Ranitidine= H2 antagonist
Note that there is much more H. pylori in eastern europe
What is the Ddx?
What is a peptic ulcer?
A discontinuity that occurs in the Gi epithelium that is exposed to acid and pepsin, most commonly in the stomach or duodenum
T or F. You cannot distinguish a gastric from duodenal peptic ulcer based on the pts. symptoms
What parts of this mans Hx favor peptic ulcer over functional dyspepsia?
-localized pain to the epigastrium
-waking the pt. at night
- helps by eating (pain with functional dyspepsia usually get worse with eating)
-helps with acid suppressing meds. (also true of functional dyspepsia)
-the intermittent nature of the pain (chronic, every-day pain would be highly uncharacteristic of peptic ulcer)
T or F. The pain of peptic ulcer typically waxes and wanes
T. Not constant like in functional dyspepsia
Functional dyspepsia is much more common today!
What is 'dyspepsia'?
really more of a symptom than a diagnosis- can be interchanged with indigestion, but it is a localized pain/burning in the upper abdomen
T or F. With a diagnosis of functional dyspepsia, the normal anatomy of the GI will be normal and functioning properly
T. It is more idiopathic
Want to know about OTC pain meds
Being from eastern europe (and east asia, south america)= H. pylori risk
Endoscopy too expensive
Barium X-ray pretty hardcore- endoscopy better
Gall bladder might be bad
H. pylori can be checked at the time of endoscopy or via blood draw
Youre not expecting to feel a peptic ulcer on abdominal exam
Pointing sign= can the pt. point to the source of pain with 1 finger. If they can, increased likelihood of peptic ulcer
Note that a positive test for H. pylori means hes been infected at some pt. and he may/may not still have it.
Most H. pylori infections are acquired pediatrically (first 6-7 yrs of life) and highly unlikely to be acquired after. These infections manifest during adulthood, however.
Children can clear the infection on their own and get re-infected but adults cannot clear the infection alone despite the presence of an immune response
How does H. pylori spread?
-mother-child via close contact
Note that for Americans, the incidence of H. pylori infection has continually dropped so that most positive pts. will be older
Endoscopy of pt. 1
the tx of an ulcer depends on whethers its H. pylori + or -
Note that H. pylori is the cause of roughly 60-70% of duodenal ulcers and
you cant tell whether its H. pylori positive or negative just by looking a the ulcer via endocopy OR by biopsy
Need an ANTRAL biopsy. The neutrophils have to be in the glands!!!
If you have either active (neutrophils) or chronic (lymphocytic) inflammation, look for H. pylori!
Must get a biopsy of the antrum and like to live in the crypts- described as seagulls. Can also do silver stains or IHC (right- black things)
there there is no inflammation but the crypts become very squiggly and elongated in reactive/chemical gastropathy
H. pylori will not be found in intestinal metaplasia (notice the goblet cells).. it needs normal gastric epithelium
These pts. have an icnreased risk of LYMPHOMA due to the presence of MALT tissue (note that this is kind of a fake lymphoma in that it is a monoclonal proliferation of cells but if you treat the H. pylori a lot of pts, will get better)
Notice that HP is brown on IHC
Note that if a population of B cells in the GI express BOTH CD20 and CD43, it is a lymphoma
Note that pts. should never be given the diagnosis of gastritis.. that is a histological finding and doesnt describe any clinical or endoscopic abnormality
Note that duodenal ulcers are almost (99+%) NEVER malignant (so dont biopsy typically), while gstric ulcers are more likely and warrant a biopsy. You are NOT going to find H. pylori anywhere but the stomach
Definitely treat the infection
T or F. ALL peptic ulcer pts. MUST be tested for H. pylori and all who have it MUST be treated for it
Despite feeling better, you MUST complete the full 14 days
Only need to recheck endoscopy to make sure if it healed if it was a gastric ulcer, but not a duodenal ulcer (duodenal malignancies very rare)
You do want to confirm eradication of H. pylori infection (only about 70% will clear with ABX)
NEVER do serology in a pt. after tx for H. pylori- pts. may remain positive for yrs. even after clearing
The negative breath test does mean he's cured
chances of re-infection are less than 1%/yr in adults (more likely in children)
Note that H. pylori clarithromycin resistance is a big problem
H. pylori has urease activity! It will split the urea to ammonia and Co2 to be breathed out
Notice the causes of false-negatives
Probably has an upper GI bleed
the black, tarry stool comes from melana (means 'black')
Dont want to biopsy the ulcer for risk of further bleed (might be okay if she hadnt bled before)
H. pylori serology has a very good NEGATIVE predictive value (but not good positive predictiveness)
The process of NSAID induced damage is typically painless.. especially in older pts.
Yes it is right to restart aspirin therapy
dont restart diclofenac, switch to the safer celecoxib
She definitiely needs to be on a PPI for the rest of her life if shes gonna stay on aspirin
She does need another EGD
Remember that peptic uclers can have no Hx of pain especially in older pts and those taking NSAIDs!!