Case #1 Answers:
Answer 1
Use
the beginning of this case to construct a problem list and be certain that the
students can construct a reasonable problem list without excessive splitting or
lumping. A reasonable differential diagnosis in this patient would include
GERD, PUD, gastritis, cholelithiasis, and pancreatitis. The history should lead
them to PUD and be thinking gastric ulcer. The weight loss, epigastric pain
aggravated by food should make the student think of gastric ulcer (possible
gastric cancer) rather than duodenal ulcer which should not have associated
weight loss and would be relieved with food.
Answer 2
The
procedure of choice after resuscitation is to perform UGI endoscopy (EGD).
Helicobacter should be looked for and the students should understand that
biopsy of the ulcer is essential since gastric ulcer carries with it a cancer
risk. Helicobacter can be evaluated by serology, but at endoscopy, a Clo-test
is performed which involves taking a biopsy of the antrum and embedding the
tissue in a gel (Clo-test) which test for the presence of urease. The tissue
can also be sent for biopsy and the pathologist will look for the organisms.
The Clo-test is the cheaper way to make the diagnosis. Patient on proton pump
inhibitors may have a false negative Clo-test.
Answer 3
Gastric ulcers have normo or hypo acid secretion. Other mechanism should
include pyloric incompetence with reflux of biliary and pancreatic secretions
onto gastric mucosa, gastric dysmotility with delayed gastric emptying. and
disruption of gastric mucosal resistance due to drugs and other host factors.
Gastric secretory testing is usually not done in GU and Du and should be
considered when the Zollinger-Ellison syndrome is suspected.
Answer 4 (and 5)
Treatment regimens range from antacids (archaic) to h-2 blockers and the
proton pump inhibitors. This can be explored as deeply as the expertise of the
students demands. The need to treat Helicobacter with one of the accepted
regimens should be addressed. Helicobacter should be looked for in all DU, GU,
and gastritis patients, especially if symptoms are chronic or recurrent.
Helicobacter becomes invasive and if not eradicated results in non-healing or
recurrence. A good regimen is triple therapy with omeprazole (20 mg BID),
metronidazole (250 mg TID), and clarithromycin (500 mg BID). This regimen
results in >95% eradication.
Answer 5
(and 4)
Treatment regimens range from antacids (archaic) to h-2 blockers and the proton
pump inhibitors. This can be explored as deeply as the expertise of the students
demands. The need to treat Helicobacter with one of the accepted regimens should
be addressed. Helicobacter should be looked for in all DU, GU, and gastritis
patients, especially if symptoms are chronic or recurrent. Helicobacter becomes
invasive and if not eradicated results in non-healing or recurrence. A good
regimen is triple therapy with omeprazole (20 mg BID), metronidazole (250 mg TID),
and clarithromycin (500 mg BID). This regimen results in >95% eradication.
Answer 6
The
complication that has occurred is GI bleeding. Students could quickly review GI
bleeding which was covered in another session if they wish. Complications such
as obstruction, perforation, and non-healing, cancer should be discussed since
these complications usually require surgical intervention.
Answer 7
Answer 8
Answer 9
Answer 10
Answer 11
Answer 12
Answer 13
Answer 14
Answer 15
Answer 16
Answer 17
Answer 18
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Answer 20
Answer 21
Answer 22
Answer 23