Clinical case talk

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Clinical case examination Zhi Hua Ran Department of gastroenterology Ren Ji Hospital

Questions What are the basic reasons for upper stomach torment?

Answer Gastroesophageal reflux Biliary colic Functional dyspepsia Peptic ulcer (duodenal ulcer, gastric ulcer) Gastric growth Irritable entrail disorder

Questions How to separate the basic reasons for upper stomach torment?

Answer - the clinical elements Gastroesophageal reflux regularly creates "heart consume", or consuming epigastric or mid-trunk torment after suppers and more terrible with supineness Biliary colic brought on by gallstones ordinarily has an intense onset of extreme torment situated in the correct upper quadrant or epigastrium encouraged by dinners, greasy nourishments specifically endures 30~60 min with unconstrained determination more typical in ladies

Answer - the clinical elements Functional dyspepsia can be related with totality, early satiety, bloating or sickness can be discontinuous or consistent could possibly be identified with suppers side effect holding on no less than 12 weeks Irritable inside disorder is a finding of prohibition proposed by interminable dysmotility manifestations - bloating, cramping that is frequently mitigated with poo without weight reduction or dying

Answer - the clinical elements Peptic ulcer (duodenal ulcer, gastric ulcer) DU: the exemplary side effects of duodenal ulcers are brought on by the nearness of corrosive without sustenance or different cushions indications are normally delivered after the stomach is purged however nourishment animated corrosive generation still perseveres, commonly 2~5 h after a feast torment wake patients around evening time, when circadian rhythms increment corrosive creation it is normally calmed inside minutes by balance of corrosive by nourishment or acid neutralizers GU: are more factor in their introduction nourishment may really intensify side effects torment won't not be soothed by stomach settling agents

Answer - the clinical components Gastric malignancy >45y alert side effects: weight reduction, intermittent retching, dysphagia, dying, pallor prior satiety, torment

Answer - Peptic Ulcer Disease Summary: A 37-year-old man presents whining of incessant and repetitive upper stomach torment with attributes suggestive of duodenal ulcer: the agony is copying in quality, happens when the stomach is void, and is eased inside minutes by nourishment or stomach settling agents. He doesn't have proof of gastrointestinal draining or paleness. He doesn't take nonsteroidal mitigating drugs, which may bring about ulcer development, yet he has serological proof of H. pylori disease.

Question What are the parts of Helicobacter pylori (H. pylori ) contamination and how to analyze H. pylori contamination?

Answer H. pylori is related with duodenal and gastric ulcers, incessant dynamic gastritis, gastric adenocarcinoma, and gastric MALT (mucosa-related lymphoid tissue) lymphoma.

Answer The finding of H. pylori disease Diagnostic strategies for H. pylori contamination are ordered into two gatherings as: Invasive Noninvasive

Answer Noninvasive: does not require endoscopic strategy Urea breath test - confirmation of current dynamic disease advantageous technique H. pylori neutralizer - proof of earlier contamination, will stay positive forever Stool antigen test

Answer Invasive: require endoscopic biopsy of gastric mucosal specimen Pathology (utilizing unique recoloring: Giemsa recoloring, silver recoloring, Gimenez recoloring, immunohistochemistry, notwithstanding Hematoxylin-eosin recoloring) Rapid urease test (RUT): H. pylori parts the urea in the test compartment to yield alkali. Rise of the pH by ammonium hydroxide delivered in distinguished by a shading change of the pH pointer. Advantage: economical, simplicity to utilize, fast symptomatic techniques Disadvantage: require endoscopy, false-negative

Answer Invasive: Microaerobic bacterial culture Advantage: idealize specificity (100%), permitting further portrayal of the life forms (deciding its affectability to anti-toxins) Disadvantage: most hard to use in clinical setting

Question What is the most widely recognized reason for duodenal and gastric ulcers?

Answer H. pylori contamination and utilization of NSAIDs are the regular reasons for peptic ulcer

Question What are the parts of Helicobacter pylori disease in the etiology of peptic ulcer illness?

Proposed regular history of H. pylori contamination in human Environmental variables Gastric Cancer 80%~90% Multifocal Atrophic Gastritis Gastric Ulcer lymphoma Acute Gastritis Chronic Active Gastritis 95%~100% Duodenal Ulcer Antral Predominant Gastritis lymphoma

Question What are the parts of NSAIDs use in the etiology of peptic ulcer ailment?

Answer In endoscopic clinical research investigations of patients who take NSAIDs, 10~ 20% of patients in the initial 3 months of NASID utilize grow new gastric ulcers and 4% to 10% create duodenal ulcers. They advance ulcer development by repressing gastroduodenal prostaglandin union, bringing about lessened emission of bodily fluid and bicarbonate and diminished mucosal blood stream. To put it plainly, they disable nearby safeguard against corrosive harm. The danger of ulcer arrangement created by NASID utilize is measurement subordinate, and can happen inside days after treatment is started.

Answer An uncommon reason for ulcer is the Zollinger – Ellison disorder. It is the condition in which a gastrin-creating tumor (generally pancreatic) causes corrosive hypersecretion, peptic ulceration, and the runs. This condition ought to be suspected if ulcer sickness happens and the patient is H.pylori negative and does not utilize NSAIDs. To analyze this condition, serum gastrin levels ought to be measured (>1000 pg/ml), and afterward attempt to confine the tumor with an imaging study.

Question What are the other clinical signs of peptic ulcer infection?

Answer - entanglements Hemorrhage: is the most widely recognized extreme intricacy of peptic ulcer sickness, and can give hematemesis or melena. Free aperture into the stomach hole may happen, with a sudden onset of agony and improvement of peritonitis Gastric outlet impediment may create in a few patients with perpetual ulcers, with hold on regurgitating and weight reduction Perforation and deterrent are signs for surgical intercession

Question What is your next stride?

Answer Eradication of H.pylori

Question Do you know any treatment regimen for H.pylori annihilation?

Answer PPI based triple treatment omeprazole, lansoprazole, pantoprazole, rabeprazole Bismuth based triple treatment (colloidal bismuth subcitrate) Metronidazole: 400 mg offer Amoxicillin: 500 mg offer Clarithromycin: 250 ~ 500 mg offer Tetracycline: 500 ~1000mg offer Furazolidone: 100 mg offer Ranitidine Bismuth Citrate (RBC) 7~14 days

Answer Antisecretory treatment: goes on for 2~4 weeks

Comprehension questions (I) A 42-year-old overweight, however generally solid, ladies presents with the sudden onset of right upper stomach colicky torment 45 minutes after a supper of browned chicken. The torment is related with queasiness and regurgitating, and any endeavor to eat since has brought about expanded agony. The generally cause is: A: Gastric ulcer B: Cholelithiasis C: Duodenal ulcer D: Acute hepatitis

Answer - B Right upper stomach torment that has an intense onset after the ingestion of a greasy dinner and that is related with sickness and spewing is most suggestive of biliary colic accordingly of gallstones. Duodenal ulcer torment is probably going to be resolved with nourishment, and gastric ulcer agony is not liable to have the intense serious onset. Intense hepatitis will probably create dull throb and delicacy

Comprehension questions (II) Which of the accompanying is not valid for H.pylori disease: A. It is more typical in creating provinces It is related with the improvement of gastric lymphoma It is accepted to be the reason for nonulcer dyspepsia The course of transmission is accepted to be fecal – oral It is accepted to be a reason for most duodenal and gastric ulcer

Answer - C While H.pylori is plainly connected to gastric and duodenal ulcers, and presumably to gastric carcinoma and lymphoma, it is misty whether it is more typical in patients with nonulcer dyspepsia, or whether treatment in those patients decreases indications.

Comprehension questions (III) A 45-year-old male was conveyed to the crisis room subsequent to regurgitating splendid red blood. He has a circulatory strain of 88/46 mmHg and heart rate of 120 bpm. Which of the accompanying is the best next stride? IV liquid revival and readiness for a transfusion Administration of a proton pump inhibitor Guaiac test the stool Treatment for H.pyroli

Answer - A This patient is hemodynamically precarious with hypotension and tachycardia as a result of the intense blood misfortune. Volume revival, promptly with crystalloid or colloid arrangement, trailed by blood transfusion, if important, is the underlying stride to forestall irreversible stun and passing. Afterward, after adjustment, corrosive concealment and H.pylori treatment may be valuable to mend a ulcer, in the event that one is available.

Comprehension questions (IV) Which one of the accompanying patients ought to be expeditiously alluded for endoscopy? A 65-year-old man with another onset of epigastric agony and weight reduction A 3