1. 10조
Case Presentation
10조 이현경

2. 백O기 71/M Chief complaints Hematemesis, 2회 Melena Onset : 6.17
Vector : spontaneous (최근 음주량 증가)

3. Present illness 상기 71세 남자환자는 6월 17일 오후에 발생한
Hematemesis, melena 주소로 ER 내원하여
시행한 GFS 상 Dieulafoy’s Ulcer 소견보여
Hemoclipping 시행 후 입원함

4. Past History ‘95 gastric ulcer Dx & Tx
No known DM,HTN, pul Tb, hepatitis

5. Personal history Family history Smoking (-)
Alcohol (+), 소주 1병/회, 주 3~4회
Allergy (-)
Family history
Non-specific

6. Review of system Fever/ Chills/Weight loss (ㅡ /ㅡ/ ㅡ)
Cough/Coryza/Sputum (ㅡ/ㅡ/ ㅡ)
Anorexia/Nausea/ Vomiting /Constipation/ Diarrhea (ㅡ/ㅡ/ㅡ/ㅡ/ㅡ)

7. Vital sign

8. Physical Examination General Appearance Head/Neck Chest
Relatively well appearance
 Head/Neck
No anemic conjunctiva
Anicteric sclera
 Chest
Regular heart beat without murmur
Clear breathing sound without rale

9. Abdomen Extremities Soft & Flat Usual bowel sound No DT & RT
No pretibial pitting edema

10. Lab - CBC

12. Lab - Chemistry

13. CXR
FINDING
- Rt lower lung에 2.2cm 크기의 nodular lesion이 calcification과 함께 보임 - Enhancement는 미약함
CONCLUSION
Tuberculoma R/O Hamartoma

14. Abdomen
FINDING
Normal range of bowel gas patterns. No abnormal calcific density.
CONCLUSION
Nonspecific findings

15. GFS(6/18) [Esophagus] Non-specific [Stomach]
Deep ulcerative lesion with basal exposed vessel was noted at the pylorus.-hemoclipping done (*2)
[Duodenum]
Circular opening with outpouching of the mucosa at the 2nd portion

16. Impression Acute gastric ulcer with exposed vessel
Anemia due to gastric ulcer bleeding

17. Plan
Diagnostic plan
GFS F/U
CBC F/U

18. Therapeutic plan GI bleeding
Volume replacement(crystalloid solution or plasma expander)
Transfusion(Packed RBC, peniramine, albumin)
NPO
Ulcer : IV PPI therapy + endoscopic therapy
Pantoloc, Macool(metoclopromide)

19. Radiology
폴리클 10조 44번
민현준

20. 6/20 (HD #2) S O A P General weakness WBC: 4740 Hb: 9.4 PLT: 108000
Upper gastroendoscopy A
Acute gastric ulcer with exposed vessel P
Ulcermin(sucralfate): 항pepsin제
Dulanta(Boehmite), Lamina G sol(sodium Alginate): GU & DU
Upper gastroendoscopy F/U
CBC F/U
Sip's diet start , liquid 증량

21. Upper Gastroendoscopy (6/20)
Known dieulafoy ulcer with bleeding at p-ring LC side
-previous two hemoclip state
-near completed healing state
Reflux esophagitis
Acute erosive gastritis

22. 6/22 (HD #4) S O A P Melena(+), hematemesis(-) WBC: 7500 Hb: 9.0
PLT:
F/U GFS due to bleeding A
Known dieulafoy ulcer c bleeding
Reflux esophagitis, acute erosive gastritis P
NPO, PPI Tx
CBC F/U
PRC transfusion

23. Endoscopic Hemostasis (6/22)
Large exposed vessel without difinite ulceration was noted at upper portion of pyloric ring- hemoclipping
Dieulafoy ulcer

24. 6/23 (HD #5) O A P WBC: 4200 Hb: 9.4 PLT: 158000
Known dieulafoy ulcer c bleeding, near complete healing stage
Reflux esophagitis, acute erosive gastritis P
CBC F/U

25. 6/25 (HD #7) O A P WBC: 5080 Hb: 9.6 PLT: 230000
Upper Gastrointestinal endoscopy A
Known dieulafoy ulcer c bleeding, near complete healing stage
Reflux esophagitis, acute erosive gastritis P
CBC F/U
Diet start

26. Upper gastrointestinal endoscopy (6/25)
Just below pyloric channel-linear ulcer was noted.
Pyloric channel- two hemoclips without bleeding
Duodenal ulcer
P-channel ulcer

27. 6/26 (HD #8) S O A P Melena (+), hematemesis (-) WBC: 5700 Hb: 8.2
PLT:
GFS시행
Angiography, TAE A
Known dieulafoy ulcer c bleeding, near complete healing stage
Duodenal Ulcer, P-channel ulcer
Reflux esophagitis, acute erosive gastritis P
High dose PPI
PRC transfusion
CBC F/U
NPO

28. Upper gastrointestinal endoscopy (6/26)
Duodenum bulb에서 active한 arterial ejection관찰
UGI bleeding due to Duodenal ulcer with exposed vessel
Angiographic embolization recommended

29. Transarterial Embolization (6/26)
Retroduodenal A’ br’에서 bleeding focus가 보여 microcatheter를 이용하여 superselection 한 후 emblization함.
Successful TAE due to GI bleeding

30. 6/28 (HD #10) S O A P Melena (+), hematemesis (-) WBC: 4540 Hb: 12.2
PLT: A
Known dieulafoy ulcer c bleeding, near complete healing stage
Duodenal Ulcer, P-channel ulcer
Reflux esophagitis, acute erosive gastritis P
PRC transfusion
CBC F/U
Sip’s water

31. Peptic ulcer disease
10조 김경민

32. Definition
Ulcers defined as a break in the mucosal surface >5mm in size, with depth to the submucosa.
PUD encompasses both gastric and duodenal ulcers.

33. Epidemiology Duodenal ulcers (DU) Gastirc ulcers (GU)
Occur in 6~15% of the western population
Incidence has steadily declined from 1960 to 1980 and has remained since than.
This is related to decreasing frequency of H.pylori
Gastirc ulcers (GU)
Tend to occur later in life than duodenal ulcers
Peak incidence in the sixth decade.

34. Pathology Duodenal ulcers Gastric ulcers
DUs occur most often in the first portion of duodenum (>95%)
Usually < 1 cm in diameter
Gastric ulcers
GUs are most often found in the antrum (60%)

35. Pathophysiology
A major causative factor (60% of gastric and 90% of duodenal ulcers) is chronic inflammation due to H.pylori that colonizes the antral mucosa.
The bacterium can cause a chronic active gastritis resulting in a defect in the regulation of gastrin production
Gastrin secretion is increased. gatrin, in turn, stimulates the production of gastric acid by parietal cells. The acid erodes the mucosa and causes the ulcer.

36. Pathophysiology Another major cause is the use of NSAIDs.
The gastric mucosa protects itself from gastric acid with a layer of mucous, the secretion of which is stimulated by certain prostaglandins.
NSAIDs block the function of cycloxygenase 1 (cox-1), which is essential for the production of these prostaglandins.

37. Symptoms Epigastirc pain Duodenal ulcers Gastric ulcers
Occurs 90 min to 3hr after a meal
Relieved by antacid or food.
Pain that awakes the patient from sleep is the most discriminating symptom.
Gastric ulcers
Discomfort precipitated by food.
Nausea and weight loss occur more commonly in GU patient.

38. Symptoms Bloating and abdominal fullness Nausea, vomiting
Loss of appetite and weight loss
Hematemesis
Melena

39. PUD - related complication
Gastrointestinal bleeding
Most common complication in PUD.
Occurs in 15% of patients and more often in > 60 years old.
Perforation
Second most common ulcer-related complication.
Reported as many as 6~7% of PUD patients.

40. PUD - related complication
Penetration
Form of perforation in which the ulcer bed tunnels into adjacent organs.
DUs tend to penetrate posterioly into pancreas, leading to pancreatitis.
GUs tend to penetrate into the left hepatic lobe.

41. PUD - related complication
Gastric outlet obstruction
The least common complication, occuring in 1~2% of patients.
Relative obstruction due to inflammation and edema in the peripyloric region.
Mechanical obstruction secondary to scar formation.

42. Treatment Acid neutralizing / inhibitory agent Cytoprotective agents
Antacid
H2 receptor antagonist
Cimetidine, ranitidine, famotidine
Proton pump inhibitors
Omeprazole, esomeprazole, lansoprazole
Cytoprotective agents
Sucralfate
Bismuth – containing preparations
Prostaglandin analogues
misoprostal

43. Treatment Eradication of H.pylori infection Triple therapy
Bismuth + Metronidazole + Tetracyclin
Ranitidine + Tetracyclin + Clarithromycin or Metronidazole
Omeprazole + Clarithromycin + Metronidazole or Amoxicillin
Quadruple therapy
Omeprazole + Bismuth + Metronidazole + Amoxicillin

44. Treatment NSAID – related gastric or duodenal injury Active ulcer
NSAID discontinued : H2 blocker or PPI
NSAID continued: PPI
Prophylactic therapy
Misoprostol
PPI
Selective COX-2 inhibitor