🫀 Interná medicína · 11

Peptický vred

Definícia

• Peptický vred je defekt sliznice tráviacej rúry – typicky žalúdka (ulcus ventriculi) alebo prvých centimetrov dvanástnika (ulcus duodeni) – ktorý preniká cez lamina muscularis mucosae; erózie sú povrchnejšie a muscularis mucosae nezasahujú. Vzniká pri nerovnováhe medzi ochrannými a agresívnymi faktormi žalúdočnej sliznice.

Etiológia a patogenéza

• Takmer všetky vredy spôsobuje infekcia Helicobacter pylori alebo užívanie nesteroidových antiflogistík (NSAID); oba faktory narúšajú obranu a reparáciu sliznice a zvyšujú jej citlivosť na kyselinu.
• NSAID inhibíciou COX-1 blokujú syntézu prostaglandínov, čím znižujú tvorbu hlienu a bikarbonátu aj prekrvenie sliznice.
• Ďalšie lieky spojené so vznikom vredu sú napr. kortikosteroidy, bisfosfonáty, chlorid draselný a fluorouracil.
• Fajčenie zvyšuje riziko vzniku vredu a jeho komplikácií, zhoršuje hojenie a zvyšuje výskyt recidív; hypersekrécia gastrínu pri gastrinóme (Zollingerov-Ellisonov syndróm) je zriedkavá.

Klinický obraz

• Najčastejšia je pálivá alebo hlodavá bolesť v epigastriu, často zmiernená jedlom alebo antacidami; priebeh býva chronický a recidivujúci. Mnohí pacienti, najmä starší, majú málo príznakov alebo žiadne.
• Duodenálny vred: bolesť chýba po prebudení, objaví sa dopoludnia, jedlo ju zmierni, ale vracia sa 2–3 hodiny po jedle; nočná bolesť budiaca zo spánku je častá a silne svedčí pre duodenálny vred.
• Žalúdočný vred: príznaky často nemajú konzistentný vzorec (jedlo bolesť niekedy zhoršuje); bolesť sa môže zhoršiť 15–30 minút po jedle a viesť k chudnutiu.
• Alarmujúce príznaky vyžadujúce urgentné odoslanie: nechcené chudnutie, progresívna dysfágia, zjavné krvácanie do GIT, sideropenická anémia, opakované vracanie, malignita horného GIT v rodine.

Diagnostika

• Diagnózu potvrdzuje endoskopia (ezofagogastroduodenoskopia); pri alarmujúcich príznakoch je indikovaná bez ohľadu na vek.
• Pri žalúdočnom vrede biopsia alebo cytologická kefka na odlíšenie ulcerovaného karcinómu; duodenálne lézie sa pre extrémne nízky výskyt malignity bežne nebiopsujú.
• Pri zistení vredu treba vyšetriť infekciu H. pylori: neinvazívne dychovým ureázovým testom alebo antigénom v stolici; ak sa robí endoskopia, z biopsie rýchlym ureázovým testom alebo histologicky.
• Sérový gastrín pri podozrení na gastrinóm: mnohopočetné vredy, atypická lokalizácia (napr. postbulbárne), refraktérnosť na liečbu, výrazná hnačka alebo chudnutie.

Liečba

• Liečba vredu žalúdka aj dvanástnika vyžaduje eradikáciu H. pylori (ak je prítomný) a zníženie žalúdočnej acidity – na supresiu kyseliny sa používajú najmä inhibítory protónovej pumpy; pri duodenálnom vrede je dôležité potlačiť nočnú sekréciu kyseliny.
• Eradikácia H. pylori: pri rezistencii na klaritromycín > 15 % alebo neznámej rezistencii je iniciálnou liečbou kvadruplová liečba (odporúčaná európskymi aj ACG odporúčaniami); ACG 2024 u doteraz neliečených pacientov odporúča 14-dňovú optimalizovanú bizmutovú kvadruplovú liečbu (IPP + bizmut + tetracyklín + metronidazol).
• Eradikáciu treba overiť (ACG 2024: u všetkých pacientov) dychovým testom, antigénom v stolici alebo endoskopicky, najskôr 4 týždne po skončení liečby.
• Pri vrede z NSAID vysadiť NSAID alebo znížiť dávku; pacient, ktorý po prekonanom vrede potrebuje NSAID, je kandidátom na dlhodobú antisekrečnú liečbu. Fajčenie treba ukončiť.

Komplikácie a prognóza

• Krvácanie (ľahké až ťažké) je najčastejšou komplikáciou – hemateméza, hematochézia alebo meléna, slabosť, ortostáza, synkopa.
• Voľná perforácia: náhla intenzívna trvalá bolesť v epigastriu rýchlo sa šíriaca po bruchu, doskovito stuhnuté brušné svalstvo; diagnózu potvrdí voľný vzduch pod bránicou alebo v peritoneálnej dutine na RTG či CT; nutná je okamžitá operácia.
• Penetrácia do susedného orgánu (napr. zadný duodenálny vred do pankreasu s bolesťou vyžarujúcou do chrbta) alebo obštrukcia výtoku žalúdka (opakované objemné vracanie, strata chuti do jedla, pocit plnosti po jedle).
• Karcinóm žalúdka – pri vredoch spojených s H. pylori 3- až 6-násobne vyššie riziko; pri vredoch inej etiológie riziko rakoviny zvýšené nie je.

Kľúčové pojmy

peptický vred	ulcus pepticum
vred žalúdka	ulcus ventriculi
vred dvanástnika	ulcus duodeni
Helicobacter pylori	Helicobacter pylori
inhibítory protónovej pumpy
eradikácia	eradicatio
perforácia	perforatio
hemateméza	haematemesis
meléna	melaena
stenóza pyloru	stenosis pylori

📎 Zdroje:

Peptic Ulcer Disease - MSD Manual Professional Edition (definícia)A peptic ulcer is an erosion in a segment of the gastrointestinal mucosa, typically in the stomach (gastric ulcer) or the first few centimeters of the duodenum (duodenal ulcer), that penetrates through the muscularis mucosae.
Peptic Ulcer Disease - MSD Manual Professional Edition (definícia)Ulcers are delineated from erosions by the depth of penetration; erosions are more superficial and do not involve the muscularis mucosae.
Peptic Ulcer Disease - StatPearls - NCBI Bookshelf (definícia)The peptic ulcer disease (PUD) mechanism results from an imbalance between gastric mucosal protective and destructive factors.
Peptic Ulcer Disease - MSD Manual Professional Edition (etiology[0])Nearly all ulcers are caused by Helicobacter pylori infection or nonsteroidal anti-inflammatory drug (NSAID) use.
Peptic Ulcer Disease - MSD Manual Professional Edition (etiology[0])H. pylori and nonsteroidal anti-inflammatory drugs (NSAIDs) disrupt normal mucosal defense and repair, making the mucosa more susceptible to acid.
Peptic Ulcer Disease - StatPearls - NCBI Bookshelf (etiology[1])NSAIDs block prostaglandin synthesis by inhibiting the COX-1 enzyme, resulting in decreased gastric mucus and bicarbonate production and a decrease in mucosal blood flow.
Peptic Ulcer Disease - StatPearls - NCBI Bookshelf (etiology[2])Apart from NSAIDs, corticosteroids, bisphosphonates, potassium chloride, and fluorouracil have been implicated in the etiology of PUD.
Peptic Ulcer Disease - MSD Manual Professional Edition (etiology[3])Cigarette smoking is a risk factor for the development of ulcers and their complications
Peptic Ulcer Disease - MSD Manual Professional Edition (etiology[3])Also, smoking impairs ulcer healing and increases the incidence of recurrence.
Peptic Ulcer Disease - MSD Manual Professional Edition (etiology[3])Very few patients have hypersecretion of gastrin caused by a gastrinoma (Zollinger-Ellison syndrome).
Peptic Ulcer Disease - MSD Manual Professional Edition (clinical[0])many patients, particularly older patients, have few or no symptoms. Pain is most common, often localized to the epigastrium and relieved by food or antacids. The pain is described as burning or gnawing, or sometimes as a sensation of hunger. The course is usually chronic and recurrent.
Peptic Ulcer Disease - MSD Manual Professional Edition (clinical[1])Pain is absent when the patient awakens but appears mid-morning and is relieved by food but recurs 2 to 3 hours after a meal. Pain that awakens a patient at night is common and is highly suggestive of duodenal ulcer.
Peptic Ulcer Disease - MSD Manual Professional Edition (clinical[2])Gastric ulcer symptoms often do not follow a consistent pattern (eg, eating sometimes exacerbates rather than relieves pain).
Peptic Ulcer Disease - StatPearls - NCBI Bookshelf (clinical[2])The pain of gastric ulcers increases 15 to 30 minutes after a meal and may result in weight loss
Peptic Ulcer Disease - StatPearls - NCBI Bookshelf (clinical[3])Warning symptoms or alarm symptoms that should prompt urgent referral include:[6] Unintentional weight loss Progressive dysphagia Overt gastrointestinal bleeding Iron deficiency anemia Recurrent emesis Family history of upper gastrointestinal malignancy
Peptic Ulcer Disease - MSD Manual Professional Edition (diagnostics[0])Diagnosis of peptic ulcer is suggested by patient history and confirmed by endoscopy.
Peptic Ulcer Disease - StatPearls - NCBI Bookshelf (diagnostics[0])Anyone with the presence of alarm symptoms should undergo EGD, irrespective of age.
Peptic Ulcer Disease - MSD Manual Professional Edition (diagnostics[1])endoscopy allows for biopsy or cytologic brushing of gastric and esophageal lesions to distinguish between simple ulceration and ulcerating stomach cancer.
Peptic Ulcer Disease - MSD Manual Professional Edition (diagnostics[1])The incidence of malignant duodenal ulcer is extremely low, so biopsies of duodenal lesions are generally not warranted.
Peptic Ulcer Disease - MSD Manual Professional Edition (diagnostics[2])Endoscopy can also be used to definitively diagnose H. pylori infection, which should be sought when an ulcer is detected
Helicobacter pylori Infection - MSD Manual Professional Edition (diagnostics[2])Make initial diagnosis with a urea breath test or stool antigen assay; if endoscopy is being done for other reasons, analyze biopsy samples using a rapid urease test or histologic staining.
Peptic Ulcer Disease - MSD Manual Professional Edition (diagnostics[3])Gastrin-secreting cancer and gastrinoma should be considered when there are multiple ulcers, when ulcers develop in atypical locations (eg, postbulbar) or are refractory to treatment, or when the patient has prominent diarrhea or weight loss.
Peptic Ulcer Disease - MSD Manual Professional Edition (diagnostics[3])Serum gastrin levels should be measured in these patients.
Peptic Ulcer Disease - MSD Manual Professional Edition (treatment[0])Treatment of gastric and duodenal ulcers requires eradication of H. pylori when present and a reduction of gastric acidity
Peptic Ulcer Disease - MSD Manual Professional Edition (treatment[0])For duodenal ulcers, it is particularly important to suppress nocturnal acid secretion.
Peptic Ulcer Disease - StatPearls - NCBI Bookshelf (treatment[0])PPIs have largely replaced H2 receptor blockers due to their superior healing and efficacy.
Helicobacter pylori Infection - MSD Manual Professional Edition (treatment[1])Quadruple therapy is the best initial therapy in areas where the clarithromycin resistance rate is > 15% or in patients in whom microbial resistance data are not available and is recommended in both the European guidelines (4) and in the ACG guidelines (1).
ACG Guideline on Treatment of Helicobacter pylori (Evidence-Based GI, ACG 2024 summary, PDF) (treatment[1])Optimized bismuth-based quadruple therapy (BQT) for 14-days is the recommended therapy for treatment-naïve patients
ACG Guideline on Treatment of Helicobacter pylori (Evidence-Based GI, ACG 2024 summary, PDF) (treatment[1])Optimized BQT consists of PPI twice daily, tetracyclince 500 mg 4 times daily, metronidazole 500 mg 3 or 4 times daily, and bismuth subcitrate or bismuth subsalicylate 4 times daily for 14 days.
ACG Guideline on Treatment of Helicobacter pylori (Evidence-Based GI, ACG 2024 summary, PDF) (treatment[2])proof of H. pylori eradication is required in all patients after treatment by obtaining a fecal antigen test, urea breath testing, or gastric biopsy.
Helicobacter pylori Infection - MSD Manual Professional Edition (treatment[2])Eradication may be confirmed by a urea breath test, stool antigen test (9), or upper endoscopy done ≥ 4 weeks after completion of therapy.
Peptic Ulcer Disease - StatPearls - NCBI Bookshelf (treatment[3])NSAIDs induced PUD can be treated by stopping the use of NSAIDs or switching to a lower dose.
Peptic Ulcer Disease - MSD Manual Professional Edition (treatment[3])However, patients who require NSAIDs after having had a peptic ulcer are candidates for long-term therapy
Peptic Ulcer Disease - MSD Manual Professional Edition (treatment[3])Smoking should be stopped
Peptic Ulcer Disease - MSD Manual Professional Edition (complications[0])Mild to severe gastrointestinal hemorrhage is the most common complication of peptic ulcer disease.
Peptic Ulcer Disease - MSD Manual Professional Edition (complications[0])Symptoms include hematemesis (vomiting of fresh blood or coffee-ground material), passage of bloody stools (hematochezia) or black tarry stools (melena), and weakness, orthostasis, syncope, thirst, and sweating caused by blood loss.
Peptic Ulcer Disease - MSD Manual Professional Edition (complications[1])There is sudden, intense, continuous epigastric pain that spreads rapidly throughout the abdomen
Peptic Ulcer Disease - MSD Manual Professional Edition (complications[1])abdominal muscles are rigid (boardlike)
Peptic Ulcer Disease - MSD Manual Professional Edition (complications[1])Diagnosis of a free perforation is confirmed if a radiograph or CT scan shows free air under the diaphragm or in the peritoneal cavity.
Peptic Ulcer Disease - MSD Manual Professional Edition (complications[1])Immediate surgery is required.
Peptic Ulcer Disease - MSD Manual Professional Edition (complications[2])The ulcer may penetrate into the adjacent confined space (lesser sac) or another organ (eg, pancreas, liver).
Peptic Ulcer Disease - MSD Manual Professional Edition (complications[2])usually the back when caused by penetration of a posterior duodenal ulcer into the pancreas
Peptic Ulcer Disease - MSD Manual Professional Edition (complications[2])Symptoms include recurrent, large-volume vomiting, occurring more frequently at the end of the day and often as late as 6 hours after the last meal. Loss of appetite with persistent bloating or fullness after eating also suggests gastric outlet obstruction.
Peptic Ulcer Disease - MSD Manual Professional Edition (complications[3])Patients with H. pylori–associated ulcers have a 3- to 6-fold increased risk of gastric cancer later in life.
Peptic Ulcer Disease - MSD Manual Professional Edition (complications[3])There is no increased risk of cancer with ulcers of other etiology.

Precvičiť tému (6)

Kartičky

Vymenujte alarmujúce príznaky u pacienta s dyspepsiou/podozrením na peptický vred, ktoré vyžadujú urgentné odoslanie na endoskopiu.

Najprv si odpoveď povedz nahlas alebo v duchu – až potom ju odkry.

Vymenujte komplikácie peptického vredu.

Najprv si odpoveď povedz nahlas alebo v duchu – až potom ju odkry.

Kedy treba pri peptickom vrede myslieť na gastrinóm (Zollingerov-Ellisonov syndróm) a aké vyšetrenie indikujete?

Najprv si odpoveď povedz nahlas alebo v duchu – až potom ju odkry.