1、Clinical case discussionZhi Hua RanDepartment of gastroenterologyRen 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
2、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 p
3、ain located in the right upper quadrant or epigastrium precipitated by meals,fatty foods in particular lasts 3060 min with spontaneous resolution more common in women Functional dyspepsia can be associated with fullness,early satiety,bloating or nausea can be intermittent or continuous may or may no
4、t 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,
5、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 25 h after a meal pain wake patients at night,when circa
6、dian 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 antacidsAnswer-the clinical features Gastric cancer 45y alarm symptom
7、s:weight loss,recurrent vomiting,dysphagia,bleeding,anemia earlier satiety,pain Answer-the clinical features 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 s
8、tomach is empty,and is relieved within minutes by food or antacids.He doesnt 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.Answer-Peptic Ulcer Dis
9、easeQuestion 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 diagn
10、osis 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,wi
11、ll remain positive for life Stool antigen testAnswer 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 u
12、rea 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-negativeAnswer Invasive:Microaerobic bacterial culture Advan
13、tage:perfect specificity(100%),allowing further characterization of the organisms(determining its sensitivity to antibiotics)Disadvantage:most difficult to use in clinical settingQuestion What is the most common cause of duodenal and gastric ulcers?Answer H.pylori infection and use of NSAIDs are the
14、 common causes of peptic ulcerQuestion What are the roles of Helicobacter pylori infection in the etiology of peptic ulcer disease?Proposed natural history of H.pylori infection in human Chronic Active Gastritis Acute Gastritis AntralPredominant GastritisDuodenal UlcerlymphomaEnvironmental factorsMu
15、ltifocal Atrophic GastritisGastric CancerGastric Ulcerlymphoma95%100%80%90%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 gas
16、tric 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 formatio
17、n caused by NASID use is dose-dependent,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 condi
18、tion 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
19、 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 m
20、ay develop in some patients with chronic ulcers,with persist vomiting and weight loss Perforation and obstruction are indications for surgical interventionQuestion What is your next step?Answer Eradication of H.pyloriQuestion Do you know any treatment regimen for H.pylori eradication?Answer PPI base
21、d 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)714 daysAnswer
22、Antisecretory treatment:lasts for 24 weeksComprehension 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
23、 eat since has caused increased pain.The mostly cause is:A:Gastric ulcerB:CholelithiasisC:Duodenal ulcerD:Acute hepatitisAnswer-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
24、 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 tendernessComprehension questions(II)Which of the following is not true of H.pylori infectio
25、n:A.It is more common in developing countiesIt is associated with the development of gastric lymphomaIt is believed to be the cause of nonulcer dyspepsiaThe route of transmission is believed to be fecal oralIt is believed to be a cause of most duodenal and gastric ulcerAnswer-C While H.pylori is cle
26、arly linked to gastric and duodenalulcers,and probably to gastric carcinoma and lymphoma,it is unclear whether it is more common in patients withnonulcer dyspepsia,or whether treatment in those patients reduces symptoms.Comprehension questions(III)A 45-year-old male was brought to the emergency room
27、 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?IV fluid resuscitation and preparation for a transfusionAdministration of a proton pump inhibitorGuaiac test the stoolTreatment for H.pyroliAnswer-A This pati
28、ent 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 stabiliza
29、tion,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 65-year-old man with a new onset of epigastric pain and weight lossA 32-year-old whose symptoms a
30、re not relieved with ranitidineA 29-year-old H.pylori-positive patient with dyspeptic symptomsA 49-year-old women with intermittent right upper quadrant pain following mealsAnswer-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 reass
31、urance 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 doesnt improve following therapy.docin/sanshengshiyuandoc88/sanshenglu 更多精品资源请访问更多精品资源请访问
