Microsoft PowerPoint - public talk - GERD and HP

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1 個案一梁先生 M/45, 護士飯後胸口痛, 口苦, 間中胃灼熱心電圖, 肺 X 光, 超聲波, 胸, 腹部 CT 正常胃鏡 : 嚴重胃炎, HP 陰性個案二陳先生 M/70 吸烟長期胃酸過多, 間中服抗酸藥谷嚥困難, 食物憋在胸口

2 胃酸倒流 (GERD) Dr To Hing Ting 杜興婷醫生

3 發病率及併發症催升亞洲區發病率 2.5% to 7.1% J Gastroenterol Hepatol Dec;23(12): Gastroesophageal reflux disease: an Asian perspective.

4 甚麼是胃酸倒流? 胃部的食物及胃酸倒流入食道一個在飯後特別容易出現的生理現象 ( physiological reflux )

5 甚麼時候胃酸倒流是一種病? 當胃酸倒流導致 : 影響生活質素的病徵併發症

6 成因下食道括約肌 (LES) 藥物 eg. Adalat 食物 eg. 烟, 酒, 咖啡, 高脂肪, 朱古力食道裂孔疝氣 ( hiatus hernia ) LES 食道疾病胃部問題胃排空減緩 delayed gastric emptying 胃部出口, 例如幽門阻塞 Outlet obstruction 胃部持續膨脹, 對下食道括約肌造成壓力

7 食道裂孔疝氣 ( hiatus hernia ) Increased abdominal pressure 腹部壓力大 Heavy lifting Frequent cough, sneezing, smoking pregnancy and delivery Violent vomiting Straining with constipation Obesity Diaphragm weakness Increased with age

8 胃酸倒流的典型病徵胃酸倒流 Heartburn 胸口灼熱通常在進食後 1-3 個小時後出現躺臥向前傾及伸展身體會偶爾使情況惡化

9 Atypical symptoms 非典型病徵吞咽困難 Dysphagia, Odynophagia 口水分秘過多 Water brash 作悶, 嘔吐 Nausea and vomiting extra-oesophageal symptoms 胸痛 Chest pain 哮喘 Asthma, Chronic cough 喉炎咽 laryngitis 聲帶病變 Vocal cord ulcers, leukoplakia, 蛀牙 Dental erosion

10 個案一梁先生 M/45, 護士飯後胸口痛, 口苦, 間中胃灼熱心電圖, 肺 X 光, 超聲波, 胸, 腹部 CT 正常胃鏡 : 嚴重胃炎, HP 陰性問題:他是否患有胃酸倒流? 非典型病徵胃鏡顯示食道正常

11 胃酸倒流的檢查典型病徵質子泵抑制劑 (PPI) 測試內窺鏡酸鹼度 (ph) 考察食道阻抗

12 Therapeutic trial with PPI 質子泵抑制劑 (PPI) 測試

13 個案二陳先生 M/70 吸烟長期胃酸過多, 間中服抗酸藥谷嚥困難, 食物憋在胸口問題:假如你是他的主診醫生, 你會否作 PPI 測試?

14 目的 : oesophagitis 食道炎剔除其他可能性非典型病徵警示症狀, 例如併發症幽門螺桿菌內窺鏡 ( Endoscopy ) 例如出血, 消瘦, 吞嚥因難

15 倒流性食道炎 Los Angeles classification 內窺鏡胃酸反流陰性 Grade A Grade B Grade C Grade D

16 胃酸倒流的併發症食道潰瘍 Barrett 食道消化道收窄食道出血腺癌

17 Ambulatory ph monitoring 酸鹼度 (ph) 考察 In normal persons, Acid reflux < 2% of daytime ( upright ) and < 0.3 % night time ( supine ) % time <ph 4 ( < 5% ) No. of episodes ph<4 more than 5 min Relationship with position, eating and symptoms

18 COMBINED MULTICHANNEL INTRALUMINAL IMPEDANCE AND PH 食道阻抗可分析倒流的成份 Detect: composition as containing gas, liquid, or both proximal extent of GER content: acid, non acid reflux

19 梁先生: PPI 測試症狀明顯進步陳先生 : 內視鏡檢查幽門螺桿菌消化道收窄

20 胃酸倒流的治療選擇改變生活習慣抗酸藥及藻酸鹽質子泵抑制劑方法組胺 H 2 受體阻斷劑胃腸道蠕動促進劑手術 Hatlebakk & Berstad, Clin Pharmacokinet 1996; 31:

21 改變生活習慣以控制胃酸倒流減輕體重停止吸煙調高睡床頭部的高度避免引致胃酸倒流的物質 ( 例如酒精咖啡, 有些食物 ) 改變少食多餐不要太晚吃飯減少脂肪的吸收量考慮採用其他藥物代替會引致胃酸倒流的藥物 ( 例如茶葉鹼抗膽菋藥 )

22 Acid suppression 抑制胃酸 Acid suppression Control symptoms in 8 weeks Keep intrgastric ph>4 H2 RA H2 RA 組胺 H2 受體阻斷劑 nocturnal 晚上 50% for hours daily PPI 質子泵抑制劑 postprandial 飯後 80% For hours daily heal oesophagitis in 12 weeks safety 60% in 12 weeks 安全 90% 安全 Tolerance develops over weeks to months

23 Metoclopramide 較多副作用 Prokinetics 胃腸道蠕動促進劑 S/E: Fatigue, restlessness, tardive dyskinesia Domperidone Not cross BBB, less CNS side effects Cisapride Withdrawn from market because of serious cardiac arrhythmia and deaths, only for compassionate use

24 質子泵抑制劑緩和胃灼熱灼熱的速度 100 Lansoprazole 30 mg once daily Heartburn-free days (%) First 3 days First week First 2 weeks Entire 8 weeks n=3510 patients with erosive GORD diagnosed by endoscopy randomised to study Richter et al., Am J Gastroenterol 2001; 96:

25 Maintenance therapy 維持治療再發性 Chronic relapsing disease 再發性下降式療法 Step Step-down approach From multiple dosing PPI to single dosing PPI From PPI to H2RAs Off medication completely, life style modification

26 胃酸倒流的維持治療 : 質子泵抑制劑 vs 組胺 H 2 受體阻斷劑 90 一年內復發率 Cumulative relapse at 1 year (%) Placebo 安慰劑 Ranitidine mg Lansoprazole 15 mg Bardhan, Res Clin Forum 1998; 20:

27 Anti-reflux surgery 手術 Predicts good Response to surgery *Well controlled With medication But consider alternative Rx Symptoms Not well controlled Workup: Endoscopy Manometry ph study Refractory GERD True PPI failure or other cause of symptoms Nissen fundoplication >30% symptoms relapse after 2 years >60% return to usual medication after 10 years

28 胃酸倒流治療 : 總結診斷 : 在一般情况下, 典型測試已可初部診症測試典型病徵, 質子泵抑制劑 (PPI) 非典型病徵和有警示症狀, 則需作內視鏡檢查治療 : 下降式療法再發性普遍, 多要維持治療

29 梁先生 : PPI 維持治療生活習慣改變情况進步, 仍偶有發作陳先生 : PPI 維持治療戒烟接受幽門螺桿菌治療

30 幽門螺桿菌 (H. pylori)

31 幽門螺桿菌與胃酸倒流的關係 Negative association between H pylori and GERD in Asian patients In most patients, eradication of H pylori does not lead to development or aggravate symptoms of GERD

32 Prevalence of H pylori Infection

35 幽門螺桿菌在門螺桿菌在消化性潰瘍中的病發率 Prevalence of H. pylori seropositivity in bleeding ulcer disease Prevalence of H. pylori seropositivity in non-bleeding ulcer disease 100 Prevalence rate (%) Germany Italy Hong Kong Spain USA Hong Kong Denmark Taiwan Germany Turkey Vaira et al., Gastroenterology 1997; 113(Suppl 6): S78 84.

36 可能導致幽門螺桿菌感染的危機因子年齡於發展中國家在幼年時快速受感染感染地於發展中國家抗體陽性的比率較高收入收入與抗體陽性成反比家族家族集結? 配偶之間經口部 / 腸胃相互傳染? 性別酒精血型吸煙兩性有相似的發病率不會增加風險大部份研究顯示沒有聯繫不會增加風險 Logan & Walker, BMJ 2001; 323: Report of the Digestive Health Initiative, Gastroenterology 1997; 113: S4 8.

37 診斷測試非內窺鏡抗體檢測尿素呼氣試驗糞便抗原測試內窺鏡尿素酶試驗組織結構檢查細菌培植 Logan & Walker, BMJ 2001; 323:

38 Lansoprazole 加上兩種抗生素根除幽門螺桿菌的效能 Eradication rate (%) Intention to treat analysis Per protocol analysis LAN: lansoprazole CLA: clarithromycin AMO: amoxicillin MET: metronidazole 20 LAN 30 mg bd CLA 500 mg bd AMO 1 g bd LAN 30 mg od CLA 250 mg bd MET 500 mg bd Bazzoli et al., Aliment Pharmacol Ther 2002; 16:

39 成功根除幽門螺桿菌對治癒潰瘍的影響 Review of 60 trials; 4329 patients Ulcer healing rate according to post-treatment H. pylori status 100 *** 95 ** 88 H. pylori eradicated H. pylori persisted Healing rate (%) **p<0.01 ***p< Duodenal ulcer Gastric ulcer Treiber & Lambert, Gastroenterology 1998; 93:

40 胃潰瘍治療 : 總結受幽門螺桿菌感染的病人必需根除此病菌質子泵抑制劑是最有效抑制胃酸的藥物, 亦是治療胃潰瘍最恰當的第一線療法 Soll, JAMA 1996; 275: Malfertheiner et al., Aliment Pharmacol Ther 2002; 16:

41 The end Thank you!

Microsoft PowerPoint - 17-10-2008《都市病─胃酸倒流及腸胃病》.ppt

Microsoft PowerPoint - 17-10-2008《都市病─胃酸倒流及腸胃病》.ppt 胃酸倒流 ( 胃食道反流性疾病 GERD) 馮騰達醫生腸胃及肝臟專科醫生甚麼是胃酸倒流? 胃部的食物及胃酸倒流入食道一個在飯後特別容易出現的生理現象甚麼時候胃酸倒流是一種病? 當胃酸倒流導致 : 併發症影響生活質素的症狀下食