349.4 📋 章末速蚘 Summary

349.4.1 🔑 䞀句話瞜結

PUD (peptic ulcer disease) = mucosal break > 5 mm penetrating muscularis mucosaDU > GUetiologiesH. pylori (70-95% DU, 60-80% GU — most common globally) + NSAIDs (most in developed) + ZES + stress + idiopathicclinicalDU pain relieved by food (2-3 hr after meal, night pain), weight gain; GU pain worsened by food, weight loss — all GU need biopsy (cancer risk); complications: bleeding (most common), perforation, penetration, obstruction, malignancydiagnosis EGD gold standard; H. pylori testing: urea breath test (preferred non-invasive), stool antigen, biopsy + CLO test (during EGD), histology, serology (less specific)H. pylori treatment 2024quadruple therapy preferred (bismuth + PPI + tetracycline + metronidazole × 14 d) due to rising clarithromycin resistance > 15%; clarithromycin-based triple (PPI + clarithromycin + amoxicillin × 14 d) only if local resistance < 15%; vonoprazan-based dual or triple (FDA 2022) higher eradication; levofloxacin-based rescue; verification 4+ weeks after off PPI 2 wkNSAID-induced PUDstop NSAID or switch to COX-2 selective + PPI prophylaxisfunctional dyspepsia (Rome IV)PDS (postprandial distress) or EPS (epigastric pain); H. pylori eradication + PPI + prokinetics + TCA/SSRI refractoryZollinger-Ellison syndrome (ZES)gastrinoma (pancreas/duodenum) + hypergastrinemia + multiple atypical ulcers; MEN1 25%; gastrin > 1000 + acidic pH; high-dose PPI + surgical resection + octreotide/lanreotide + PRRT (Lutathera)。

349.4.2 💊 治療粟芁

  • H. pylori quadruple (preferred)bismuth subsalicylate 525 mg QID + PPI BID + tetracycline 500 mg QID + metronidazole 500 mg TID × 14 days
  • H. pylori triple (only if local clarithromycin < 15%)PPI BID + clarithromycin 500 mg BID + amoxicillin 1 g BID × 14 days
  • vonoprazan-based (FDA 2022)vonoprazan 20 mg BID + amoxicillin 1 g TID (dual) or + clarithromycin 500 mg BID (triple) × 14 d — higher eradication rates
  • levofloxacin rescuePPI + amoxicillin + levofloxacin (if standard fails)
  • verificationUBT or stool antigen 4+ weeks after off PPI 2 weeks
  • PUD with NSAIDstop NSAID or switch to COX-2 selective + PPI prophylaxis
  • functional dyspepsiaH. pylori eradication if positive + PPI + prokinetic (metoclopramide cautious) + TCA/SSRI for refractory
  • ZEShigh-dose PPI (BID often) + surgical resection if localized + octreotide/lanreotide for unresectable + sunitinib/everolimus advanced + PRRT (Lutathera) for SST receptor+ tumors

349.4.3 🎯 盧醫垫的考前提醒

  1. PUD top causesH. pylori (most worldwide, 70-95% DU, 60-80% GU) + NSAID (most in developed countries); ZES, stress, idiopathic
  2. DU vs GU clinicalDU pain relieved by food (rarely malignant) vs GU pain worsened by food (all GU need biopsy — cancer risk)
  3. H. pylori testingurea breath test (preferred non-invasive) or stool antigen; biopsy with CLO during EGD; off PPI 2 weeks for accurate testing
  4. H. pylori treatment paradigm shiftclarithromycin resistance > 15-20% globally → quadruple therapy preferred (bismuth + PPI + tetracycline + metronidazole × 14 d)
  5. vonoprazan (PCAB) FDA 2022alternative to PPI; faster + more sustained acid suppression; vonoprazan-based H. pylori dual/triple therapy higher eradication rates
  6. NSAID + ulcer preventionadd PPI for high-risk (age > 65, prior PUD, anticoagulant, ASA, steroid); switch to COX-2 selective if possible
  7. functional dyspepsia (Rome IV)PDS (postprandial distress) vs EPS (epigastric pain); ≥ 3 mo symptoms + 6 mo onset; PPI + H. pylori eradication + TCA/SSRI for refractory
  8. Zollinger-Ellison syndrome diagnosisserum gastrin > 1000 pg/mL + acidic gastric pH (off PPI 1-2 weeks); secretin stimulation test; imaging (octreotide scan, MRI, EUS)
  9. ZES + MEN1 association 25%multi-endocrine neoplasia type 1 — parathyroid, pancreas, pituitary; screen for other tumors
  10. gastric MALT lymphoma + H. pylorieradication of H. pylori → 70-80% lymphoma regression in low-grade; surveillance EGD essential