消化不良(英文).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,Gastric acid secretion,Helicobacter Pylori,Symptomatic treatment,Antacids,MOA:Weak bases that react with gastric acid to form H20+salt.pepsin activity as pepsin inactive at pH4,Symptom relief,liquidstablets,E.g.Maalox=Mg(OH)2+Al(OH)3,Drug,Side effect,Magnesium,severe osmotic diarrhoea(therefore combined with AlOH),drug absorption,Aluminium,phosphate,absorption of tetracycline,thyroxine&chlorpromazine,constipation,Calcium,Ca in blood&urine(high doses),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+,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,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,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,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,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,