消化性溃疡（PU）诊疗，基础必备！

2021-12-18 陈飞帆纷飞之翼之住院医师学习笔记陈飞帆纷飞之翼之住院医师学习笔记

两条咸鱼

陕西省西安市中心医院医生/ 医师

消化性溃疡是各种致病因子导致黏膜炎性坏死，形成溃疡，缺损穿透黏膜肌层，严重者可达固有肌层，可发生于食管、胃或十二指肠，以胃十二指肠最常见。

1、概述

定义：各种致病因子导致黏膜炎性坏死，形成溃疡，缺损穿透黏膜肌层，严重者可达固有肌层
可发生于食管、胃或十二指肠，以胃十二指肠最常见
以20-50岁居多，男：女（2-5）：1，十二指肠溃疡：胃溃疡3:1

2、发病机制

3、诊断及鉴别

（1）诊断思路

（2）症状

中上腹痛，周期性、节律性发作

胃溃疡腹痛：餐后0.5-1h
十二指肠溃疡腹痛：空腹

NSAIDs溃疡

无症状者居多
部分以上消化道出血为首发症状
或恶心、厌食、纳差、腹胀等非特异症状

（3）并发症

上消化道出血：PU尤其是NSAIDs溃疡最常见并发症
穿孔：老年患者多见
梗阻：现较少发生
癌变

DU不增加胃癌发生，甚至呈复相关
GU与胃癌尤其是非贲门部胃癌呈正相

（4）辅助检查

胃镜

诊断PU最主要方法，注意部位、形态大小、深度、病期，以及周围黏膜情况
胃溃疡应常规活检，治疗后应复查胃镜至溃疡愈合
NSAIDs溃疡

胃窦、胃体、胃角等不同部位，形态多样，大小不一，常呈多发、浅表性溃疡

PU出血Forrest分级

PU内镜分期

不典型或难愈合溃疡

应进一步完善胃肠钡餐、超声内镜、共聚焦内镜等

HP检查

PU常规做尿素酶试验、组织学检测，或核素标记C13/14呼气试验
粪便抗原检测：准确性与呼气试验相似
细菌培养：用于药物敏感试验和细菌学研究
血清抗体检测：只适用于普查，不能分辨是否为现症
注：

抗菌药物、铋剂停药至少４周后进行检测
应用抑酸剂停药至少２周后进行检测
PU出血，严重萎缩，MT可能导致尿素酶试验假阴性
病理提示活动性炎性反应高度提示HP+
活动性PU排除NSAID溃疡后，Hp感染可能＞95%

（5）鉴别

MT、MALT、CD、TB、CMV感染等

4、治疗

（1）PU治疗

（2）NSAID溃疡

病情允许的情况下，首选停用NSAID
药物

PPI是治疗首选药物，预防出血，促进溃疡愈合
胃黏膜保护剂可增加前列腺素合成，对NSAID溃疡有一定作用

并发症

风险分级及处理

预防

患者既往无PU史，仍推荐抑酸以预防低剂量阿司匹林（LDA）相关溃疡的发生

除菌：存在争议

部分认为长期接受NSAID和阿司匹林治疗根除Hp有益
另外部分认为使用PPI疗效优于除菌，且除菌不加速溃疡愈合

参考文献

消化性溃疡诊断与治疗规范（2016）中华消化杂志编委会

消化性溃疡出血的Forrest分级与内镜治疗李兆中

消化性溃疡中西医结合诊疗共识意见（2017）中国中西医结合学会消化系统疾病专业委员会

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2022-01-14 ms8000000682821176

谢谢

54 0
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2022-01-08 ms7000001201090467

学习

53 0
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2021-12-20 柳叶一刀

#消化性溃疡#

48 0
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2021-12-19 ms3271824264220729

学习了，C13与粪便抗原检测准确性相似，一直被误解了！

71 0
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2021-12-19 ms5000000518166734

学习学习学习学习学习学习学习学习学习学习学习学习学习学习学习学习学习

72 0
[GetPortalCommentsPageByObjectIdResponse(id=1184434, encodeId=680e118443484, content=谢谢, beContent=null, objectType=article, channel=null, level=null, likeNumber=54, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=40645466484, createdName=ms8000000682821176, createdTime=Fri Jan 14 23:56:33 CST 2022, time=2022-01-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1182190, encodeId=31ae11821906a, content=学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=2fff5573682, createdName=ms7000001201090467, createdTime=Sat Jan 08 13:37:10 CST 2022, time=2022-01-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1369765, encodeId=b71a1369e65c6, content=<a href='/topic/show?id=312e65e4420' target=_blank style='color:#2F92EE;'>#消化性溃疡#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=48, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=65744, encryptionId=312e65e4420, topicName=消化性溃疡)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=778d36, createdName=柳叶一刀, createdTime=Mon Dec 20 12:57:30 CST 2021, time=2021-12-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1081857, encodeId=6b75108185ed1, content=学习了，C13与粪便抗原检测准确性相似，一直被误解了！, beContent=null, objectType=article, channel=null, level=null, likeNumber=71, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=0c871822863, createdName=ms3271824264220729, createdTime=Sun Dec 19 18:24:32 CST 2021, time=2021-12-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1081740, encodeId=de101081e4083, content=学习学习学习学习学习学习学习学习学习学习学习学习学习学习学习学习学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=72, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f03a5433387, createdName=ms5000000518166734, createdTime=Sun Dec 19 10:43:25 CST 2021, time=2021-12-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1081688, encodeId=2bf4108168883, content=简单，全面，前卫。, beContent=null, objectType=article, channel=null, level=null, likeNumber=64, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=e9535642297, createdName=刘萌田ms2000000945841279, createdTime=Sun Dec 19 06:57:42 CST 2021, time=2021-12-19, status=1, ipAttribution=)]
2021-12-19 刘萌田ms2000000945841279

简单，全面，前卫。

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消化性溃疡（PU）诊疗，基础必备！

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