Case حلوة Flashcards
(20 cards)
A 63-year-old woman presents to the emergency department with severe abdominal pain.
She reports 4 days of recurrent vomiting prior to presenting for care, culminating in 3 hours of
intense pain and retching, but with an inability to vomit. A nasogastric tube is placed but cannot be advanced beyond 30 cm in length. Vital signs include a respiratory rate of 24, heart rate of 110, temperature of 99.3°F, and blood pressure of 132/88. Examination reveals epigastric tenderness
with distension but no rebound or guarding. The liver and spleen are not enlarged. Laboratories reveal a white blood cell count of 14,200, hemoglobin = 12.9, and platelet = 321. Electrolytes are
unremarkable. Review of the patient’s medical record reveals that she had recurrent nausea and vomiting 6 months prior, and a barium upper GI series was performed at▶
*What is the diagnosis?
Acute gastric volvulus
What is the name of the clinical triad described in this case?
Borchardts triad
▶ What is the next step in management?
Surgical consultant
Retching without vomiting + Epigastric pain + Inability to pass nasogastric tube
Borchardtʼs triad (gastric volvulus)
A 22-year-old woman presents with repeated episodes of regurgitation daily for the past
3 years. The symptoms are post-prandial, effortless, and usually preceded by belching. She also has post-prandial fullness but has not lost weight. She does not report heartburn, nausea, or dysphagia. She had acid reflux symptoms that did not respond well to a prolonged course of PPI therapy. She had a normal-appearing upper endoscopy, an unrevealing manometry, and a normal
4-hour gastric emptying study.
What is the most likely diagnosis?
rumination syndrome
▶ How do you treat it?
Behavioral therapy by
diaphragmatic breathing for 5 minutes before and after meals to compete with the urge to regurgitate.
Recurrent effortless regurgitation without retching or vomiting
rumination syndrome
Rome IV diagnostic criteria
: Must include both of the followin
(1) regurgitation of recently ingested food into the mouth with subsequent spitting
or re-mastication and swallowing
(2) Regurgitation is not preceded by retching.
↑Na + ↓K + ↓Cl + ↑HC03 + ↑BUN + recurrent vomiting.
Gastric outlet obstruction
40-year-old woman has suffered from chronic heartburn and diarrhea for the past 2
years. She takes Omeprazole, which gives some relief of heartburn, but not the diarrhea
which is 5-6 loose stools per day. She has some epigastric discomfort. Upper endoscopy
showed grade “C” lower oesophagitis, pangastritis, shallow ulcers in the duodenal bulb
and minute ulcers in the second part.
A-What is the most probable diagnosis?
Zollinger-Ellison Syndrome (ZES)
This is suggested by:
1-Chronic heartburn and refractory peptic ulcers despite PPI use
2-Diarrhea (from acid hypersecretion inactivating pancreatic enzymes and causing malabsorption)
3-Multiple ulcers in unusual locations (e.g., second part of the duodenum)
4-Pangastritis and high acid load
B-What is the most specific diagnostic test?
Secretin Stimulation Test
gastrin levels increase significantly (>200 pg/mL) after IV secretin
خلي بالك
Gastrin level
هنا غالبا اكتر ١٠٠٠
*In contrast, normal G-cells are inhibited by secretin
C-What is the successful treatment?
1-High-dose Proton Pump Inhibitors
Often needed lifelong or until definitive surgical treatment
2. Surgical Management
Surgical resection of gastrinoma if it is localized and non-metastatic
3. If metastatic:
Long-term acid suppression
Consider somatostatin analogs (
Thick gastric folds + Diarrhea + Low albumin + Edema
Ménétrierʼs
A 22-year-old woman is referred for dyspepsia. Her symptoms began 8 months ago, and were
marked by epigastric discomfort and progressive early satiety. She has recurrent nausea and vom-iting, progressive weight loss, and recently developed lower extremity edema. She has not experi-enced subjective fevers, chills, or sweats.
Her primary care physician treated her with double-dose PPI therapy, but there was no
improvement in her symptoms after 8 weeks of treatment. Pertinent positives on examination
include moderate epigastric tenderness to palpation and lower extremity pitting edema. Pertinent negatives include lack of fever, no abdominal masses, and no lymphadenopathy.
Her primary care physician previously ordered an upper GI series that revealed diffusely thick-ened gastric folds but no discrete mass. Her gastrin was elevated at 230. With a secretin challenge
the gastrin rose to 300. Her albumin is 2.7.
خلي بالك
Secretin زاد ٧٠ بس بعد الحقن
يعني دي مش Ellison zollinger
What is this condition?
Minteres
▶ What specific abnormality may be seen on biopsy of the gastric body?
“corkscrew” foveolar hyperplasia (thus lots of mucus production) and a relative lack of oxyntic gland mucosa.
How can this be treated?
1-H pylori eradication
2-Antiepidermal growth factor receptor antibody
DD of thickened gastric fold in upper endoscopy
1-Lymphoma
2-zollinger Ellison syndrome
(معاها gastrin اكتر من ١٠٠٠+ diarrhea+ refractory ulcers+pangastritis+ ulcers في اماكن غريبة+esophigitis)
3-Menteres disease
(Diarrhea+hypoalbuminemia+gastric fold +moderate elevation of gastrin test+edema.
4-H .pylori gastritis
Increase Gastrin level +
Decreased gastric PH+
Parietal cell mass +
Positive secretin test
Zollinger ellison syndrome
Increase Gastrin level +
Increased gastric PH+
Parietal cell mass +
Negative secretin test
Chronic use of ppi
Increase Gastrin level +
Increased gastric PH+
No Parietal cell mass +
Negtive secretin test
Pernicious anemia
Corpus h pylori infection (the predominant form of infection
بيعسكر في Parietal cell mass ويقللها ويعمل pernicious anemia)
خلي بالك
H pylori against acidity
Increase Gastrin level +
Decreased gastric PH+
Parietal cell mass +
Negative secretin test
Antral H pylori infection
A 50-year-old woman presents with diarrhea, abdominal pain, and acid reflux symptoms.
Endoscopy reveals thick gastric folds, voluminous gastric secretions, and post bulbar denal ulcers. Jejunal biopsy reveals villous atrophy.
Zollinger ellison syndrome
A young patient with vitiligo and premature gray hair undergoes endoscopy, which
reveals prominent submucosal vessels and multiple erythematous nodules. Biopsy reveals
increased endocrine cells throughout the body of the stomach, and biopsy of the nodules
reveals nests of enterochromaffin-like (ECL) cells.
Carcinoid
patient with thickened gastric folds and a low albumin has foveolar hyperplasia on biopsy.
Ménétrierʼs
Dyspepsia + thick gastric folds + foveolar hyperplasia.
Ménétrierʼs
Thick gastric folds + diarrhea + low albumin + protein-losing enteropathy +
edema.
Ménétrierʼs
63-year-old man consulted his physician because of tiredness, lethargy, and an
abdominal pain centered around the lower end of his sternum, which woke him in
the early hours of the morning. Pain was relieved by food and antacids. He gave a
history of receiving a 10-day course of treatment for Helicobacter pylori 2 months
earlier in the form of combined omeprazole/amoxicillin/clarithromycin. His
physician advised him to do esophagogastroduodenoscopy (EGD) that showed a 2
cm prepyloric healing ulcer.
A) Was it correct to advise doing EGD, explain?
Yes, because there is alarm signs
B) What are the next steps
1-Confirm ulcer healing and exclude malignancy:
So, biopsy is needed
2- Confirm H. pylori eradication:
Do CLO test on endoscopy
3-Continue acid suppression:
6-8 weeks
4-Lifestyle modifications
