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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 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 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 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% 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 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