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TRIGGER 1A! !

PBL GIT W01 SUMMARY!

En. Ahmad, a 34 year old factory executive was brought to the accident and emergency

unit of HUSM with a sudden onset of severe epigastric pain while at work.!

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TRIGGER 1B! Further questioning revealed that he had suffered from epigastric pain for the past 2 years.

The pain occurred every 3-4 months and lasted for 2 weeks at a time. It was burning in nature and appeared 2 hours after a meal. Sometimes the pain woke him up from sleep and was relieved by taking milk. En. Ahmad said he smokes 40 cigarettes a day. He often continues working until late night. He admitted to be a constant worrier.! ! On examination, he was in pain but was lying still on bed. There was pallor but no jaundice.

His temperature was 37", pulse rate 132/min, blood pressure 130/80 mmHg. The abdomen was not distended and did not move with respiration. There were generalised tenderness and guarding with board-like rigidity. On percussion, liver dullness was absent and no bowel sounds were heard on auscultation.!

TRIGGER 2! The following investigations were carried out:! Haematology:! 1. Blood group : O +! 2. Haemoglobin : 10.8 g/dL! 3. White blood cell count : 16 x 109 per L (80% polymorphs)! Chemical Pathology:! 1. Blood urea : 7.8 mmol/L! 2. Na+ : 136 mmol/L! 3. K+ : 4.2 mmol/L! 4. Cl- : 100 mmol/L! 5. Serum amylase : 300 IU/L at 37"! Radiology report:! ! Plain chest x-ray of chest and abdomen (erect) showed free gas under the right dome of

diaphragm. A diagnosis of generalised peritonitis due to perforated peptic ulcer was made.! ! The patient underwent emergency laparotomy after consenting to the surgery. During

surgery, a perforated duodenal ulcer was noted, the perforation was closed with mental patching and peritoneal debridement. A highly selective vagotomy was performed.!

TRIGGER 3! ! Encik Ahmad recovered fully from the emergency operation and was well for the following

12 months. He then return to the clinics with complaints of recurrent epigastric pain and vomiting.! Gastroscopy (endoscopy) was performed and it conrms the presence of a 1cm active ulcer in the rst part of duodenum. Stomach was normal.!

Two biopsies of stomach antrum was taken:! 1. One was immersed in a urea medium which turned purple! 2. The other biopsy was sent to pathology lab for histological examination! ! ! ! ! ! En. Ahmad was commenced on omeprazole, clarithromycin and amoxycillin.! ! En. Ahmads employer wrote to the doctor in charge requesting a medical report. He has

apparently been taking time off from work frequently each time producing medical certicate (MC) from a private practitioner.!

LECTURER NOTES! 1. Curlings ulcer! 2. Tuberculosis of ileum - ileitis! 3. Most common malignant ulcer of colon - sigmoid colon! 4. Gastric ulcer - usually at lesser curvature - not caused by hyperacidity states! 5. Gastric antrum ulcer usually due to hyperacidity states! 6. H. Pylori reduces urea from yellow to purple, spiral ight of the seagull, bismuth can eradicate, can cause malignant ulcers! 7. Convergent ulcer, benign; divergent ulcer, malignant!

HYPOTHESIS! 1. Hyperacidity state - acid reux! 2. Peptic ulcer! 3. Retrosternal burning! 4. Perforation of GIT! 5. Peritonitis!

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LEARNING ISSUES! 1. Hyperacidity states (causes)! Increased secretion of Hydrochloric acid! Due to :! Irregular eating habits! Excessive fasting! Stress and aspirin intake! Increased citrus intake! Stomach malignancies! Zollinger-ellison syndrome (pancreatic tumor)! Antral G Cell hyperplasia or hyper function (made by H. Pylori)! Post-gastrectomy retained antrum! Massive small bowel resection - less in bicarbonate secretion! Chronic gastric outlet obstruction! 2. Epigastric pain! Discomfort in the epigastric region! Abdominal origin :! Parietal peritoneal inammation! Obstruction of hollow viscera! Vascular disturbances! Abdominal wall! Extra abdominal origin :! Referred pain, i.e. : MI! Metabolic causes, i.e. : pancreatitis! Neurologic! Psychiatric! Toxic! Idiopathic! Due to :! Peptic ulcer disease (burning at night)! Gastritis (burning)! GERD (heartburn)! Pancreatitis (constant pain and radiates to back)! MI (referred pain)! Pericarditis (blood back to abdomen)! Ruptured aortic aneurysm (sudden severe pain)! Oesophagitis (heartburn)!

3. Acid reux (causes & relations)! Acids rise up to oesophagus because LES faulty! Persistent and untreated : GERD, may be malignant in chronic cases! Causes :! Pressure in stomach is higher! Weak LES! Smoking : Stimulates acid production, relaxes LES! Hiatus hernia : Upper part stomach protruding into thoracic cavity due to severe coughing, vomiting, straining, sudden physical exertion, pregnancy, obesity! Pregnancy : Hormone changes LES, foetal growth increase intra abdominal pressure! Obesity! Large meal and diet! Acid reux : Movement of acid; Heartburn : Pain sensation! 4. Peptic ulcer & complications! Break in supercial epithelial cells up to muscular is mucosa of stomach or duodenum (1 : 4)! Types :! Acute (stress) : Multiple, small erosions, common in stomach! Chronic : Single, either in gastric and duodenal ulcers! Causes of acute ulcers :! Psychological! Physiological! Intracranial lesions (Cushings ulcers)! Pathogenesis : Ischemia of the mucosal barrier! Causes of chronic ulcers :! H. Pylori gastritis! Hyper secretions of acid-pepsin! NSAIDs! Psychological! Genetic (blood group O)! Alcohol, tobacco, hyperparathyroidism! Pathogenesis : Hyper secretion > rapid emptying > duodenal mucosa exposed to acid; H. Pylori breaks the mucosal barrier! Clinical features :! Stress! Tenderness in right hypochondriac region! Night pain! Pain food relief!

 Melaena! No vomiting heartburn! Good appetite, gain weight! Complications :! Obstructions (oedema or scarring)! Haemorrhage (erosion of small blood vessels)! Perforation (in chronic duodenal ulcer > peritonitis; subphrenic abscess)! 5. Gastric ulcer & complications! Pathogenesis : Increased gastrin levels, H. Pylori! Pathophysiology : Irritants > damage barrier > reduced mucosal cell function, reduced mucus quality, lost of tight junctions > diffusion of acid into gastric mucosa > ulcer formation! 1% of chronic gastric ulcer may become malignant! 6. Vagus nerve supply & role in peptic ulcer! Motor sympathetic bers to viscera! Stimulate glandular secretions of stomach acid! Role in peptic ulcer :! Central role in gastric acid secretion and gastrin levels! Through M3 cholinergic receptors, release of acetylcholine, release of gastrin! Vagus nerve disorder : Overactive! Cause of nerve disorder :! Trauma! Brain stem lesion! CNS malignancy! Polio! Gullian-barr syndrome! 7. Endoscopy! Procedure to examine insides of body using endoscope! Has a lighted camera for us to monitor! Diagnosis of various diseases! Can be used together with accessories! Gastroscopy :! Upper GI endoscopy! Procedure :! Fast at least 4 hours! Anaesthesia (IV benzodiazepine or local anaesthesia)! Left lateral position! Mouth guard placed!

 Endoscope inserted! Indications :! Dyspepsia! Atypical chest pain! Dysphagia! Contraindications :! Severe shock! Recent MI, angina, arrhythmia! Perforations! Complications :! Cardiorespiratory depression! Aspiration pneumonia! Perforation! 8. H. Pylori! Has ability to survive in our stomach! Spiral shaped, gram negative bacteria! Secretes urease (urea > CO2 + ammonia) > gastric mucosa broken > ulcer > metaplasia > malignancy! 50 - 60% population is infected! Invasive tests :! Rapid urease! Histology! Culture! Serology IgG! Non invasive tests :! Urea isotope! Dipstick! 9. Medical treatments for peptic ulcer ! Drugs reduce gastric acid secretions :! H2 anti Histamines (inhibition of adenyl cyclase) : Ulcers, inammation of GIT, ZES, GERD; Ranitidine, clemitidine! Proton Pump Inhibitor (inhibit pump of parietal cells) : Ulcers, GERD; Prazole family! Anticholinergics (M1 selective receptor blocker) : Pirenzepine & telezepine! Prostaglandin analogues : Mitoprostol! Ulcer protectives :! Sucralfate (extensive polymerisation and cross linking, as physical barrier)! Bismuth (complex mucin and coats ulcer)!

10. Antacids! Weak base that neutralise acid, inhibit pepsin, increase the pH; DO NOT reduce acid secretion! For symptomatic relief and promote healing of ulcers; acid indigestion! Types :! Systemic : Absorbed into circulation, neutralise H+, can lead to metabolic alkalosis! GI : Not absorbed, do not lead to metabolic alkalosis! Examples :! Systemic : Sodium bicarbonate, sodium citrate! GI : Magnesium hydroxide, aluminium hydroxide, calcium carbonate, magnesium trisilicate, magaldrate! 11. Antibiotics as anti H. Pylori! Types :! Triple therapy : PPI + clarithomycin / metronidazole / tetracycline + amoxicillin for 2 weeks! Quadruple therapy : PPI + metronidazole + bismuth + tetracycline for 2 weeks! Indications :! Ulcer! MALToma! Dyspepsia! 12. Surgical measures! Laparotomy! GIT resection! Peritoneal debridement! Highly selective vagotomy!