A patient who has chronic peptic ulcer asks for the best method for curing this disease. Your answer is:
Correct Answer A: H. pylori and NSAIDs disrupt normal mucosal defense and repair, making the mucosa more susceptible to acid. H. pylori infection is present in 50 to 70% of patients with duodenal ulcers and 30 to 50% of patients with gastric ulcers. If H. pylori is eradicated, only 10% of patients have recurrence of peptic ulcer disease, compared with 70% recurrence in patients treated with acid suppression alone.
Symptoms include pain often localized to the epigastrium and relieved by food or antacids. The pain is described as burning or gnawing, or sometimes as a sensation of hunger. The course is usually chronic and recurrent.
Diagnosis of peptic ulcer is suggested by patient history and confirmed by endoscopy (EGD). Treatment of gastric and duodenal ulcers requires eradication of H. pylori when present.
Methods of decreasing acidity include a number of drugs including proton pump inhibitors and H2 blockers. Nissen fundoplication is a surgical treatment for chronic GERD.
A 35-year-old woman who was born in Vietnam has had her dyspepsia diagnosed by endoscopy as a duodenal ulcer. Her pathology is positive for Helicobacter pylori. She has not previously been diagnosed with peptic ulcer disease.
What would be the preferred treatment option?
Correct Answer A: A peptic ulcer is a round or oval sore where the lining of the stomach or duodenum has been eaten away by stomach acid and digestive juices. Because infection with H. pylori bacteria is a major cause of ulcers, antibiotics are often used. Neutralizing or reducing stomach acid by taking drugs that directly inhibit the stomach's production of acid promotes healing of peptic ulcers regardless of the cause. In most people, treatment is continued for 4 to 8 weeks.
Proton pump inhibitors (eg omeprazole) are the most potent of the drugs that reduce acid production. Proton pump inhibitors promote healing of ulcers in a greater percentage of people in a shorter period of time than do histamine (H2) blockers.
A 65-year-old man presents with a history of paroxysms of sweating, palpitations, headaches and anxiety. This happens off and on. His blood pressure on exam is 156/95 mmHg. On further history he tells you that one of his relatives had thyroid cancer.
At this time what tests should be done first?
Correct Answer A: This patient needs to be screened for pheochromocytoma. Pheochromocytoma is a tumor of the adrenal gland which causes very high levels of the catecholamines (epinephrine and norepinephrine) to be secreted into the bloodstream. This can lead to many sympathetic nervous system symptoms like elevated blood pressure, palpitations, anxiety, diaphoresis, headaches, weight loss. These symptoms happen is spurts or paroxysms.
Diagnoses is made by measuring the level of the catecholamines and their breakdown products or metabolites which are called metanephrines in a 24 hour urine collection. Treatment involves medicines to control the blood pressure and surgery to remove the tumor. (Metanephrine levels are considered the most sensitive and specific test for a pheochromocytoma, while vanillylmandelic acid is the least specific test and has a false-positive rate greater than 15%.).
Recall the MEN syndromes. MEN (Multiple endocrine neoplasia) has three types:
This patient could have MEN IIb if you consider his family history.
A 40-year-old woman has episodic headaches that last 30 minutes and are associated with sweating, palpitations, and feelings of apprehension. She has lost 6.8 kg over the past three months. Physical examination reveals a thin woman with a pulse of 112 beats/minute and a blood pressure of 150/100 mmHg lying and 130/80 mmHg standing.
Which one of the following is the most likely diagnosis?
Correct Answer A: A pheochromocytoma is a catecholamine-secreting tumor of chromaffin cells typically located in the adrenals. It causes persistent or paroxysmal hypertension. Diagnosis is by measuring catecholamine products in blood or urine. Imaging tests, especially CT or MRI, help localize tumors. Treatment involves removal of the tumor when possible. Drug therapy for control of BP includes alpha-blockade, possibly combined with beta-blockade. Initiate a beta blocker only after adequate alpha blockade (usually, 2 days).
A 38-year-old woman has episodic headaches that are associated with sweating, palpitations, and feelings of apprehension. She has lost 7 kg over the past three months. Physical examination reveals:
Which one of the following is the most helpful diagnostic test?
Correct Answer E: A pheochromocytoma is a catecholamine-secreting tumor of chromaffin cells typically located in the adrenals. It causes persistent or paroxysmal hypertension. Diagnosis is by measuring catecholamine products in blood or urine. Imaging tests, especially CT or MRI, help localize tumors. Treatment involves removal of the tumor when possible. Drug therapy for control of BP includes alpha-blockade, possibly combined with beta-blockade.
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