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
 

 

 

 

 

 

 

 

Answer 19

 

 

 

 

 

 

 

 

 

 

 

Answer 20
 

 

 

 

 

 

 

 

 

 

 

Answer 21
 

 

 

 

 

 

 

 

 

 

 

Answer 22
 

 

 

 

 

 

 

 

 

 

 

 

Answer 23