消化不良(英文)课件.ppt

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Dyspepsia,Peptic Ulcer Disease and,Helicobacter Pylori,Pharmacology&Therapeutics February 2007,Dyspepsia,40%of all adults,4%GP consultations,10%further investigations,10-20%NSAID users,Endoscopy findings,15%Duodenal or Gastric ulcer,15%Oesophagitis=GORD,30%Gastritis duodenitis or hiatus hernia,30%Normal=functional dyspepsia,Pathogenesis of Dyspepsia,Factor,Treatment approach,Infection with,H.pylori,Eradication of H.pylori infection,e.g.triple tx,gastric HCl secretion,HCl secretion or neutralizing it,e.g.H2 antagonists,pirenzepine,antacids,PPIs,Inadequate mucosal defence against gastric HCl,Agents that protect gastric mucosa,e.g.sucralfate,Altered gastric motility,Prokinetic agents eg metoclopramide,Gastric acid secretion,Helicobacter Pylori,Mucosal Protective Agents,1),Sulcralfate,MOA:Binds to positively charged proteins present on damaged mucosa forming a protective coat,Useful in“stress ulceration”,As effective as H2-R antagonists/high dose antacids,SE:Constipation,absorption of cimetidine,digoxin,phenytoin&tetracycline,2),Bismuth,MOA:Antimicrobial action.Also inhibit pepsin activity,mucus secretion&interact with proteins in necrotic mucosal tissue to coat&protect the ulcer crater,Additional agents,Antifoaming agent,Dimethicone to relieve flatulence(surfactant),Alginates,-form a raft on surface of stomach contents to reduce reflux,Carbenoxolone,-liquorice derivative?Alters mucin s/e H2O retention,K+,H2-receptor antagonists,Drug,Side effects,Cimetidine,-reversible impotence,gynaecomastia&,sperm count(high doses)(nonsteroidal antiandrogen),-mental status abnormalities-confusion,hallucinations(elderly/renal impairment),-leukopenia&thrombocytopenia(rare),-cytochrome P450 inhibitor(e.g.impairs metabolism of warfarin,theophylline&phenytoin),Ranitidine,famotidine,-Impotence,gynaecomastia&confusion less frequently than cimetidine.,-Little interference with cytochrome P450,-Reversible drug-induced hepatitis with all H2-antagonists,Proton-pump Inhibitors(PPI),MOA:block parietal cell H,+/K+ATPase enzyme system(proton pump)secretion of H+ions into gastric lumen,More effective than H2-antagonists or antacids,Used in antimicrobial regimens to eradicate H.pylori,SE:n&v,diarrhoea,dizziness,headaches,gynaecomastia&impotence(rare),thrombocytopenia,rashes,Helicobacter Pylori,95%Duodenal ulcers,70%Gastric ulcers,10%Non-ulcer dyspepsia,Treatment benefits gastritis more than reflux symptoms,Diagnosing,H.pylori,Urea breath test,95%sensitive&specific,Stool antigen test,92%,sensitive&specific,Serology,80%,sensitive&specific,Endoscopy CLO test,98%,sensitive&specific,(urea and phenol red,a dye that turns pink in a pH of 6.0 or greater),H.Pylori,Eradication,1st line eradication tx for H.pylori,2,nd,line tx,Preferred tx=PPI PO+Clarithromycin 500mg BD PO+Amoxicillin 1 gm BD PO for 7 days,If Penicillin allergic=PPI+Clarithromycin 500mg BD PO+Metronidazole 400mg BD PO for 7 days,E.g.of PPI:Lansoprazole 30mg BD PO,PPI+Bismuth 120mg QDS PO+Metronidazole 500mg TDS PO+Tetracycline 500mg QDS PO for 7 days,Subsequent failures handled on individual basis with advice from gastro/micro,H.Pylori,eradication,1 week triple-therapy regimens eradicate,H.Pylori,in 90%cases.Usually no need for continued antisecretory tx unless ulcer complicated by bleeding/perforation,2 week triple-therapy offer higher eradication rates cf 1 week but SE common&poor compliance,2-week dual-therapy with PPI&antibacterial produce low rates of H.pylori eradication&not recommended,H.pylori eradication,Treatment failure may be due to,-Resistance to antibacterial drugs,-Poor compliance,Drug,Side effects,Bismuth,n&v,unpleasant taste,darkening of tongue&stools,caution in renal disease,Metronidazole,n&v,unpleasant taste,effectiveness OCP,care with lithium/warfarin,Amoxicillin,&tetracycline,GI side effects,effectiveness OCP,pseudomenbranous colitis,Lansoprazole,effectiveness OCP,Practical Management of dyspepsia,Who needs endoscopy?,GI bleeding,Unintentional weight loss,Dysphagia,Persistent vomiting,Iron deficiency anaemia,Epigastric mass,55 with unexplained persistent/recent onset dyspepsia,PUD on endoscopy,Stop NSAIDs,Start full dose PPI for 2 months,Eradication treatment if,H Pylori,positive,Repeat endoscopy for gastric ulcer 2%cancer risk,GORD on endoscopy,Lifestyle advice,Full dose PPI for 1-2 months,H Pylori,Eradication may not benefit reflux symptoms,If recurrence-lowest dose PPI to control symptoms,GORD,GORD=Symptoms of“heartburn”,General advice includes AVOIDING,Drug Tx,Meals at night,lying down after meals,Elevate head of bed,Heavy lifting,tight clothing,bending,Being overweight,Smoking(nicotine relaxes lower oesophageal sphincter),Aggravating substances(spicy foods,C2H5OH),Drugs which encourage reflux(e.g.antimuscarinic,smooth muscle relaxants,theophylline),antacids=+/-alginic acid,Pro-kinetic agent,e.g.metoclopramide,H2-antagonist,PPI,If severe sx when tx stopped,or bleed from oesophagitis or stricture maintenance tx with PPI or surgery may be necessary,NSAID Induced Dyspepsia,10-20%develop endoscopically visible PUD,1-5%perforation or major bleeding,Endogenous prostaglandins(PGE2&I2)contribute to GI mucosa integrity by,-stimulation of mucus&bicarbonate secretion,-maintenance of blood flow(allows removal of luminal H-ions),-prevent luminal H-ions from diffusing into the mucosa,-,gastric acid secretion,-helping to repair damaged epithelium,NSAID Induced Dyspepsia,Elderly 65 years,History PUD,Other drugs eg bisphosphonates,Steroids,PPI or misoprostol protection for at risk,Consider screening&eradicating,H Pylori,infection,Prostaglandin analogues,Misoprostol,=synthetic prostaglandin E1 analogue,Prevents NSAID induced ulcers&heals chronic GU&DU,SE:Abdo pain,n&v,diarrhoea,abortifacient(produces uterine contractions),Non ulcer dyspepsia,Treat H pylori(no routine retesting),Symptomatic treatment,PPI(proven benefit),Prokinetic agent eg metoclopramide(probable benefit),Dyspepsia without alarm symptoms,Lifestyle advice,Antacids and medication review,Empiric PPI,Test and treat for H Pylori,Copyright 2007,BMJ Publishing Group Ltd,.,Shah,R.,BMJ 2007;334:41-43,