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  2 nd most common cause of cancer- related 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 H 2 -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