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What are the sx/signs that change in the intermediate phase of perforated peptic ulcer that might incorrectly cause you to think that the patient’s condition is improving and that a surgical consult is not needed?

sxs: sudden onset, initially intense pain in epigastrium then might move to hypogastrium (acids may pool there), temp can drop to 95-96, shallow breathing, fainting, cold extremities, 1st few hours

2-12 hours is intermediate stage, person looks better (normal color), temp normalizes or increased, pain lessons —> not a good sign


What is the finding found on percussion of the abdomen that is highly correlated with perforated peptic ulcer?

if distinct resonance over mid axillary line on the liver (not dullness)


To what location is pain referred from a perforated peptic ulcer?

top of shoulder in the supraspinous fossa, over the acromion, and the clavicle —> cutaneous branches of the 4th cervical nerve


What is the finding on a plain x-ray film that is a highly likely sign of a perforated peptic ulcer (80-85% of cases are positive for this?)

small quantities of free gas between liver and diaphragm


Summarize the prevention of dysplasia and adenocarcinoma of the esophagus in patients with long segment Barrett esophagus.

Drugs- statins and NSAIDs decrease risk of EAC in pt with BE
Diet- incr intake of veg and fruit
Bile acid (prevents cytoxicity, DNA damage, and ROS), polyphenon E (inhibits growth of transformed epithelial cells), retinoids (increase apoptosis), selenium (slows abnormal growth, prevent DNA damage, accelerate apoptosis), curcumin (down regulates COX-2, LOX and PGE2)


What is NERD? What are dilated intercellular spaces? What is DGER?

Non-erosive reflux disease -sx of GERD with no signs of abnormality on upper endoscopy
What are dilated intercellular spaces-? leaky gut, irritated by even neutral reflux
What is DGER-


Understand the spectrum of GERD including NERD, erosive and non-erosive esophagitis, Barrett esophagus, dysplasia and adenocarcinoma.

GERD- gastroesophageal reflux defined by presence of sx (heartburn, regurg and AbN findings on upper endoscopy)
NERD- sx of GERD with normal tissue on upper endoscopy
Barret esophagus- tissue changes seen in esophagus where the cells change to resemble cells of the intestines. Etiology: GERD
Dysplasia & adenocarcinoma- complications of Barret’s esophagus


What are the components of the mnemonic – “cut out the CRAP?”

C - coffee, cigarettes, chocolate
R - refined carbohydrates, Rx
A - acid foods, alcohol, allergic foods
P - peppermint and progesterone (smooth muscle relaxants), packin food before bed, pop (soda)


Understand the flowchart of Naturopathic GERD evaluation.

suspect serious pathology? EGD, Barium swallow
evaluate pancreatic function- stool chymotrypsin
evaluate gastric pH - hypo/hyer/achlorhydria - eval gastric flora including H. pylori
R/O SIB (breath test) , hernia (imaging, reflex or muscle testing), food sensitivities (elimination diet)


Know the most distal site that may be assessed by upper endoscopy (EGD), that H. pylori status will be assessed and that celiac disease biopsies are performed with this procedure (not colonoscopy.)

upper endoscopy (EGD) visualizes the throat through the 2nd portion of the duodenum (duodenal ulcer unlikely to beyond this point)
H. pylori status assessed
Celiac disease bx performed during EGD (not during colonoscopy)


Discuss why H. pylori screening of patients who do not have sx of PUD may lead to unnecessary treatment.

H. pylori is a commensurate and although it is linked to PUD, there are plenty of cases where people that have H. pylori don’t have PUD


What cause of GERD might be managed with phosphatidylcholine and Huperzine A?

To improve tone of sphincters, mucosal health, and GI motility


List the effect of the following on gastric acid levels:
antral gastritis
early (1st 3 mo) of gastritis

a) H. pylori pangastritis - hypochlorhydria
b) H. pylori antral gastritis- hyperchlorhydria
c) early (first 3 months) of any H. pylori gastritis - hypochlorydria