醫(yī)學(xué)專業(yè)英語課件

ClinicalcasediscussionZhiHuaRanDepartmentofgastroenterologyRenJiHospital第一頁，共三十八頁。Questions

Whatarethecommoncausesofupperabdominalpain?第二頁，共三十八頁。AnswerGastroesophagealrefluxBiliarycolicFunctionaldyspepsiaPepticulcer(duodenalulcer,gastriculcer)GastriccancerIrritablebowelsyndrome第三頁，共三十八頁。QuestionsHowtodifferentiatethecommoncausesofupperabdominalpain?第四頁，共三十八頁。Answer---theclinicalfeatures

Gastroesophagealrefluxtypicallyproduces“heartburn”,orburningepigastricormid-chestpainaftermealsandworsewithrecumbencyBiliarycoliccausedbygallstonestypicallyhasanacuteonsetofseverepainlocatedintherightupperquadrantorepigastriumprecipitatedbymeals,fattyfoodsinparticularlasts30~60minwithspontaneousresolutionmorecommoninwomen第五頁，共三十八頁。Functionaldyspepsiacanbeassociatedwithfullness,earlysatiety,bloatingornauseacanbeintermittentorcontinuousmayormaynotberelatedtomealssymptompersistingatleast12weeksIrritablebowelsyndromeisadiagnosisofexclusionsuggestedbychronicdysmotilitysymptoms---bloating,crampingthatisoftenrelievedwithdefecationwithoutweightlossorbleedingAnswer---theclinicalfeatures

第六頁，共三十八頁。Pepticulcer(duodenalulcer,gastriculcer)DU:theclassicsymptomsofduodenalulcersarecausedbythepresenceofacidwithoutfoodorotherbufferssymptomsaretypicallyproducedafterthestomachisemptiedbutfood-stimulatedacidproductionstillpersists,typically2~5hafteramealpainwakepatientsatnight,whencircadianrhythmsincreaseacidproductionitistypicallyrelievedwithinminutesbyneutralizationofacidbyfoodorantacidsGU:aremorevariableintheirpresentationfoodmayactuallyworsensymptomspainmightnotberelievedbyantacidsAnswer---theclinicalfeatures

第七頁，共三十八頁。Gastriccancer>45yalarmsymptoms:weightloss,recurrentvomiting,dysphagia,bleeding,anemiaearliersatiety,painAnswer---theclinicalfeatures

第八頁，共三十八頁。Summary:A37-year-oldmanpresentscomplainingofchronicandrecurrentupperabdominalpainwithcharacteristicssuggestiveofduodenalulcer:thepainisburninginquality,occurswhenthestomachisempty,andisrelievedwithinminutesbyfoodorantacids.Hedoesn’thaveevidenceofgastrointestinalbleedingoranemia.Hedoesnottakenonsteroidalantiinflammatorydrugs,whichmightcauseulcerformation,buthedoeshaveserologicalevidenceofH.pyloriinfection.Answer---PepticUlcerDisease第九頁，共三十八頁。QuestionWhataretherolesofHelicobacterpylori(H.pylori)infectionandhowtodiagnoseH.pyloriinfection?第十頁，共三十八頁。Answer

H.pyloriisassociatedwithduodenalandgastriculcers,chronicactivegastritis,gastricadenocarcinoma,andgastricMALT(mucosa-associatedlymphoidtissue)lymphoma.第十一頁，共三十八頁。AnswerThediagnosisofH.pyloriinfectionDiagnosticmethodsforH.pyloriinfectionarecategorizedintotwogroupsas:Invasive

Noninvasive

第十二頁，共三十八頁。AnswerNoninvasive:doesnotneedendoscopicprocedure

Ureabreathtest---evidenceofcurrentactiveinfection

convenientmethod

H.pyloriantibody---evidenceofpriorinfection,willremainpositiveforlife

Stoolantigentest第十三頁，共三十八頁。AnswerInvasive:needendoscopicbiopsyofgastricmucosalsample

Pathology(usingspecialstaining:Giemsastaining,silverstaining,Gimenezstaining,immunohistochemistry,inadditiontoHematoxylin-eosinstaining)Rapidureasetest(RUT):H.pylorisplitstheureainthetestcontainertoyieldammonia.ElevationofthepHbyammoniumhydroxideproducedindetectedbyacolorchangeofthepHindicator.

Advantage:inexpensive,easetouse,rapiddiagnosticmethodsDisadvantage:requireendoscopy,false-negative第十四頁，共三十八頁。AnswerInvasive:MicroaerobicbacterialcultureAdvantage:perfectspecificity(100%),allowingfurthercharacterizationoftheorganisms(determiningitssensitivitytoantibiotics)Disadvantage:mostdifficulttouseinclinicalsetting第十五頁，共三十八頁。QuestionWhatisthemostcommoncauseofduodenalandgastriculcers?

第十六頁，共三十八頁。AnswerH.pyloriinfectionanduseofNSAIDsarethecommoncausesofpepticulcer第十七頁，共三十八頁。QuestionWhataretherolesofHelicobacterpyloriinfectionintheetiologyofpepticulcerdisease?第十八頁，共三十八頁。ProposednaturalhistoryofH.pyloriinfectioninhuman

ChronicActiveGastritisAcuteGastritisAntralPredominantGastritisDuodenalUlcerlymphomaEnvironmentalfactorsMultifocalAtrophicGastritisGastricCancerGastricUlcerlymphoma95%~100%80%~90%第十九頁，共三十八頁。QuestionWhataretherolesofNSAIDsuseintheetiologyofpepticulcerdisease?第二十頁，共三十八頁。AnswerInendoscopicclinicalresearchstudiesofpatientswhotakeNSAIDs,10~20%ofpatientsinthefirst3monthsofNASIDusedevelopnewgastriculcersand4%to10%developduodenalulcers.Theypromoteulcerformationbyinhibitinggastroduodenalprostaglandinsynthesis,resultinginreducedsecretionofmucusandbicarbonateanddecreasedmucosalbloodflow.Inshort,theyimpairlocaldefenseagainstaciddamage.TheriskofulcerformationcausedbyNASIDuseisdose-dependent,andcanoccurwithindaysaftertreatmentisinitiated.第二十一頁，共三十八頁。AnswerArarecauseofulceristheZollinger–Ellisonsyndrome.Itistheconditioninwhichagastrin-producingtumor(usuallypancreatic)causesacidhypersecretion,pepticulceration,anddiarrhea.ThisconditionshouldbesuspectedifulcerdiseaseoccursandthepatientisH.pylorinegativeanddoesnotuseNSAIDs.Todiagnosethiscondition,serumgastrinlevelsshouldbemeasured(>1000pg/ml),andthentrytolocalizethetumorwithanimagingstudy.第二十二頁，共三十八頁。QuestionWhataretheotherclinicalmanifestationsofpepticulcerdisease?第二十三頁，共三十八頁。Answer---complications

Hemorrhage:isthemostcommonseverecomplicationofpepticulcerdisease,andcanpresentwithhematemesisormelena.

Free

perforationintotheabdominalcavitymayoccur,withasuddenonsetofpainanddevelopmentofperitonitis

Gastricoutletobstructionmaydevelopinsomepatientswithchroniculcers,withpersistvomitingandweightlossPerforationandobstructionareindicationsforsurgicalintervention第二十四頁，共三十八頁。QuestionWhatisyournextstep?第二十五頁，共三十八頁。AnswerEradicationofH.pylori第二十六頁，共三十八頁。QuestionDoyouknowanytreatmentregimenforH.pylorieradication?第二十七頁，共三十八頁。AnswerPPIbasedtripletherapyomeprazole,lansoprazole,pantoprazole,rabeprazoleBismuthbasedtripletherapy(colloidalbismuthsubcitrate)Metronidazole:400mgbidAmoxicillin:500mgbidClarithromycin:250~500mgbidTetracycline:500~1000mgbidFurazolidone:100mgbidRanitidineBismuthCitrate(RBC)7~14days第二十八頁，共三十八頁。AnswerAntisecretorytreatment:lastsfor2~4weeks第二十九頁，共三十八頁。Comprehensionquestions(I)A42-year-oldoverweight,thoughotherwisehealthy,womenpresentswiththesuddenonsetofrightupperabdominalcolickypain45minutesafteramealoffriedchicken.Thepainisassociatedwithnauseaandvomiting,andanyattempttoeatsincehascausedincreasedpain.Themostlycauseis:A:GastriculcerB:CholelithiasisC:DuodenalulcerD:Acutehepatitis第三十頁，共三十八頁。Answer---BRightupperabdominalpainthathasanacuteonsetaftertheingestionofafattymealandthatisassociatedwithnauseaandvomitingismostsuggestiveofbiliarycolicasaresultofgallstones.Duodenalulcerpainislikelytobedeterminedwithfood,andgastriculcerpainisnotlikelytohavetheacutesevereonset.Acutehepatitisismorelikelytoproducedullacheandtenderness第三十一頁，共三十八頁。Comprehensionquestions(II)WhichofthefollowingisnottrueofH.pyloriinfection:A.ItismorecommonindevelopingcountiesItisassociatedwiththedevelopmentofgastriclymphomaItisbelievedtobethecauseofnonulcerdyspepsiaTherouteoftransmissionisbelievedtobefecal–oralItisbelievedtobeacauseofmostduodenalandgastriculcer第三十二頁，共三十八頁。Answer---CWhileH.pyloriisclearlylinkedtogastricandduodenalulcers,andprobablytogastriccarcinomaandlymphoma,itisunclearwhetheritismorecommoninpatientswithnonulcerdyspepsia,orwhethertreatmentinthosepatientsreducessymptoms.第三十三頁，共三十八頁。Comprehensionquestions(III)A45-year-oldmalewasbroughttotheemergencyroomaftervomitingbrightredblood.Hehasabloodpressureof88/46mmHgandheartrateof120bpm.Whichofthefollowingisthebestnextstep?IVfluidresuscitationandpreparationforatransfusionAdministrationofaprotonpumpinhibitorGuaiactestthestoolTreatmentforH.pyroli第三十四頁，共三十八頁。Answer---AThispatientishemodynamicallyunstablewithhypotensionandtachycardiaasaconsequenceoftheacutebloodloss.Volumeresuscitation,immediatelywithcrystalloidorcolloidsolution,followedbybloodtransfusion,ifnecessary,istheinitialsteptopreventirreversibleshockanddeath.Later,afterstabilization,acidsuppressionandH.pyloritreatmentm