Transcript Diagnostic Workup

Daguman, Emmanuel II
Dadgardoust, Persia
Case 2
45 y/o
 male
 c/c: severe abdominal pain

HPI
3 yrs PTA – crampy, epigastric pain
Relieved by food intake or antacids
Later accompanied by melena → UGI endoscopy
Diagnosis: erosive gastritis
Unrecalled medications - irregular
1 yr PTA, same symptoms
Self medicated with Omeprazole
Few hrs PTA, severe epigastric pain

Review of Systems
 (-) weight loss, (-) dizziness, (-) chest pain

Personal History
 10 pack years smoking, drinks alcoholic beverage
for 8 years

Past Medical History
 (-) HPN, DM

Family History
 (-) Cancer
Physical Examination
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Conscious, coherent, in distress
BP = 140/90 mmHg
PR = 105/min
RR = 26/min
T = 37.8˚C
Warm moist skin, no active dermatoses
Pink palpebral conjunctivae, anicteric sclerae
Physical Examination
Heart and lungs: regular rate and rhythm, clear
breath sounds
 Abdomen: flat, hypoactive bowel sounds, (+)
guarding and tenderness on all quadrants
 DRE: brown stool on tactating fingers

Salient Features
Sudden severe epigastric pain
 History of erosive gastritis
 (+) guarding and tenderness on all quadrants

Differentials
Perforated Peptic ulcer disease
 Gastritis
 Gastric carcinoma

Peptic ulcer disease
Mucosal breaks that extend into
submucosa or beyond
 H. pylori, NSAIDs, acid, pepsin
 Can be aggravated by alcohol and
smoking
 Symptoms: epigastric pain, nausea and
vomiting,
dyspepsia,
hematemesis,
melena

Gastritis
Can be acute or chronic
 Acute: usually infectious
 Chronic: long-term exposure to noxious
substances
 H. pylori seen in both
 Symptoms: epigastric pain, nausea and
vomiting, dependent on etiology

Gastric carcinoma
2nd most common cause of cancerrelated deaths
 Often diagnosed late
 Multiple etiologies
 Symptoms: Abdominal pain, weight loss
 PE usually normal

Perforation secondary to
Peptic Ulcer Disease
Diagnostic workup
All patients over 45 with dyspepsia and/or epigastric pain should
have an upper endoscopy, and all patients, regardless of age,
should have this study if any alarm symptoms are present
Alarm Symptoms That Indicate the Need for
Esophagogastroduodenoscopy
Weight loss
Recurrent vomiting
Dysphagia
Bleeding
Anemia
Upright chest x-ray shows free air in
about 80% of patients
* Presence of air in the diaphragm
Other tests

ulcers should be adequately biopsied,
and any sites of gastritis should be
biopsied to rule out H. pylori, and for
histologic evaluation

a baseline serum gastrin level is
appropriate to rule out gastrinoma.
Medical Treatment
Surgical Treatment
Medical Treatment
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Smoking cessation and avoidance of alcohol
and NSAIDs (including aspirin).
(-) H. pylori testing  the ulcer patient may be
treated with H2-receptor blockers or proton
pump inhibitors (Sucralfate or misoprostol may
also be effective)
If ulcer symptoms persist  empiric trial of
anti-H. pylori therapy (false-negative H. pylori
tests are common)
Antisecretory therapy stopped after 3 months if
the ulcerogenic stimulus (usually H. pylori,
NSAIDs, or aspirin) has been removed
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Long-term maintenance therapy for peptic
ulcer in all patients admitted to hospital with an
ulcer complication, all high-risk patients on
NSAIDs or aspirin (the elderly or debilitated),
refractory smokers and all patients with a
history of recurrent ulcer or bleeding.
Misoprostol, sulcralfate, and acid suppression
may be quite comparable in many of these
groups, but misoprostol may cause diarrhea
and cramps, and cannot be used in women of
childbearing age because of its abortifacient
properties
Treatment Regimens for Helicobacter pylori Infections
Bismuth triple therapy
Bismuth, 2 tablets four times daily plus
Metronidazole, 250 mg three times daily plus
Tetracycline, 500 mg four times daily
PPI triple therapy
PPI twice daily plus
Amoxicillin, 1000 mg two times daily plus
Clarithromycin, 500 mg two times daily or
Metronidazole, 500 mg two times daily
Quadruple therapy
PPI twice daily plus
Bismuth, 2 tablets four times daily plus
Metronidazole, 250 mg three times daily plus
Tetracycline, 500 mg four times daily
NOTE: Treatment for 10–14 days is recommended.
PPI = proton pump inhibitor.
Surgical Treatment
Indications for surgery in peptic ulcer
disease: bleeding, perforation,
obstruction, and intractability or
nonhealing
 Vast majority of peptic ulcers are
adequately treated by a variant of one of
the three basic operations: highly
selective vagotomy, vagotomy and
drainage, and vagotomy and distal
gastrectomy

Highly Selective Vagotomy
AKA parietal cell vagotomy or proximal
gastric vagotomy, is safe (mortality risk
<0.5%) and causes minimal side effects
 Severs the vagal nerve supply to the
proximal two thirds of the stomach, where
essentially all the parietal cells are located
 HSV decreases total gastric acid secretion
by about 65 to 75%
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Vagotomy and Drainage
Can be performed safely and quickly by
the experienced surgeon
 Main disadvantages are the side effect
profile (10% of patients have significant
dumping and/or diarrhea), and a 10%
recurrent ulcer rate
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Vagotomy and Antrectomy
extremely low ulcer recurrence rate and
the applicability of the operation to many
patients with complicated peptic ulcer
disease (e.g., bleeding duodenal and
gastric ulcer, obstructing peptic ulcer,
nonhealing gastric ulcer, and recurrent
ulcer)
 disadvantage of V+A is the somewhat
higher operative mortality rate when
compared with HSV or V+D

Complications
bleeding
 perforation
 obstruction
