Lab 1: GIT Cases PDF

Lab. 1: GIT Cases Dr. Safy Salah Code: OSM 2-1 b 2 Issue 1/ 2018 Code: OSM 2-1 b 3 Code: OSM 2-1 b 4 Issue 1/ 2018  Code of conductEffectiv e interact...

Lab. 1: GIT Cases Dr. Safy Salah Code: OSM 2-1 b 2 Issue 1/ 2018 Code: OSM 2-1 b 3 Code: OSM 2-1 b 4 Issue 1/ 2018  Code of conductEffectiv e interact ion Switch off Mutual mobile respect phones Smile Appreci Struggl ate our e to be differen on time ces Code: OSM 2-1 Focus b on topic 5 Issue 1/ 2018  Case 1 An adult daughter takes her mother, a 75-year-old woman, to her primary care physician because she is losing weight and can't keep meals down. The patient has had trouble swallowing both solid and liquid food for several months. She regurgitates undigested food regularly. The patient reports a feeling of "fullness" and pain in her chest. She also coughs and aspirates a lot while eating. Physical examination was normal but X-ray of the chest showed an air-fluid interface in an enlarged, fluid-filled esophagus. Barium esophagography revealed esophageal dilation, a loss of esophageal peristalsis, and poor Code: OSM 2-1 b esophageal emptying. Endoscopic examination was normal 6 with no sign of carcinoma. Esophageal manometry: Confirms complete absence of  Case 1 1. What is the most probable diagnosis of this case? 2. Which structure that limit the retrograde entry of food into the oesophagus ? Explain ? 3. Explain mechanisms of movement of swallowed food through oesophagus? 4. Which symptom in this case directed you to think about this diagnosis? Code: OSM 2-1 b 5. How to treat this condition? 7  Case 1 1. What is the most probable diagnosis of this case? Achalasia 2. Which structure that limit the retrograde entry of food into the oesophagus ? Explain ? LES The LES is made up of three components. 1. Esophageal smooth muscle is more prominent at junction with stomach (intrinsic sphincter). 2. Fibers of crural portion of diaphragmsurround the esophagus at this point (extrinsic sphincter) Intrinsic and extrinsic sphincters operate together to permit flow of food into stomach and prevent reflux of gastric contents into esophagus. Code: OSM 2-1 b 3. Oblique fibers of stomach wall create a flap valve that helps close off the esophagogastric 8 junction and prevent regurgitation when intragastric pressure rises.  Case 1 3. Explain mechanisms of movement of swallowed food through oesophagus? Primary peristalsis: continuation of the peristaltic wave of pharynx. Secondary peristaltic waves: If primary peristaltic wave fails. Code: OSM 2-1 b Result from distention of esophagus by food. 9  Case 1 4. Which symptom in this case directed you to think about this diagnosis? 1. losing weight 2. Trouble swallowing 3. Regurgitates undigested food regularly 4. "fullness" and pain in her chest. Code: OSM 2-1 5. coughs and aspirates a lot while eating. b 10  Case 1 5. How to treat this condition? It is treated by dilation of the sphincter, esophageal muscle incision or by injection of botulinum toxin in the LES to inhibit acetylcholine release. Code: OSM 2-1 b 11  Case 2 A 33-year-old male presents with a one-month history of episodes of mid-epigastric pain, a “burning” sensation in his chest. The pain worsens after eating and when he is lying flat. He also states waking up from the pain and burning, with a sore throat and hoarse voice. The patient reports intake of aspirin and ibuprofen to relive pain. The symptoms are partially relieved by adjusting from a lying to a sitting position and with the use of over-the-counter (OTC) medications Zantac. The physician has decreased the patient’s dose of daily aspirin and Code: OSM 2-1 b recommended discontinuing his ibuprofen. The physician has 12 prescribed omeprazole.  Case 2 1. What is your possible diagnosis? 2. How is acid produced and controlled within the gastrointestinal tract? 3. What is the etiology of GERD? What factors affect LES pressure? 4. Identify the patient’s signs and symptoms that could suggest the diagnosis of gastroesophageal reflux disease. 5. The physician decreased the patient’s dose of daily aspirin and recommended discontinuing his ibuprofen. How do aspirin and NSAIDs affect gastroesophageal disease? 6. The physician has prescribed omeprazole. What class of Code: OSM 2-1 medication is this? b 13  1. What is your possible diagnosis? Gastro esophageal reflux disease GERD Code: OSM 2-1 b 14  2. How is acid produced and controlled within the gastrointestinal tract? The acids are produced by parietal cells in the stomach. These cells secrete HCL and intrinsic factors. Acetylcholine, histamine, and gastrin which stimulate secretions and then somatostatin which inhibits secretions. 3 phases. 1. cephalic phase: HCL and pepsinogen are released from the smell, taste, or even sight of food. 2. gastric phase: food enters the stomach and more gastric juices are released. 3. intestinal phase: chyme entry in small intestine. Code: OSM 2-1 b 15  3. What is the etiology of GERD? What factors affect LES pressure? LES control the release of the bolus from the esophagus into the stomach. LES tone prevent stomach contents from refluxing back into the esophagus, which will allow more air to enter the stomach. The tone of the LES is under neural control: a. Acetylcholine released from vagal nerve endings causes contractions of LES. b. Nitric oxide (NO) and VIP from interneurons innervated by other Code: OSM 2-1 b vagal fibres cause it to relax. 16 Other factors that affect it are smoking, some foods, some medications, a hormone gastrin.  4. Identify patient’s signs and symptoms that could suggest the diagnosis of gastroesophageal reflux disease. Mid-epigastric pain, a “burning” sensation in his chest. Pain worsens after eating and when he is lying flat. Symptoms are partially relieved by adjusting from a lying to a sitting position and with the use of over-the-counter (OTC) medications Zantac. Code: OSM 2-1 b 17  5. How do aspirin and NSAIDs affect gastroesophageal disease? Aspirin or NSAIDs are non-steroidal anti- inflammatory drugs promote reflux to happen. Code: OSM 2-1 b 18  6. The physician has prescribed omeprazole. What class of medication is this? Omeprazole is a proton pump inhibitor, this means that they block H+, K+-ATPase enzyme, a component of HCL production. Code: OSM 2-1 b 19  Case 3 A cigarette-smoking, nervous, 52 years old man goes to his doctor with extreme burning epigastric pain that starts right after he eats. After eating, the pain may subside for a short time then reappearing two hours later. Antacids have previously relieved the pain, but not by nonsteroidal anti-inflammatory drugs (NSAIDs). History of the patient showed that he has smoked one pack of cigarettes per day and consumed 5 cups of coffee per day. He claims to have lost 9 pounds in the last 4 months without dieting or exercising. On physical examination, the patient appears to be in good health, but he reports epigastric tenderness to deep palpation. Laboratory stool analysis revealed positive occult blood and Code: OSM 2-1 b positive Helicobacter pylori antigen assay. 20 Endoscopic examination with gastric mucosal biopsy found an ulcer and H. pylori infection confirmed by the biopsy.  Case 3 1. What is the most probable diagnosis of this case? 2. Explain the pathophysiological mechanisms involved in developing such diagnosis in this case? 3. Discuss the exact mechanism of acid secretion in the stomach? 4. What are the factors the increase gastric acid secretion? 5. Suggest the most effective treatment of this case? Code: OSM 2-1 b 21  Case 3 1. What is the most probable diagnosis of this case? Peptic ulcer Code: OSM 2-1 b 22  Case 3 2. Explain the pathophysiological mechanisms involved in developing such diagnosis in this case? Breakdown of Gastric Mucosal Barrier produced by: A cigarette-smoking, nervous, 52 years. History of the patient showed that he has smoked one pack of cigarettes per day and consumed 5 cups of coffee per day. Code: OSM 2-1 b 23  Case 3 3. Discuss the exact mechanism of acid secretion in the stomach? Code: OSM 2-1 b 24  Case 3 4. What are the factors the increase? 1. Histamine: acts via H2 receptors. H2 receptor stimulation increases intracellular cAMP. 2. Acetylcholine: acts via M3 muscarinic receptors. M3 receptor increases intracellular ca++. 3. Gastrin: it acts either directly on oxyntic cells by increasing intracellular ca++ (like acetylcholine) or indirectly through Code: OSM 2-1 b stimulating the secretion of histamine from enterochromaffin-like 25 cells (ECL cells).  Case 3 5. Suggest the most effective treatment of this case? (1) Inhibition of acid secretion: a) Blockage of H2 histamine receptors on the parietal cells, e.g. by cimetidine. b) Inhibit H+-K+ ATPase in apical membrane of parietal cells by proton pump inhibitors e.g. Omeprazole. (2) Eradication of Helicobacter pylori with antibiotics. (3) Stop smoking, use of aspirin and non-steroidal anti-inflammatory Code: OSM 2-1 b drugs. 26 (4) Surgical removal of gastrin-secreting tumors. Code: OSM 2-1 b 27 Issue 1/ 2018