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class="sub_title clear"> <span id="e286xo47mbob" class="sp2 c6 fl">時(shí)間：<time class="fxtime">2016-12-02 13:48:54</time></span> <span id="e286xo47mbob" class="sp1 c6 fl"><em id="zuozhe" class="noshow">謝君</em><em class="user_id noshow">787</em>由 <em class="nickname"></em> 分享</span> <span id="e286xo47mbob" class="fl arc_btn"></span> </div> </div> </div> <div id="e286xo47mbob" class="y_ju"><script type="text/javascript">a("title");</script></div> <div id="e286xo47mbob" class="con_article con_main" id="contentText"> <p>潰瘍?cè)趺葱纬傻臐兊闹委煼椒?/p></p><h2> 　　潰瘍的治療方案</h2><p> 　　治療目的在于消除病因、解除癥狀、愈合潰瘍、防止復(fù)發(fā)和避免并發(fā)癥。消化性潰瘍?cè)诓煌幕颊卟∫虿槐M相同，發(fā)病機(jī)制亦各異，所以對(duì)每一例應(yīng)分析其可能涉及的致病因素及病理生理，給以適當(dāng)?shù)奶幚怼?/p><p> 　　一、一般治療生活要有規(guī)律，工作宜勞逸結(jié)合，要避免過度勞累和精神緊張，如有焦慮不安，應(yīng)予開導(dǎo)，必要時(shí)可給鎮(zhèn)靜藥。原則上需強(qiáng)調(diào)進(jìn)餐要定時(shí)，避免辛辣、過咸食物及濃茶、咖啡等飲料。牛乳和豆醬雖能一時(shí)稀釋胃酸，但其所含鈣和蛋白質(zhì)能刺激胃酸分泌，故不宜過飲。如有煙酒嗜好而確認(rèn)與潰瘍的發(fā)病有關(guān)者，應(yīng)即戒除。服用NSAID者，應(yīng)盡可能停服;即使患者未服此類藥物，亦應(yīng)告誡其今后慎用。</p><p> 　　二、藥物治療70年代以前本病的治療主要依賴抗酸藥和抗膽堿藥，H2RA的問世在治療上引起第一次變革;根除Hp是治療上的重大里程碑。</p><p> 　　(一)根除Hp治療根除Hp可使大多數(shù)Hp相關(guān)性潰瘍患者完全達(dá)到治療目的。國(guó)際已對(duì)Hp相關(guān)性潰瘍的處理達(dá)成共識(shí)，即不論潰瘍初發(fā)或復(fù)發(fā)，不論活動(dòng)或靜止，不論有無并發(fā)癥史，均應(yīng)抗Hp治療。</p><p> 　　1、根除Hp的治療方案由于大多數(shù)抗菌藥物在腸內(nèi)低pH環(huán)境中活性降低和不能穿透粘液層到達(dá)細(xì)菌，因此Hp感染不易根除。迄今為止，尚無單一藥物能有效根除Hp，因而發(fā)展了將抑制胃酸分泌藥、抗菌藥物或起協(xié)同作用的膠體鉍劑聯(lián)合應(yīng)用的治療方案。根除Hp的治療方案大體上可分為質(zhì)子泵抑制劑(PPI)為基礎(chǔ)和膠體鉍劑為基礎(chǔ)的兩大類。一種PPI或一種膠體鉍劑加上克拉霉素(甲紅霉素)、阿莫西林(或四環(huán)素)、甲硝唑(或替硝唑)3種抗菌藥物中的2種，組成三聯(lián)療法。Hp菌株對(duì)甲硝唑耐藥率正在迅速上升。呋喃唑酮抗Hp作用強(qiáng)，Hp不易產(chǎn)生耐藥性，可用呋喃唑酮替代甲硝唑，劑量為200mg/d，分兩次服。可用H2RA替代PPI，以降低費(fèi)用，但療效亦有所降低。初次治療失敗者，可用PPI、膠體鉍劑合并兩種抗菌藥物的四聯(lián)療法。</p><p> 　　2、根除Hp治療結(jié)束后是否需繼續(xù)抗?jié)冎委煂?duì)此尚未統(tǒng)一。治療方案療效高而潰瘍面積又不很大時(shí)，單一抗Hp治療1-2周就可使活動(dòng)性潰瘍有效愈合。若根除Hp方案療效稍低、潰瘍面積較大、抗Hp治療結(jié)束時(shí)患者癥狀未緩解或近期有出血等并發(fā)癥史，應(yīng)考慮在抗Hp治療結(jié)束后繼續(xù)用抑制胃酸分泌藥治療2-4周。</p><p> 　　3、抗Hp治療后復(fù)查抗Hp治療后，確定Hp是否根除的試驗(yàn)應(yīng)在治療完成后不少于4周時(shí)進(jìn)行。接受高效抗Hp方案(根除率≥90%)治療的大多數(shù)DU患者無必要進(jìn)行證實(shí)Hp根除的試驗(yàn)。難治性潰瘍或有并發(fā)癥史的DU，應(yīng)確立Hp是否根除。因GU有潛在惡變的危險(xiǎn)，原則上應(yīng)在治療后適當(dāng)時(shí)間作胃鏡和Hp復(fù)查。對(duì)經(jīng)過適當(dāng)治療仍有頑固消化不良癥狀的患者，亦應(yīng)確立Hp是否根除。</p><p> 　　(二)抑制胃酸分泌藥治療潰瘍的愈合特別是DU的愈合與抗酸治療強(qiáng)度和時(shí)間成正比。堿性抗酸藥(如氫氧化鋁、氫氧化鎂及其復(fù)方制劑)中和胃酸(兼有一定細(xì)胞保護(hù)作用)，對(duì)緩解樣疼痛癥狀有較好效果，但要促使?jié)冇蟿t需大劑量多次服用才能奏效。多次服藥的不便和長(zhǎng)期服用大劑量抗酸藥物可能帶來的不良反應(yīng)限制了其應(yīng)用。目前已很少單一應(yīng)用抗酸藥來治療潰瘍，可作為加強(qiáng)止痛的輔助治療。抗膽堿藥哌侖西平(哌吡氮平)和促胃液素受體拮抗劑丙谷胺治療潰瘍療效不夠理想，已很少用于治療潰瘍。目前臨床上常用的抑制胃酸分泌藥有H2RA和PPI兩大類。PPI作用于壁細(xì)胞胃酸分泌終末步驟中的關(guān)鍵酶--H+-K+-ATP酶生成時(shí)，壁細(xì)胞才恢復(fù)泌酸功能。因此PPI抑制胃酸分泌作用比H2RA更強(qiáng)，且作用持久。目前至少有四種PPI已用于臨床，分別為奧美拉唑、蘭索拉唑、潘托拉唑和拉貝拉唑。一般劑量為奧美拉唑20mg、蘭索拉唑30mg、潘托拉唑40mg和拉貝拉唑10mg，每天一次口服;根除Hp治療時(shí)劑量需加倍。</p><p> 　　(三)保護(hù)胃粘膜治療胃粘膜保護(hù)劑主要有三種，即硫糖鋁、枸櫞酸鉍鉀和前列腺素類藥物米索前列醇。這些藥物治療4-8周的潰瘍愈合率與H2RA相似。硫糖鋁抗?jié)冏饔玫臋C(jī)制主要與其粘附覆蓋作潰瘍面上阻止為散和胃蛋白酶繼續(xù)侵襲潰瘍面、促進(jìn)內(nèi)源性前列腺素合成和刺激表皮生長(zhǎng)因子分泌等有關(guān)。硫糖鋁不良反應(yīng)少，便秘是其主要不良反應(yīng)。枸櫞酸鉍鉀除了具有硫糖鋁類似的作用機(jī)制外，尚有較強(qiáng)的抗Hp作用。短期服用枸櫞酸鉍鉀除了舌苔發(fā)黑外，很少出現(xiàn)不良反應(yīng);為避免鉍在體內(nèi)過量積蓄，不宜連續(xù)長(zhǎng)期服用。米索前列醇具有抑制胃酸分泌、增加胃十二指腸粘膜粘液/碳酸氫鹽分泌和增加粘膜血流的作用。腹瀉是其主要不良反應(yīng)，因可引起子宮收縮，孕婦忌服。</p><p> 　　(四)NSAID潰瘍的治療和預(yù)防對(duì)NSAID相關(guān)性潰瘍，應(yīng)盡可能暫?；驕p少NSAID劑量，并檢測(cè)Hp感染和進(jìn)行根除治療。用PPI治療，GU或DU的愈合可能不受或較少受到繼續(xù)服用NSAID的影響，故當(dāng)未能中止NSAID治療時(shí)，應(yīng)選用PPI進(jìn)行治療。既往有消化性潰瘍病史或有嚴(yán)重疾病、高齡等因素對(duì)潰瘍及其并發(fā)不能承受者，可預(yù)防性地同時(shí)服用抗消化性潰瘍病藥。米索前列醇可預(yù)防NSAID誘發(fā)的GU和DU。PPI亦能起到預(yù)防作用，但標(biāo)準(zhǔn)劑量的H2RA則否。</p><p> 　　(五)潰瘍復(fù)發(fā)的預(yù)防Hp感染、服用NSAID、吸煙等是影響潰瘍復(fù)發(fā)的可除去的危險(xiǎn)因素，應(yīng)盡量除去;潰瘍復(fù)發(fā)頻繁時(shí)，不要忘記排除促胃液素瘤。由于極大多數(shù)消化性潰瘍是Hp相關(guān)性潰瘍，而Hp真正根除后，潰瘍的復(fù)發(fā)率可顯著降低，因此確定有無Hp感染非常重要。需要指出的是，Hp感染"根除"后，或初次檢測(cè)陰性者，仍有陽性可能。出現(xiàn)這種情況大多是由于檢測(cè)當(dāng)時(shí)未排除干擾因素，Hp暫時(shí)受到抑制而未能檢出，或由于檢測(cè)方面不夠可靠。Hp真正根除后成人的再感染率很低，約為每年1%-3%。在根除Hp治療中，由于耐藥菌株藥物不良反應(yīng)、患者依從性差等因素，在一個(gè)甚至兩個(gè)療程治療后仍有部分患者的Hp未能得到根除。有并發(fā)癥的潰瘍和難治性潰瘍?nèi)菀讖?fù)發(fā)，高齡或伴有嚴(yán)重疾病者對(duì)潰瘍及其并發(fā)癥不能承受，這些都是預(yù)防復(fù)發(fā)的重點(diǎn)對(duì)象。維持治療曾是預(yù)防潰瘍復(fù)發(fā)的主要措施，但與根除Hp治療相比，維持治療需沉淀服藥，停藥后潰瘍?nèi)詴?huì)復(fù)發(fā)，療效也不如前者，因此需對(duì)維持治療的地位作重新評(píng)價(jià)。由于存在Hp陰性潰瘍、根除Hp后仍有少部分潰瘍會(huì)復(fù)發(fā)、目前根除治療方案的療效尚難達(dá)到百分之百以及Hp根除后仍有一定再感染率等原因，維持治療仍有一定地位。實(shí)際上，根除Hp治療與維持治療互補(bǔ)，才能最有效地減少潰瘍復(fù)發(fā)和并發(fā)癥。維持治療一般多用H2RA體拮抗劑，常用方案為標(biāo)準(zhǔn)劑量半量睡前頓服，也可用奧美拉唑10mg/d或20mg每周2-3次口服進(jìn)行維持治療。維持治療的時(shí)間長(zhǎng)短，需根據(jù)具體情況決定，短者3-6個(gè)月，長(zhǎng)者1-2年，甚至更長(zhǎng)時(shí)間。</p><p> 　　三、消化性潰瘍治療的策略對(duì)胃鏡或X線檢查診斷明確的DU或GU，首先要區(qū)分Hp陽性還是陰性。如果陽性，則應(yīng)首先抗Hp治療，必要時(shí)在抗Hp治療結(jié)束后再給予2-4周抑制胃酸分泌治療。對(duì)Hp陰性的潰瘍包括NSAID相關(guān)性潰瘍，可按過去的常規(guī)治療，即服任何一種H2RA或PPI，DU療程為4-6周，GU為6-8周。也可用粘膜保護(hù)劑替代抑制胃酸分泌藥治療GU。至于是否進(jìn)行維持治療，應(yīng)根據(jù)潰瘍復(fù)發(fā)聘禮、患者年齡、服用NSAID、吸煙、合并其他嚴(yán)重疾病、潰瘍并發(fā)癥史等危險(xiǎn)因素的有無，綜合考慮后作出決定。至于外科治療，由于內(nèi)科治療的進(jìn)展，僅限少數(shù)有并發(fā)癥者。手術(shù)適應(yīng)證為：①大量出血經(jīng)內(nèi)科緊急處理無效時(shí);②急性穿孔;③瘢痕性幽門梗阻;④內(nèi)科治療無效的頑固性潰瘍;⑤胃潰瘍疑有癌變。<br/> 看過“潰瘍的治療方法”的人還看了：</p><p> 1.<a _href="http://www.yishupeixun.net/baikezhishi/1688591.html" href="http://www.yishupeixun.net/baikezhishi/1688591.html" target="_blank">什么是皮膚潰瘍</a></p><p> 2.<a _href="http://www.yishupeixun.net/zhishi/kexue/821796.html" href="http://www.yishupeixun.net/zhishi/kexue/821796.html" target="_blank">腸潰瘍形成的原因</a></p><p> 3.<a _href="http://www.yishupeixun.net/fangfa/zhiliao/984503.html" href="http://www.yishupeixun.net/fangfa/zhiliao/984503.html" target="_blank">徹底治療口腔潰瘍方法</a></p><p> 4.<a 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