Transcript Clinical case discussion

Clinical case discussion
Zhi Hua Ran
Department of gastroenterology
Ren Ji Hospital
Questions
What are the common causes of upper
abdominal pain?
Answer
• Gastroesophageal reflux
• Biliary colic
• Functional dyspepsia
• Peptic ulcer (duodenal ulcer, gastric ulcer)
• Gastric cancer
• Irritable bowel syndrome
Questions
How to differentiate the common causes of
upper abdominal pain?
Answer --- the clinical features
• Gastroesophageal reflux
typically produces “heart burn”, or burning epigastric
or mid-chest pain after meals and worse with recumbency
• Biliary colic
caused by gallstones typically has an acute onset of
severe pain located in the right upper quadrant or
epigastrium
precipitated by meals, fatty foods in particular
lasts 30~60 min with spontaneous resolution
more common in women
Answer --- the clinical features
• Functional dyspepsia
can be associated with fullness, early satiety, bloating or
nausea
can be intermittent or continuous
may or may not be related to meals
symptom persisting at least 12 weeks
• Irritable bowel syndrome
is a diagnosis of exclusion
suggested by chronic dysmotility symptoms --- bloating,
cramping that is often relieved with defecation
without weight loss or bleeding
Answer --- the clinical features
• Peptic ulcer (duodenal ulcer, gastric ulcer)
DU: the classic symptoms of duodenal ulcers are caused by the
presence of acid without food or other buffers
symptoms are typically produced after the stomach is emptied
but food- stimulated acid production still persists, typically 2~5
h after a meal
pain wake patients at night, when circadian rhythms increase
acid production
it is typically relieved within minutes by neutralization of acid
by food or antacids
GU: are more variable in their presentation
food may actually worsen symptoms
pain might not be relieved by antacids
Answer --- the clinical features
• Gastric cancer
>45y
alarm symptoms: weight loss, recurrent vomiting,
dysphagia, bleeding, anemia
earlier satiety, pain
Answer --- Peptic Ulcer Disease
Summary:
A 37-year-old man presents complaining of chronic and
recurrent upper abdominal pain with characteristics
suggestive of duodenal ulcer: the pain is burning in quality,
occurs when the stomach is empty, and is relieved within
minutes by food or antacids. He doesn’t have evidence of
gastrointestinal bleeding or anemia. He does not take
nonsteroidal antiinflammatory drugs, which might cause
ulcer formation, but he does have serological evidence of H.
pylori infection.
Question
What are the roles of Helicobacter pylori
(H. pylori ) infection and how to diagnose
H. pylori infection?
Answer
H. pylori is associated with duodenal
and gastric ulcers, chronic active gastritis,
gastric adenocarcinoma, and gastric MALT
(mucosa-associated lymphoid tissue)
lymphoma.
Answer
• The diagnosis of H. pylori infection
Diagnostic methods for H. pylori infection are
categorized into two groups as:
Invasive
Noninvasive
Answer
• Noninvasive:
does not need endoscopic procedure
Urea breath test --- evidence of current active infection
convenient method
H. pylori antibody --- evidence of prior infection, will
remain positive for life
Stool antigen test
Answer
• Invasive: need endoscopic biopsy of gastric mucosal
sample
Pathology (using special staining: Giemsa staining, silver
staining, Gimenez staining, immunohistochemistry,
in addition to Hematoxylin-eosin staining)
Rapid urease test (RUT): H. pylori splits the urea in the test
container to yield ammonia. Elevation of the pH by ammonium
hydroxide produced in detected by a color change of the pH
indicator.
Advantage: inexpensive, ease to use, rapid diagnostic
methods
Disadvantage: require endoscopy, false-negative
Answer
• Invasive:
Microaerobic bacterial culture
Advantage: perfect specificity (100%), allowing
further characterization of the organisms (determining its
sensitivity to antibiotics)
Disadvantage: most difficult to use in clinical setting
Question
What is the most common cause of
duodenal and gastric ulcers?
Answer
H. pylori infection and use of NSAIDs are
the common causes of peptic ulcer
Question
What are the roles of Helicobacter pylori
infection in the etiology of peptic ulcer
disease?
Proposed natural history of H. pylori infection in human
Environmental
factors
Multifocal
Atrophic
Gastritis
Acute
Gastritis
Gastric Cancer
Gastric Ulcer80%~90%
lymphoma
Chronic Active Gastritis
Antral
Predominant
Gastritis
95%~100%
Duodenal Ulcer
lymphoma
Question
What are the roles of NSAIDs use in the
etiology of peptic ulcer disease?
Answer
• In endoscopic clinical research studies of patients who take
NSAIDs, 10~ 20% of patients in the first 3 months of NASID
use develop new gastric ulcers and 4% to 10% develop duodenal
ulcers.
• They promote ulcer formation by inhibiting gastroduodenal
prostaglandin synthesis, resulting in reduced secretion of mucus
and bicarbonate and decreased mucosal blood flow. In short,
they impair local defense against acid damage.
• The risk of ulcer formation caused by NASID use is dosedependent, and can occur within days after treatment is initiated.
Answer
• A rare cause of ulcer is the Zollinger – Ellison syndrome.
• It is the condition in which a gastrin-producing tumor (usually
pancreatic) causes acid hypersecretion, peptic ulceration, and
diarrhea.
• This condition should be suspected if ulcer disease occurs and the
patient is H.pylori negative and does not use NSAIDs.
• To diagnose this condition, serum gastrin levels should be measured
(>1000 pg/ml), and then try to localize the tumor with an imaging
study.
Question
What are the other clinical manifestations
of peptic ulcer disease?
Answer---complications
• Hemorrhage: is the most common severe complication of peptic
ulcer disease, and can present with hematemesis or melena.
• Free perforation into the abdominal cavity may occur, with a
sudden onset of pain and development of peritonitis
• Gastric outlet obstruction may develop in some patients with
chronic ulcers, with persist vomiting and weight loss
• Perforation and obstruction are indications for surgical intervention
Question
What is your next step?
Answer
Eradication of H.pylori
Question
Do you know any treatment regimen for
H.pylori eradication?
Answer
• PPI based triple therapy
omeprazole, lansoprazole, pantoprazole, rabeprazole
• Bismuth based triple therapy (colloidal bismuth subcitrate)
Metronidazole: 400 mg bid
Amoxicillin:
500 mg bid
Clarithromycin: 250 ~ 500 mg bid
Tetracycline: 500 ~1000mg bid
Furazolidone: 100 mg bid
• Ranitidine Bismuth Citrate (RBC)
7~14 days
Answer
• Antisecretory treatment:
lasts for 2~4 weeks
Comprehension questions (I)
A 42-year-old overweight, though otherwise healthy,
women presents with the sudden onset of right upper
abdominal colicky pain 45 minutes after a meal of fried
chicken. The pain is associated with nausea and vomiting,
and any attempt to eat since has caused increased pain.
The mostly cause is:
A: Gastric ulcer
B: Cholelithiasis
C: Duodenal ulcer
D: Acute hepatitis
Answer --- B
Right upper abdominal pain that has an acute onset after
the ingestion of a fatty meal and that is associated with
nausea and vomiting is most suggestive of biliary colic as a
result of gallstones.
Duodenal ulcer pain is likely to be determined with food,
and gastric ulcer pain is not likely to have the acute severe
onset.
Acute hepatitis is more likely to produce dull ache and
tenderness
Comprehension questions (II)
Which of the following is not true of H.pylori infection:
A. It is more common in developing counties
B. It is associated with the development of gastric
lymphoma
C. It is believed to be the cause of nonulcer dyspepsia
D. The route of transmission is believed to be fecal – oral
E. It is believed to be a cause of most duodenal and
gastric ulcer
Answer --- C
While H.pylori is clearly linked to gastric and duodenal
ulcers, and probably to gastric carcinoma and lymphoma,
it is unclear whether it is more common in patients with
nonulcer dyspepsia, or whether treatment in those patients
reduces symptoms.
Comprehension questions (III)
A 45-year-old male was brought to the emergency room
after vomiting bright red blood. He has a blood
pressure of 88/46 mmHg and heart rate of 120 bpm.
Which of the following is the best next step?
A.
B.
C.
D.
IV fluid resuscitation and preparation for a transfusion
Administration of a proton pump inhibitor
Guaiac test the stool
Treatment for H.pyroli
Answer --- A
This patient is hemodynamically unstable with
hypotension and tachycardia as a consequence of the
acute blood loss. Volume resuscitation, immediately
with crystalloid or colloid solution, followed by blood
transfusion, if necessary, is the initial step to prevent
irreversible shock and death. Later, after stabilization,
acid suppression and H.pylori treatment might be useful
to heal an ulcer, if one is present.
Comprehension questions (IV)
Which one of the following patients should be promptly
referred for endoscopy?
A. A 65-year-old man with a new onset of epigastric
pain and weight loss
B. A 32-year-old whose symptoms are not relieved with
ranitidine
C. A 29-year-old H. pylori- positive patient with
dyspeptic symptoms
D. A 49-year-old women with intermittent right upper
quadrant pain following meals
Answer --- A
Patient “A” has a red flag: he is older than 45 years of age with
new onset symptoms.
Patient “B” may benefit from the reassurance of a negative
endoscopic exam.
Patient “C” may benefit from treatment of the her H.pylori first.
Some studies indicate this approach may be cost-saving overall.
This patient could be sent for an endoscopic examination if she
doesn’t improve following therapy.