醫(yī)學(xué)專(zhuān)業(yè)英語(yǔ)課件-4

1、Clinical case discussionZhi Hua RanDepartment of gastroenterologyRen Ji Hospital 2021/9/101Questions What are the common causes of upper abdominal pain?2021/9/102Answer Gastroesophageal reflux Biliary colic Functional dyspepsia Peptic ulcer (duodenal ulcer, gastric ulcer) Gastric cancer Irritable bo

2、wel syndrome 2021/9/103Questions How to differentiate the common causes of upper abdominal pain?2021/9/104Answer - the clinical features Gastroesophageal reflux typically produces “heart burn”, or burning epigastric or mid-chest pain after meals and worse with recumbency Biliary colic caused by gall

3、stones typically has an acute onset of severe pain located in the right upper quadrant or epigastrium precipitated by meals, fatty foods in particular lasts 3060 min with spontaneous resolution more common in women2021/9/105 Functional dyspepsia can be associated with fullness, early satiety, bloati

4、ng or nausea can be intermittent or continuous may or may not be related to meals symptom persisting at least 12 weeks Irritable bowel syndrome is a diagnosis of exclusion suggested by chronic dysmotility symptoms - bloating, cramping that is often relieved with defecation without weight loss or ble

5、eding Answer - the clinical features 2021/9/106 Peptic ulcer (duodenal ulcer, gastric ulcer) DU: the classic symptoms of duodenal ulcers are caused by the presence of acid without food or other buffers symptoms are typically produced after the stomach is emptied but food- stimulated acid production

6、still persists, typically 25 h after a meal pain wake patients at night, when circadian rhythms increase acid production it is typically relieved within minutes by neutralization of acid by food or antacids GU: are more variable in their presentation food may actually worsen symptoms pain might not

7、be relieved by antacidsAnswer - the clinical features 2021/9/107 Gastric cancer 45y alarm symptoms: weight loss, recurrent vomiting, dysphagia, bleeding, anemia earlier satiety, pain Answer - the clinical features 2021/9/108Summary: A 37-year-old man presents complaining of chronic and recurrent upp

8、er abdominal pain with characteristics suggestive of duodenal ulcer: the pain is burning in quality, occurs when the stomach is empty, and is relieved within minutes by food or antacids. He doesnt have evidence of gastrointestinal bleeding or anemia. He does not take nonsteroidal antiinflammatory dr

9、ugs, which might cause ulcer formation, but he does have serological evidence of H. pylori infection.Answer - Peptic Ulcer Disease2021/9/109Question What are the roles of Helicobacter pylori (H. pylori ) infection and how to diagnose H. pylori infection?2021/9/1010Answer H. pylori is associated with

10、 duodenal and gastric ulcers, chronic active gastritis, gastric adenocarcinoma, and gastric MALT (mucosa-associated lymphoid tissue) lymphoma.2021/9/1011Answer The diagnosis of H. pylori infection Diagnostic methods for H. pylori infection are categorized into two groups as: Invasive Noninvasive 202

11、1/9/1012Answer Noninvasive: does not need endoscopic procedure Urea breath test - evidence of current active infection convenient method H. pylori antibody - evidence of prior infection, will remain positive for life Stool antigen test2021/9/1013Answer Invasive: need endoscopic biopsy of gastric muc

12、osal sample Pathology (using special staining: Giemsa staining, silver staining, Gimenez staining, immunohistochemistry, in addition to Hematoxylin-eosin staining) Rapid urease test (RUT): H. pylori splits the urea in the test container to yield ammonia. Elevation of the pH by ammonium hydroxide pro

13、duced in detected by a color change of the pH indicator. Advantage: inexpensive, ease to use, rapid diagnostic methods Disadvantage: require endoscopy, false-negative2021/9/1014Answer Invasive: Microaerobic bacterial culture Advantage: perfect specificity (100%), allowing further characterization of

14、 the organisms (determining its sensitivity to antibiotics) Disadvantage: most difficult to use in clinical setting2021/9/1015Question What is the most common cause of duodenal and gastric ulcers? 2021/9/1016Answer H. pylori infection and use of NSAIDs are the common causes of peptic ulcer2021/9/101

15、7Question What are the roles of Helicobacter pylori infection in the etiology of peptic ulcer disease?2021/9/1018Proposed natural history of H. pylori infection in human Chronic Active Gastritis Acute Gastritis AntralPredominant GastritisDuodenal UlcerlymphomaEnvironmental factorsMultifocal Atrophic

16、 GastritisGastric CancerGastric Ulcerlymphoma95%100%80%90%2021/9/1019Question What are the roles of NSAIDs use in the etiology of peptic ulcer disease?2021/9/1020Answer In endoscopic clinical research studies of patients who take NSAIDs, 10 20% of patients in the first 3 months of NASID use develop

17、new gastric ulcers and 4% to 10% develop duodenal ulcers. They promote ulcer formation by inhibiting gastroduodenal prostaglandin synthesis, resulting in reduced secretion of mucus and bicarbonate and decreased mucosal blood flow. In short, they impair local defense against acid damage. The risk of

18、ulcer formation caused by NASID use is dose-dependent, and can occur within days after treatment is initiated. 2021/9/1021Answer A rare cause of ulcer is the Zollinger Ellison syndrome. It is the condition in which a gastrin-producing tumor (usually pancreatic) causes acid hypersecretion, peptic ulc

19、eration, and diarrhea. This condition should be suspected if ulcer disease occurs and the patient is H.pylori negative and does not use NSAIDs. To diagnose this condition, serum gastrin levels should be measured (1000 pg/ml), and then try to localize the tumor with an imaging study. 2021/9/1022Quest

20、ion What are the other clinical manifestations of peptic ulcer disease?2021/9/1023Answer-complications Hemorrhage: is the most common severe complication of peptic ulcer disease, and can present with hematemesis or melena. Free perforation into the abdominal cavity may occur, with a sudden onset of

21、pain and development of peritonitis Gastric outlet obstruction may develop in some patients with chronic ulcers, with persist vomiting and weight loss Perforation and obstruction are indications for surgical intervention2021/9/1024Question What is your next step?2021/9/1025Answer Eradication of H.py

22、lori2021/9/1026Question Do you know any treatment regimen for H.pylori eradication?2021/9/1027Answer PPI based triple therapy omeprazole, lansoprazole, pantoprazole, rabeprazole Bismuth based triple therapy (colloidal bismuth subcitrate) Metronidazole: 400 mg bid Amoxicillin: 500 mg bid Clarithromyc

23、in: 250 500 mg bid Tetracycline: 500 1000mg bid Furazolidone: 100 mg bid Ranitidine Bismuth Citrate (RBC)714 days2021/9/1028Answer Antisecretory treatment: lasts for 24 weeks2021/9/1029Comprehension questions (I) A 42-year-old overweight, though otherwise healthy, women presents with the sudden onse

24、t of right upper abdominal colicky pain 45 minutes after a meal of fried chicken. The pain is associated with nausea and vomiting, and any attempt to eat since has caused increased pain.The mostly cause is:A: Gastric ulcerB: CholelithiasisC: Duodenal ulcerD: Acute hepatitis2021/9/1030Answer - B Righ

25、t upper abdominal pain that has an acute onset after the ingestion of a fatty meal and that is associated with nausea and vomiting is most suggestive of biliary colic as a result of gallstones. Duodenal ulcer pain is likely to be determined with food, and gastric ulcer pain is not likely to have the

26、 acute severe onset. Acute hepatitis is more likely to produce dull ache and tenderness2021/9/1031Comprehension questions (II) Which of the following is not true of H.pylori infection:A. It is more common in developing countiesIt is associated with the development of gastric lymphomaIt is believed t

27、o be the cause of nonulcer dyspepsiaThe route of transmission is believed to be fecal oralIt is believed to be a cause of most duodenal and gastric ulcer2021/9/1032Answer - C While H.pylori is clearly linked to gastric and duodenalulcers, and probably to gastric carcinoma and lymphoma,it is unclear

28、whether it is more common in patients withnonulcer dyspepsia, or whether treatment in those patients reduces symptoms.2021/9/1033Comprehension questions (III) A 45-year-old male was brought to the emergency room after vomiting bright red blood. He has a blood pressure of 88/46 mmHg and heart rate of

29、 120 bpm. Which of the following is the best next step?IV fluid resuscitation and preparation for a transfusionAdministration of a proton pump inhibitorGuaiac test the stoolTreatment for H.pyroli2021/9/1034Answer - A This patient is hemodynamically unstable with hypotension and tachycardia as a consequence of the acute blood loss. Volume resuscitation, immediately with crystalloid or colloid solution, followed by blood transfusion, if necessary, is the initia