医学专业英语课件_4

ClinicalcasediscussionZhiHuaRanDepartmentofgastroenterologyRenJiHospitalQuestionsWhatarethecommoncausesofupperabdominalpain?Answer•Gastroesophagealreflux•Biliarycolic•Functionaldyspepsia•Pepticulcer(duodenalulcer,gastriculcer)•Gastriccancer•IrritablebowelsyndromeQuestionsHowtodifferentiatethecommoncausesofupperabdominalpain?Answer---theclinicalfeatures•Gastroesophagealrefluxtypicallyproduces“heartburn”,orburningepigastricormid-chestpainaftermealsandworsewithrecumbency•Biliarycoliccausedbygallstonestypicallyhasanacuteonsetofseverepainlocatedintherightupperquadrantorepigastriumprecipitatedbymeals,fattyfoodsinparticularlasts30~60minwithspontaneousresolutionmorecommoninwomen•Functionaldyspepsiacanbeassociatedwithfullness,earlysatiety,bloatingornauseacanbeintermittentorcontinuousmayormaynotberelatedtomealssymptompersistingatleast12weeks•Irritablebowelsyndromeisadiagnosisofexclusionsuggestedbychronicdysmotilitysymptoms---bloating,crampingthatisoftenrelievedwithdefecationwithoutweightlossorbleedingAnswer---theclinicalfeatures•Pepticulcer(duodenalulcer,gastriculcer)DU:theclassicsymptomsofduodenalulcersarecausedbythepresenceofacidwithoutfoodorotherbufferssymptomsaretypicallyproducedafterthestomachisemptiedbutfood-stimulatedacidproductionstillpersists,typically2~5hafteramealpainwakepatientsatnight,whencircadianrhythmsincreaseacidproductionitistypicallyrelievedwithinminutesbyneutralizationofacidbyfoodorantacidsGU:aremorevariableintheirpresentationfoodmayactuallyworsensymptomspainmightnotberelievedbyantacidsAnswer---theclinicalfeatures•Gastriccancer45yalarmsymptoms:weightloss,recurrentvomiting,dysphagia,bleeding,anemiaearliersatiety,painAnswer---theclinicalfeaturesSummary:A37-year-oldmanpresentscomplainingofchronicandrecurrentupperabdominalpainwithcharacteristicssuggestiveofduodenalulcer:thepainisburninginquality,occurswhenthestomachisempty,andisrelievedwithinminutesbyfoodorantacids.Hedoesn’thaveevidenceofgastrointestinalbleedingoranemia.Hedoesnottakenonsteroidalantiinflammatorydrugs,whichmightcauseulcerformation,buthedoeshaveserologicalevidenceofH.pyloriinfection.Answer---PepticUlcerDiseaseQuestionWhataretherolesofHelicobacterpylori(H.pylori)infectionandhowtodiagnoseH.pyloriinfection?AnswerH.pyloriisassociatedwithduodenalandgastriculcers,chronicactivegastritis,gastricadenocarcinoma,andgastricMALT(mucosa-associatedlymphoidtissue)lymphoma.Answer•ThediagnosisofH.pyloriinfectionDiagnosticmethodsforH.pyloriinfectionarecategorizedintotwogroupsas:InvasiveNoninvasiveAnswer•Noninvasive:doesnotneedendoscopicprocedureUreabreathtest---evidenceofcurrentactiveinfectionconvenientmethodH.pyloriantibody---evidenceofpriorinfection,willremainpositiveforlifeStoolantigentestAnswer•Invasive:needendoscopicbiopsyofgastricmucosalsamplePathology(usingspecialstaining:Giemsastaining,silverstaining,Gimenezstaining,immunohistochemistry,inadditiontoHematoxylin-eosinstaining)Rapidureasetest(RUT):H.pylorisplitstheureainthetestcontainertoyieldammonia.ElevationofthepHbyammoniumhydroxideproducedindetectedbyacolorchangeofthepHindicator.Advantage:inexpensive,easetouse,rapiddiagnosticmethodsDisadvantage:requireendoscopy,false-negativeAnswer•Invasive:MicroaerobicbacterialcultureAdvantage:perfectspecificity(100%),allowingfurthercharacterizationoftheorganisms(determiningitssensitivitytoantibiotics)Disadvantage:mostdifficulttouseinclinicalsettingQuestionWhatisthemostcommoncauseofduodenalandgastriculcers?AnswerH.pyloriinfectionanduseofNSAIDsarethecommoncausesofpepticulcerQuestionWhataretherolesofHelicobacterpyloriinfectionintheetiologyofpepticulcerdisease?ProposednaturalhistoryofH.pyloriinfectioninhumanChronicActiveGastritisAcuteGastritisAntralPredominantGastritisDuodenalUlcerlymphomaEnvironmentalfactorsMultifocalAtrophicGastritisGastricCancerGastricUlcerlymphoma95%~100%80%~90%QuestionWhataretherolesofNSAIDsuseintheetiologyofpepticulcerdisease?Answer•InendoscopicclinicalresearchstudiesofpatientswhotakeNSAIDs,10~20%ofpatientsinthefirst3monthsofNASIDusedevelopnewgastriculcersand4%to10%developduodenalulcers.•Theypromoteulcerformationbyinhibitinggastroduodenalprostaglandinsynthesis,resultinginreducedsecretionofmucusandbicarbonateanddecreasedmucosalbloodflow.Inshort,theyimpairlocaldefenseagainstaciddamage.•TheriskofulcerformationcausedbyNASIDuseisdose-dependent,andcanoccurwithindaysaftertreatmentisinitiated.Answer•ArarecauseofulceristheZollinger–Ellisonsyndrome.•Itistheconditioninwhichagastrin-producingtumor(usuallypancreatic)causesacidhypersecretion,pepticulceration,anddiarrhea.•ThisconditionshouldbesuspectedifulcerdiseaseoccursandthepatientisH.pylorinegativeanddoesnotuseNSAIDs.•Todiagnosethiscondition,serumgastrinlevelsshouldbemeasured(1000pg/ml),andthentrytolocalizethetumorwithanimagingstudy.QuestionWhataretheotherclinicalmanifestationsofpepticulcerdisease?Answer---complications•Hemorrhage:isthemostcommonseverecomplicationofpepticulcerdisease,andcanpresentwithhematemesisormelena.•Freeperforationintotheabdominalcavitymayoccur,withasuddenonsetofpainanddevelopment