58 year old male complaining of 3-week history of increasing epigastric pain

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Dortha Porter
6 years ago
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1 Peptic Ulcer Disease 58 year old male complaining of 3-week history of increasing epigastric pain Has had dyspepsia in the past for which he took Tums, but this is much worse and only partially relieved with chewable antacids Epigastric pain can be confused with the angina or heart attack. Even in the stomach we talked in cardiovascular 1 and 2 how esophagitis, hepatitis and all that can cause pain GI disorders tend to produce very vain symptoms. Even people with appendicitis can show up with epigastric pain Dyspepsia heart burn The pain for point 2 and point 1 are very different. Sometimes people complain about heart burns and they tend to be dismissed. Dyspepsia can be cardiovascular or GI esophagus, stomach, duodenum, liver, transversal colon even respiratory: most lung disease don t hurt and when they hurt its when they reach the pleural and that is pleuritic pain the pain changes when you breathe and they say yes is most likely pleuritic pain or injury to the thoracic wall. Pain has a burning quality Relieved when eating, especially drinking milk, but recurs about 2 hours later Denies radiation to his back, melena, hematemesis or fever Denies early satiety, anorexia or weight loss Denies fatty food intolerance or change in stools Denies jaundice, increasing abdominal girth, or easy bruising Denies shortness of breath or pain with exercise If the guy is having a heart attack?? No shortness of breath or exercise this decreases possibility of CV Burning quality can help because it implies because to burn you need to have pain receptors and the stomach doesn t have pain receptors but the esophagus has especially the upper 3 rd the burning quality indicated that whatever happens affects the esophagus the most common symptom is heart burn or GERD. So this tells you there s reflux but that reflux is reaching the upper 3 rd of the esophagus and that s what causes the burning quality of the pain so guy has reflex. The problem is if its chronic can cause disease esophagitis, damage to the sphincter gastro esophageal sphincter, inflammation. If the reflux is chronic can damage the function of the sphincter and then it makes the reflux more chronic and severe. Also hiatal hernias and there are the ones when the cardiac (between stomach and esophagus) gets displaced and the sphincter doesn t work as well.

2 Radiation to his back of the pain referred pain and its one condition that very commonly causes epigastric pain at the same time very severe gastric pain pancreatitis (inflammation of the pancreas) pancreatitis many times it mimics heart attack and can lead to shock and peritonitis. Melena and hematemesis severe upper GI bleeding. Tells you maybe he has only gastritis and if he has an ulcer is most likely a gastric ulcer. Because if it was duodenal he would throw up blood. Weight loss very important because of cancer. Anyone with all these symptoms can have gastric cancer so consider weight loss and another silent killer is the cancer of the esophagus because there are many men after 50 that have it. Cancer if the esophagus is clinically very silent it doesn t cause any bleeding or anything just weight loss so think about it. Fatty food intolerance lecture. Fatty foods to be absorbed they need liver and pancreas. Liver prod bile which emulsifies the fat and pancreas because the pancreas prod lipases which breaks down the lipids. If the guy denies change in stools or fat absorption then you can say the liver and pancreas are fine Jaundice (many cues) very important manifestation of liver disease especially when cirrhosis and pancreatic disease jaundice most common symptom of pancreatic cancer. If he tells you he has jaundice you immediately think pancreatic cancer. Jaundice can indicate pancreatic disease, liver disease, hemolytic disease. Easy bruising and liver disease whenever the liver prod coagulation factors when a person has liver disease they won t produce coagulation factors so no fibrin, fibrinogen and all the coagulating things look it up Increase abdominal girth ascites so the second last point shows you he doesn t have any liver failure or cirrhosis Has been taking ibuprofen for the past 2 months for a sore knee Drinks approximately 3 mixed drinks each day Smokes 1 pack of cigarettes a day Has had recent job change with a great deal of stress Has been feeling a little tired lately but no recent illness or hospitalization Has a history of mild hypertension treated with diet No medications or known allergies Ulcers: Which one of these are important factors for ulcers? He drinks 3 times a day that s a risk factor for acute gastritis, chronic gastritis, pancreatitis and duodenal ulcers.

3 Smokes everyday 1 pack and in this case nicotine stimulated production of HCl and dilates the cardia s sphincter so not only promote gastritis but can also promote reflex. Not uncommon to have this Stress good is acute bad if chronic. Stress changes completely the GI tract and chronic stress the cortisol increases and glucocorticoids promoted gastritis and ulcers. One of the common side effects of glucocorticoids will develop ulcers or gastritis. People under stress tend to bleed and develop acute gastritis and ulcers. Chronic increase cortisol will develop gastritis and ulcers. Drugs like aspirin that directly damage the GI mucosa Lil tired but its very important in anemia s and chronic gastritis so he could have anemia because of chronic bleeding or decrease in b12 Physical Assessment This white male in no acute distress T=37C, P=90, RR=16, BP=148/96 Fundi without vascular changes Heart sounds normal with no murmurs Abdomen not distended Bowel sounds present Epigastric tenderness without rebound or guarding Liver and spleen not palpable, no hemorrhoids Stool grossly normal but weakly heme positive General in people with GI disease aren t very useful you look for very specific complications No indication there is any heart attack which is good No acute distress won t die from this immediately Jaundice none of that Complication of ulcers: Spleen Rupture perforations or ruptures the ulcers keep digging in the sub mucosa and so on until they make a hole and its more common in duodenal ulcers or most common in gastric cancers. Immediately leaves to peritonitis. Guarding or rebound when you put your hand on the abdomen and guarding cant press down, rebound - you can compress doesn t hurt that much but you lift your hand and it hurts super bad. X rays can be helpful

4 Bowel sounds aren t present when peritonitis so no major alteration in the intestinal function Liver and spleen not palpable so not increased in size and no hemorrhoids (hypertension) very important because he had a strong history of alcohol intake so basically he doesn t have cirrhosis Very important last one stool has blood which tells you that there is bleeding somewhere so you think peptic ulcer because that s the lecture In Canada whenever you see anyone with + fecal blood you think about colon cancer. Diagnostic Tests WBC 9000/mm 3 with normal differential (N: ) Hematocrit 45% (N:40-52) Liver function tests including bilirubin normal Serum and urine amylase and lipase normal ECG = sinus rhythm with no evidence of ischemic changes GI bleeding, a lot of symptoms compatible with upper GI Is he anemic?? Blood loss major but you look at point 2 and see its not. Remember what are liver function tests?? Bilirubin total vs indirect vs direct and also the enzymes transaminases enzymes SGOT SGPT that normally aren t present in the blood only present inside of liver cells and this shows liver damage if present in blood No heart attack Transamylases in the liver Lipase come from pancreas and amylase detect pancreatic cell integrity. Exocrine pancreas so this tells you he doesn t have pancreatitis. Endoscopy Results Normal esophageal mucosa Gastric mucosa with superficial gastritis without ulceration 0.5 cm duodenal ulcer with evidence of recent bleeding, but no acute hemorrhage and no visible vessels in the ulcer crater Biopsy reveals acute inflammation without dysplasia or malignancy. H. pylori rapid urease testing positive Understand the findings

5 Ulcer and is duodenal and it s bad because the complications are way worse. Recent bleeding but no acute hemorrhage. Duodenal cancer is very rare and because he has an ulcer it rules out the cancer part. Biopsy reveals acute inflammation but no dysplasia and its important Esophageal mucosa is normal Read about the final point very important When the story of h pylori thought they are going to spend hours under the microscope to look for the bacteria and then they found that h pylori has many unique properties and one of them is urease. They developed a test that developed urease production. And he is positive and this would make him a good candidate for antimicrobial treatment. H pylori didn t cause the ulcer but it was a contributing factor. So gastric pain and is discovered he has gastritis and duodenal ulcer and it has to be treated because if it isn t treated and he doesn t stop smoking and drinking it will continue bleeding perforate it and kill him. Can the ulcer kill? Yes as soon as the h pylori is removed and no more alcohol and stress is reduced then the ulcers heal very fast For the exam: Which of the following ulcers is most likely to lead to cancer: Gastric Ulcer Duodenal Ulcer is the LEAST!!!!!

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