole (洛赛赛克Losec) 兰兰索拉唑唑Ransoprazole 潘托拉唑唑Pantoprazole 拉贝贝拉唑唑rabeprazole 1.特异地抑制 H+/K+ATP酶, 阻断壁细细胞泌 酸的最终环终环 节节 2.杀灭杀灭 H.pylori. DU4-6周 GU6-8周-12 周 中 和 胃 酸 制酸剂剂 氢氢氧化铝铝凝胶10-15ml tid dPC 10-15ml QN 胃泌治等 中和胃酸,缓缓 解疼痛促进溃进溃 疡疡愈合。 镁镁-腹泻 钙铝铋钙铝铋 -便秘 6-8W With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 2.增加保护因素的药物:Drug of increase protective factors 药药 物 作用机制副作 用 备备注 胶体次枸椽酸铋铋 迪乐乐、德诺诺De-nol CBS得乐乐 果胶铋铋 1.与溃疡溃疡 面蛋白质结质结 合形成保护护 膜 2.促进进粘液及HCO3-分泌 3.刺激PGE分泌 4.吸附表皮生长长因子至溃疡处溃疡处 促 进进愈合 5.杀灭杀灭 Hp 黑便 , 黑苔 8周 ,适 于GU ,DU 硫糖铝铝 Sucralfate lg Qid A.C. 1.与溃疡溃疡 面渗出蛋白质结质结 合形成 保护护膜 2.促进进PGE合成 3.刺激表皮生长长因子分泌 便秘适于 GU, DU 前列腺素E 米索前列醇misoprostol 200μg,Qid 恩前列腺素enprostil 35 μg,Bid 1.促进进上皮细细胞DNA合成 2.促进进粘液和HCO3-分泌 3.促进进粘膜血运 4.干扰扰壁细细胞制造第二信使CAMP ,减少胃酸分泌 腹痛 , 腹泻 , 孕妇妇 禁用 DU 施维维舒、麦滋林S颗颗粒 思密达 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 3.Pu复发的预防: (三)Pu治疗的策略:Strategy of pu (四)并发症的治疗:Treatment of complication 1.上消化道出血的治疗:Treatment of upper gastroitestinal hemorrhage 2.幽门梗阻的治疗:Treatment of pyloric obstruction With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 病例2 王某某,男,29岁,司机. 自述有胃病史6年,冬秋季节易复发,每次发作 多于饭后3小时,出现上腹部隐痛,进食或服小苏 打可缓解,有时夜间疼醒,常伴反酸、灼心。近 两周来又因过劳上腹痛加重,饥饿疼,恶心,呕 吐当日食物、水,无胆汁及血液,但仍能进少量 饮食,近三天上腹胀疼,呈持续性,进食加重, 每日呕吐5-6次,呕吐物有酸酵味并伴不消化食物 及隔日食,周身乏力,见瘦来诊。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 查体:Bp 110/70mmHg,神清但较萎糜,皮肤弹 性差,巩膜无黄染,锁骨上淋巴结未触及,心率 94次/分,律齐,无杂音,肺(-),上腹膨隆, 可见胃形,震水音(+),上腹轻压痛,肝脾未触 及,移动浊音(-),肠鸣音活跃。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 病例3 男,60岁,9年来间断出现餐后1小时左右 心窝部隐痛,饱胀,嗳气,无反酸,多于秋冬季 节复发,每次持续10天左右,自服胃药(不详) 可缓解。近2个月又复发,上腹持续性疼痛加重, 服药无效,并出现食欲不振,乏力,消瘦,体重 下降6Kg,间断黑便,每次30g,未介意,近半月 自觉头 晕,活动后心悸气短,为明确诊断而入院 。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 查体:P80次/分,一般状态欠佳,贫血貌 ,双肺无异常,心律整,心尖可闻Ⅱ级收 缩期杂音,腹平软,上腹轻压痛,无反跳痛 ,未触及包块,肝脾未触及,肠鸣音5次/ 分,移动浊音(-)。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 病例5 男,32岁,3年来每于冬季出现 右上腹疼痛,并向 背部放射,尤以夜间为甚,伴反酸烧心,先后出现3次柏油 便,曾行胃镜及X线钡餐检查,胃及十二指肠球部均未见溃 疡,今冬又复发,持续性后背痛,继之发现尿黄,为 明确 诊断来院。 查体:一般状态佳,巩黄(+),心肺无异常,腹平软 ,肝脾未触及,肝区触痛(-),上腹偏右压痛(+),无 反跳痛,胆囊区触痛(-),Murphy’s(-),肠鸣音4次/ 分,移动浊音(-)。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 病例6 王某某,男,28岁. 主诉:上腹隐痛2年,晕厥半小时 现病史:患者以上腹隐痛、饱胀、嗳气2年为 主诉在消化病房住院已2天。今日早餐后自觉上腹 疼痛缓解,但出现乏力、头晕,有便意去厕所排 出黄色软便,排便后起身时,突然晕倒在地,医 务人员发现患者面色苍白,周身冷汗,无二便失 禁,神志很快恢复,被抬至床上 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 既往史:无同样发作史. 查体:T 36.5℃,P 120次/分,Bp 85/65mmHg ,神清,精神萎糜,结膜略苍白,四肢湿冷。左 锁骨上淋巴结未触及,心界不大,心律整,无杂 音。肺无罗音,腹平软,上腹部压之不适,肝脾 未触及。移动性浊音阴性,肠鸣音13次/分,未听 到气过水声,膝反射正常,巴氏征阴性。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 单击此处编辑母版标题样式 单击此处编辑母版副标题样式 *45 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本文标题:消化性溃疡Pepticulcar一概述Summary十二指肠溃疡课件_3
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