Department of gastroenterology, Second Affiliated Hospital of Nanjing Medical University Ji Guozhong （季国忠）Several Problems Relative to Peptic Ulcer Disease  南京医科大学第二附属医院Definition Introduction of peptic ulcer (PU) Ulcers are defects in the gastrointestinal mucosa that penetrate mucosa, submucosa and the muscularis mucosa GU DU 南京医科大学第二附属医院Epidemiology Introduction of peptic ulcer (PU) About 5~10 percent of all individuals develop Pu in their lifetime.  4~8 million people 350, 000 new cases each year in the U.S.  But in China? Du is more common than Gu. Introduction of peptic ulcer (PU)  Etiology(Causes)  pH (hydrochloric acid and pepsin) Hp (Helicobacter pylori) NSAIDS Smoking , tea , coffee, stress (emotion)  南京医科大学第二附属医院1910, Schwartz No acid No ulcer 1983 Marshall 、Warren No acid No Hp No ulcer (nonsteroidal anti—inflammatory drugs) It is the most common chronic bacterial infection in humans. About one-half of the world’s population are infected with Hp. It disrupts a protective layer of mucous and its enzymes and toxins can cause stomach and duodenum cells injury →develop ulcer or more serious problems—Cancer Defensive factors Aggressive factors 南京医科大学第二附属医院Introduction of peptic ulcer (PU) Aggressive factors Defensive factors Mechanisms There is an effective balance between the defensive factors and aggressive(damage) factors, Disruption of this balance leads to peptic ulcer.  南京医科大学第二附属医院Introduction of peptic ulcer (PU) Mechanisms Aggressive factors  Defensive factors acid, pepsin, bile, pancreatic enzymes, Hp,et al bicarbonate, mucus, mucosal blood flow, cell renewal,et al  南京医科大学第二附属医院Introduction of peptic ulcer (PU) Symptoms Pain ( 70 percent ) Nausea  ( 50 percent ) Vomiting ( 20 percent ) Weight loss ( 20 percent ) Bleeding  ( 15 percent ) 南京医科大学第二附属医院Diagnosis Introduction of peptic ulcer (PU)  bases on the history and physical examination and depends on radiography or endoscopy  Endoscopy is more accurate and allows directed biopsy, cytologic study and Hp diagnosis.  南京医科大学第二附属医院Treatment strategy No complications --medical therapy. Twice dramatic evolutions 1970s-1980s ：H2RA （Cimetidine ）PPI  （Omeprazole ）1980s-2000s : HP In selecting a drug with which to treat a patient with pu, four factors must be considered: effectiveness, safety, convenience, cost. A: PPI+ two antibiotics B: CBS+ two antibiotics C: H2RA+ two antibiotics  南京医科大学第二附属医院Treatment strategy H. pylori infection positive: eradicate Hp Antibiotics: clarithromycin metronidazole Amoxycillin tetracycline PPI: omeprazole Lansoprazole pantoprazole rabeprazole esomeprazole H2RA Cimetidine Ranitidine Famotidine nizatidine H. pylori infection negative H2RA or PPI only  南京医科大学第二附属医院step up and step down therapy Treatment strategy  begins empirically with lower cost alternatives such as lifestyle modifications, antacids, and H2 Antagonists reserving PPIs for treatment failures and patients with more severe forms of disease Step-Up therapy Step-Down therapy begins with a PPI for several weeks and then treatment is "stepped-down" to an H2 Antagonist 111 20mg QD omeprazole 104 30mg QD lansoprazole 107 40 mg QD esomeprazole 101 20mg QD rabeprazole 93 20mg BID Famotidine 80 40mg QD pantoprazole 21 150mg BID Ranitidine 11 400mg BID Cimetidine $ COST/30 d* AVE DOSE DRUG Acid Suppressive Therapy Cost Comparison  南京医科大学第二附属医院Complications: (Bleeding, perforation, obstruction, malignant) Treatment strategy Conservative measures(partly) Surgery Operation Bleeding, cann’t be controlled perforation pyloric obstruction carcinomatous change 南京医科大学第二附属医院Thanks! 25 Xenical Slide Kit August 1998 Section 1 25 Slide 25: Psychological impact of obesity Obesity has a profound effect on the quality of life of the individual patient. The limitations imposed by musculo-skeletal, respiratory and cardiovascular disorders are frequently compounded by the psychological consequences of obesity (low self-esteem, depression and social isolation). Prejudice and discrimination add to the misery of the obese patient and contribute to the generally lower levels of academic achievement and employment opportunities amongst obese patients. The quality of life is made poorer by reduced sexual activity. 25 Xenical Slide Kit August 1998 Section 1 25 Slide 25: Psychological impact of obesity Obesity has a profound effect on the quality of life of the individual patient. The limitations imposed by musculo-skeletal, respiratory and cardiovascular disorders are frequently compounded by the psychological consequences of obesity (low self-esteem, depression and social isolation). Prejudice and discrimination add to the misery of the obese patient and contribute to the generally lower levels of academic achievement and employment opportunities amongst obese patients. The quality of life is made poorer by reduced sexual activity. 25 Xenical Slide Kit August 1998 Section 1 25 Slide 25: Psychological impact of obesity Obesity has a profound effect on the quality of life of the individual patient. The limitations imposed by musculo-skeletal, respiratory and cardiovascular disorders are frequently compounded by the psychological consequences of obesity (low self-esteem, depression and social isolation). Prejudice and discrimination add to the misery of the obese patient and contribute to the generally lower levels of academic achievement and employment opportunities amongst obese patients. The quality of life is made poorer by reduced sexual activity.