MOD6-IM2-T3-Disorders of the Stomach and Duodenum-2 PDF

IM2 INTERNAL MEDICINE 2 Disorders of the Stomach and Duodenum TRANS 3...

IM2 INTERNAL MEDICINE 2 Disorders of the Stomach and Duodenum TRANS 3 MODULE 6 D.R.L. Sebollena, M.D. September 11, 2024 LECTURE OUTLINE III. DYSPEPSIA I Anatomy of the Stomach and Duodenum The most common condition seen in the OPD Characterized as a chronic discomfort/pain in the upper abdomen II Physiology of the Stomach Usually present with fullness, early satiety, and burning epigastric III Dyspepsia pain. A. Approach to Dyspepsia Affects 30-40% of the population 20% is caused by an underlying organic disorder, such as: IV Peptic Ulcer Disease ○ GERD A. Pathophysiology ○ Gallstones ○ Malignancy V NSAID-Induced PUD ○ Coronary Artery Disease VI H. pylori Associated PUD ○ Adverse reactions on medications (NSAIDs, anti-hypertensives, nitrates) 🧠 Must Know 📖 Book 📝 Previous Trans 80% of patients usually present with a negative test on evaluation A. APPROACH TO DYSPEPSIA I. ANATOMY OF THE STOMACH AND DUODENUM History and Physical Examination is key Muscular and highly vascular organ Very Important to note for presence of alarm symptoms such as: Celiac trunk – right and left gastric arteries, left and right gastro-omental arteries, and short gastric arteries 1 Unintentional weight loss 2 Dysphagia 4 MAIN PARTS 3 Odynophagia 1 Cardia 4 Anemia 2 Fundus 5 Vomiting 3 Body 6 History of GI malignancy 4 Pylorus TREATMENT 2 SPHINCTERS Usually proton pump inhibitors (PPI) and prokinetics ○ Also, very important is assurance. 1 Gastro-esophageal 2 Pyloric sphincter Figure 1. Parts of the Stomach Source: Batch 2025 II. PHYSIOLOGY OF THE STOMACH Digestion ○ 1 liter volume → 4 liters ○ 1-1.5 L of secretion ○ Contractions of gastric smooth muscles are generated by slow waves generated by myenteric cells of Cajal, which serve as GI pacemakers Figure 2 Overview of New-onset Dyspepsia ○ Alcohol and aspirin are directly absorbed in the stomach Source: Harrisons 21st Ed, p. 2450 - Diseases of GI System ○ Intrinsic factor – Vitamin B12 Gastrointestinal motility ○ Gastric emptying 2-6 hours Microbial defense ○ Acidic environment helps in inhibiting/killing bacteria AcaComm | Disorders of the Stomach and Duodenum 1 of 8  Exclude history of GERD, IBS, If the defense mechanisms and repair systems are overwhelmed Patient is more than 40 → gastric and duodenal ulcer development biliary pain, aerophagia, and years old with alarm medication-related symptoms symptoms 1. PRE-EPITHELIAL BARRIER which may cause dyspepsia. Mucus-bicarbonate-phospholipid layer Patient presents WITH Refer to a gastroenterologist Physiochemical barrier to acids alarm symptoms Prevents diffusion of noxious ions and molecules It is advised to do non-invasive H. Patient presents WITHOUT pylori testing or you can give an 2. EPITHELIAL BARRIER alarm symptoms empiric trial of H2 blockers or PPI Produces mucus, prostaglandins, and HCO3 Give anti-H. Pylori therapy, and Has ionic transporters to maintain intracellular pH and intracellular Patient is POSITIVE for H. after 4 weeks of treatment we tight junctions pylori testing confirm eradication via urea Has heat shock proteins to protect cells from cytotoxic agents and breath test or stool antigen test oxidative stress Symptoms remain or recur Refer to a specialist 3. SUB-EPITHELIAL BARRIER even with treatment and (gastroenterologist) Composed of microvascular system also providing HCO3 still tested POSITIVE Maintains supply of micronutrients and oxygen for H. pylori Functions to remove toxic metabolites Presently, we start PPI treatment for patients with dyspepsia. In our setting, stool antigen is available to confirm eradication of H. pylori. CASE 30 y/o male, was seen by a bystander with loss of 1 consciousness. He had bandages at the right temporal IV. PEPTIC ULCER DISEASE and orbital area. The bystander brought the patient to the emergency room. The doctor in the ER saw a EPIDEMIOLOGY medical ID indicating that the patient was recently Peptic ulcer disease prevalence declined from 35.87% in 1996 to diagnosed with dementia, status post CVD last 2019. No 18.80% in 2002 relatives were around for history taking. ○ The reduction is due to a decrease in H. pylori infection. Incidence is similar for gastric ulcer and duodenal ulcer based on autopsy studies. ○ Incidence increases with age for both gastric and duodenal ulcers. According to the latest WHO data published in 2018 peptic ulcer disease deaths in the Philippines reached 6,283 or 1.03% of total deaths. The age adjusted death rate is 9.69 per 100,000 of population and ranks Philippines #18 in the world. A. DEFINITION Chief Complaint Peptic ulcer disease is defined as the defects (5mm or greater) Loss of consciousness in the gastric/duodenal mucosa which extends to the muscularis mucosa. Vital Signs The epithelium of the stomach is constantly under attack by BP = 90/60 several substances. HR = 108 Burning epigastric pain exacerbated by fasting and improves with RR = 20 meals is a symptom complex associated with PUD. T = 36.7°C >90% of patients with this symptom do not have ulcers. Weight = 60 kg Majority of patients with ulcers are asymptomatic. Height = 1.53 m NSAIDS (Non steroidal anti-inflammatory drugs) and H. pylori BMI = 25.6 🧠 infections are the major causes of peptic ulcer disease. Bleeding is the most common complication of peptic ulcer disease. Physical Examination Chest and lungs = unremarkable Cardiovascular system = Tachycardic, with regular rate, regular [HARRISONS] PEPTIC ULCER DISEASE (p.2434) rhythm A peptic ulcer is defined as disruption of the mucosal integrity of Abdomen: the stomach and/or duodenum leading to a local defect or ○ Flabby excavation due to active inflammation. ○ 15 bowel sounds per minute Although burning epigastric pain exacerbated by fasting and ○ Soft improved with meals is a symptom complex associated with ○ Non-tender peptic ulcer disease (PUD), it is now clear that >90% patients Pallor with this symptom complex (dyspepsia) do not have ulcers and ○ Pale palpebral conjunctiva that the majority of patients with peptic ulcers may be ○ Pale nail beds asymptomatic. Ulcers occur within the stomach and/or duodenum and are often chronic in nature. B. PATHOPHYSIOLOGY A biologic system is in place to provide defense and repair from any insult or injury in the gastric and duodenal mucosa. Constitutes a three-level barrier: What can you conclude with pallor? 1 Pre-epithelial barrier The patient is pale and has lost consciousness, probably due to 2 Epithelial barrier pallor or anemia. 3 Sub-epithelial barrier AcaComm | Disorders of the Stomach and Duodenum 2 of 8 What conditions could probably lead to this? Esophagogastroduodenoscopy (EGD) Possibly there’s bleeding What diagnostic imaging modality is needed to confirm our More or less the patient is hypotensive diagnosis? Esophagogastroduodenoscopy (EGD) or Upper gastrointestinal Rectal Exam endoscopy Most sensitive and specific approach for examining the upper GI Melena tract. This examination is done via the followings steps: 1 Photographic documentation 2 Tissue biopsy 3 Therapeutic modalities to control the bleeding and relieve any strictures Can you request for FOBT based on the physical findings present? No, since bleeding is obvious. FOBT is not just a test to detect malignancy, usually FOBT is done when a patient presents with anemia and the cause cannot be determined initially. For initial evaluation, FOBT can give us a clue if the anemia is due to bleeding in the GIT. ○ FOBT finds blood in the stool that cannot be seen. Blood in the stool may be a sign of colorectal cancer or another Our patient consented for Upper Gastrointestinal Endoscopy and medical problem, such as an ulcer or polyps. these were the images obtained from the endoscopy. Image 1 (Left) shows an ulcer on the pyloric ring (yellow Neurological Exam circle). The ulcer has a white base which means that a clot has Cranial nerves = shallow nasolabial fold, right already formed on the ulcer. Motor strength = 3⁄5 right Image 2 (Right) also shows a white based ulceration on the Sensory = can’t be assessed first part of the duodenum. Deep tendon reflexes (DTRs) = 1+ right ○ This confirms our impression. Primary Impression How do we manage our patient? Upper gastrointestinal bleeding secondary to bleeding peptic History and physical examination ulcer disease, the patient has dementia, and status post (s/p) Admit the patient CVD in 2019. ○ Give IV fluids Resuscitate Differentials NPO NOTE: Always consider the age (70/M) and comorbidity Blood transfusion (dementia and s/p CVD) of the patient. Acid lowering agents Other differentials of loss of consciousness of the patient aside ○ To facilitate ulcer healing from anemia are: acute cardiac event, re-stroke, or Identification of bleeding site hypoglycemia. Prevention of recurrence and complications CBC V. NSAID-INDUCED PUD Listed are the laboratory results that were requested. For the Dyspeptic symptoms do not usually correlate with NSAID-induced CBC the patient has a hemoglobin of 68 showing anemia, PUD elevation of WBC, and segmenters predominance. ○ No dose of NSAID is completely safe. Even a single dose can ○ HGB = 68 (N: 110-150) - Anemia induce ulceration. ○ HCT = 0.25 (N: 35-55) NSAIDs and COX2 have shown direct toxic effects on the gastric ○ WBC = 15,000 (N: 4,500-10,000) and duodenal mucosa. SEG = 0.82 History and physical examination are keys in managing patients LYM = 0.18 with PUD ○ PLT = 257,000 (N: 150,000-450,000) ○ identify patients at risk then educate them of NSAID use ○ Blood type = O+ Urinalysis RISK FACTORS Within acceptable limits 1 Advanced age ○ pH = 7.0 ○ Color = amber 2 History of ulcer ○ WBC = 5-8/hpf 3 Concomitant use of steroids and anticoagulants ○ RBC = 3-5/hpf ○ Sugar = negative 4 High dose and multiple NSAID use ○ Protein = negative 5 Multisystemic and chronic diseases Fecalysis Black tarry stools are noted as well as presence of RBC and pus CONT. A relative of the patient came into the ER and disclosed cells which may indicate ongoing infection. RBC presence may CASE that the patient is s/p CVD, the patient is maintained on be associated with ongoing bacterial or parasitic infections. ○ Color = black 1 aspirin and recently, 2 weeks ago, his wound or small laceration on his right temporal area was caused by his ○ Consistency = tarry fall due to weak right side of the body. The patient was ○ Pus Cells = 2-3/hpf given pain medications. ○ RBC = positive The patient has upper GI bleeding secondary to gastric ulcer, secondary to NSAID gastropathy. AcaComm | Disorders of the Stomach and Duodenum 3 of 8 A. PATHOPHYSIOLOGY CASE A 55-year old male was admitted in the wards and the 2 impression is Upper GI Bleeding secondary to NSAID gastropathy. The patient is a diagnosed case of chronic tophaceous gout and in the wards, upon referral to you, he complained of severe abdominal pain. Physical Examination BP: 150/90 mmHg HR: 180 bpm RR: 24 bpm T: 38°C, Rebound tenderness on all quadrants What is your impression? Perforated peptic ulcer disease Hypertensive cardiovascular disease Gouty arthritis in flare What imaging modality will you request to confirm your impression? Chest X-ray PA view (upright) Figure 3. Pathogenesis of NSAID-induced gastric damage With demonstration of pneumoperitoneum on chest radiograph, Source: Batch 2025 Trans this confirms, more or less, the diagnosis in the ward, and since the patient is unstable, what will be your next step? NSAID inhibits COX-1 and COX-2, and has a direct toxic and irritant effect on gastric mucosa. Referral for surgery (laparotomy) These reduce blood flow, cause epithelial damage, and leukocyte adherence. The patient was seen by the surgeon and scheduled for surgery All lead to mucosal injury and subsequent ulceration of gastric and which went well. The team obtained a specimen from the ulcer and duodenal mucosa. histopathologic examination revealed the following: Abundance of inflammatory cells B. TREATMENT OF PUD Absence of metaplasia or dysplasia Presence of spiral-shaped bacterium in H&E stain PROTON PUMP INHIBITOR (PPI) We now identified that there are two (2) underlying causes to the Drug of choice for PUD patient’s development of ulcer: ○ Omeprazole, lansoprazole, esomeprazole, pantoprazole 1. Chronic NSAID use Omeprazole is given in the Philippines as other members 2. Detection of H. pylori on biopsy of the proton pump inhibitor class are not part of the national formulary. VI. H. PYLORI-ASSOCIATED PEPTIC ULCER DISEASE MOA Inhibits all phases of acid secretion Along with NSAIDS, Helicobacter pylori (H. Pylori) is one of the ONSET OF Rapid onset of action most common cause of peptic ulcer disease ACTION ○ usually 2-6 hours maximum inhibition Gram negative microaerophilic helical shaped bacteria Class 1 Carcinogen based on WHO: asbestos exposure and H. DURATION OF 72-96 hours pylori are the only ones with data beyond reasonable doubt that INHIBITION can cause malignancy EFFICACY Maximized if taken before meals Usually, patients are asymptomatic, and we can only determine when a patient already has complications or has done a workup for TX DURATION Duodenal ulcer: 4-6 weeks dyspepsia Gastric ulcer: 6-8 weeks A/E Intrinsic factor production is inhibited A. PATHOPHYSIOLOGY ○ However, Vitamin B12 deficiency anemia H. pylori brings about chronic inflammatory state and with that we is uncommon due to large stores of B12 develop peptic ulcer disease and eventually gastric cancer Chronic use, especially among the elderly, leads to an increased risk of community acquired pneumonia DRUG Interferes absorption of certain drugs INTERFERENCE ○ Iron ○ Digoxin (Lanoxin) ○ Theophylline ○ Warfarin ○ Phenytoin In patients presenting with upper GI bleeding, PPI is given thru IV to lower the acid production in the intra-gastric area and to facilitate healing and to stabilize blood clot formation. Figure 4. Simplified pathophysiology of H. pylori infection. Source: Batch 2025 Trans TRANSMISSION Transmission occurs from person to person, following an: ○ Oral-oral ○ Fecal-oral route AcaComm | Disorders of the Stomach and Duodenum 4 of 8  RISK FACTORS 1 Domestic crowding 2 Unsanitary living conditions 3 Exposure to gastric contents of an infected individual PRINCIPLES OF MANAGEMENT 1 History and physical examination 2 Admit 3 Resuscitate 4 NPO 5 Blood transfusion 6 Acid Lowering Agents Figure 6. Algorithm for management of H. pylori infection 7 Identification of bleeding sites Source: Batch 2025 Trans 8 Prevention of recurrence and complications CASE 53/M It is very important to prevent the recurrence and complications of 3 → Chronic vomiting peptic ulcer disease and with that we need to treat H. pylori. → Weight loss → S/P Ex-lap secondary to perforated ulcer disease What is your impression? B. TREATMENT H. pylori Eradication Gastric outlet obstruction ○ Combination therapy for 14 days provides greatest efficacy What abdominal PE maneuver will you perform to confirm your ○ Triple Therapy diagnosis? Clarithromycin 500mg OD Amoxicillin 500mg 2 caps BID Succussion splash Proton Pump Inhibitors BID Nasogastric tube can also be inserted. ○ 30 days after treatment, do a confirmatory test for H. pylori ○ It is significant to note the nasogastric tube output to note if eradication the obstruction is relieved. Stool antigen Normal stomach volume is 1.5 L and gastric emptying occurs Urea breath test every 6 hours. In an 8 hour period, the NGT output should be less than 400 mL [HARRISONS] Helicobacter pylori INFECTIONS (p.1281) as a guide indicating that the obstruction has been relieved. ○ Some authors would say less than 300 mL in an 8 hour period. GASTRIC OUTLET OBSTRUCTION 3rd most common complication of peptic ulcer disease It is important to rule out gastric malignancy in patients presenting with gastric outlet obstruction ○ Thus, both endoscopy and imaging modalities are needed For gastric outlet obstruction, management is usually surgery especially if the underlying cause is due to a neoplasm STRESS-RELATED INJURY Acute erosive gastric mucosal injury, ulceration, and bleeding. Usually seen in patients with: ○ Shock ○ Sepsis ○ Massive burns Presenting with Curling’s ulcer ○ Severe trauma ○ Head injury or massive stroke Can develop Cushing's ulcer Most commonly seen in the fundus and the body of the stomach. Treatment of choice is proton pump inhibitors. VII. SUMMARY Peptic ulcer disease remains a significant cause of mortality in our setting. NSAIDs and H. pylori infection are the major causes of peptic ulcer Figure 5. Test used to detect H. pylori infection disease. Source: Batch 2025 Trans H. pylori is a Class 1 carcinogen. Hence, once detected, eradication is needed. Bleeding is the most common complication, followed by perforation and gastric obstruction outlet. Upper gastrointestinal endoscopy is the imaging modality of choice. Proton pump inhibitors are the drug of choice. Prevention of recurrence and complication is the main goal of treatment. AcaComm | Disorders of the Stomach and Duodenum 5 of 8  VIII. SYNCHRONOUS SESSION CASE 60 y/o male known diabetic CASE 2 35 y/o female 1 Chief Complaint Chief Complaint Fatigue “Masakit na sikmura” / Epigastric pain Salient Features Approach to Abdominal Pain 60 y/o male, diabetic Early satiety History Vomiting ○ Acute or Chronic Weight loss Important to distinguish if it is a surgical case s/p lap chole ○ Location/Radiation s/p angioplasty 12 years ago ○ Chronology of symptoms s/p EGD (gastric ulcer) 10 years ago ○ Aggravating and Relieving factors 30 pack years smoking history Occasional alcoholic drinker 2 months of epigastric pain accompanied with feeling of vomiting, pain scale of 7/10. Triggered by coffee. No chest pain, no Physical Examination dizziness and no headache. Pale palpebral conjunctiva Kremil S was taken for relief. No consultation was done. Eating Anicteric sclerae can sometimes relieve the pain, but not consistently. Virchow’s Node Physical Examination Succussion splash Consent Diagnosis Positioning Gastric Outlet Obstruction Exposure Inspection Differential Diagnosis Auscultation Palpation Diabetic Gastropathy ○ Examine tender areas for direct tenderness & rebound Uremic Gastropathy tenderness GI TB ○ Do modified/special techniques of palpation: light palpation, Achalasia deep palpation (single handed & reinforced), bimanual, Esophageal New Growth ballottement Diagnosis ○ Ballottement Percussion CBC ○ Percuss entire abdomen Urinalysis ○ Assess liver span Creatinine, Na, K, Mg, and Albumin ○ Traube’s space and Castell’s sign ○ Hypoalbuminemia (malnutrition) Special Maneuvers 12-L ECG ○ Fluid wave CXR-PA ○ Shifting dullness Upper Gastrointestinal Endoscopy ○ Succussion splash Whole Abdomen CT-scan ○ Murphy’s sign Therapeutic Management ○ For appendix: Rovsing’s sign, Obturator sign, Psoas sign ○ CVA tenderness Correct anemia Rectal Exam Correct malnutrition Patient’s position: supine with partially flexed knees Control diabetes Landmark when examining the abdomen: Surgical Referral ○ Female - Xiphoid process ○ Male - nipple line IX. REFERENCES Diagnosis Batch 2025 Trans Fauci, A. S., Kasper, D. L., Hauser, S. L., Longo, D. L., Jameson, J. L. Dyspepsia / Uninvestigated Dyspepsia (Eds.). (2022). Harrison's principles of internal medicine. New Differential Diagnosis York, NY: McGraw-Hill Medical. GERD Gallstones X. REVIEW QUESTIONS Early appendicitis No. QUESTIONS Parasitism UTI 1 Which among the following is the most common artery that bleeds in duodenal ulcer? Laboratory Work-ups A. Right gastroepiploic artery CBC B. Gastroduodenal artery Urinalysis C. Celiac artery Fecalysis D. Left gastric artery Whole abdomen ultrasound Treatment Proton Pump Inhibitors AcaComm | Disorders of the Stomach and Duodenum 6 of 8  2 A 28 y/o, female was brought to the ER due to loss of consciousness. BP = 80/60 ; HR = 110 ; RR = 20 ; T = 36. Compensatory mechanisms of the heart then cause Pale palpebral conjunctiva, soft/non-tender abdomen. She tachycardia. soiled herself while unconscious enroute to the ER. A is incorrect since ascariasis is an intestinal infection from the helminth Ascaris lumbricoides which can either be asymptomatic or symptomatic with abdominal pain, distention, and diarrhea, but NOT melena. B is wrong since dysentery is due to an inflammation of the intestines and would typically present with diarrhea, abdominal cramps, and blood in the stool. Since it often involves the colon, blood is red not black as in melena. A. Ascariasis B. Dysentery C is wrong since typhoid ileitis is an inflammation of the ileum C. Typhoid Ileitis due to Salmonella enterica which typically presents with high D. Bleeding peptic ulcer disease grade fever. Source: Batch 2025 Ratio 3 What is the most common complication of peptic ulcer disease? 3 CORRECT ANSWER: A. Bleeding A. Bleeding B. Acid reflux disease GI bleeding is the most common complication observed in PUD. C. Perforation Bleeding is estimated to occur in 19.4–57 per 100,000 D. Obstruction individuals in a general population or in ~15% of patients. Bleeding and complications of ulcer disease occur more often in 4 Which among the following is the MOST appropriate test to individuals > 60 years of age. confirm your diagnosis? A. Abdominal ultrasound B is incorrect because acid reflux disease or GERD is not a B. Upper Gastrointestinal Series common complication of PUD. It presents with classic C. Upper Gastrointestinal Endoscopy symptoms such as water brash and substernal heartburn. D. Fecalysis with occult blood Persistent GERD can lead to complications, such as 5 A 50 y/o male, sought consult due to... esophagitis or Barrett's esophagus which may mimic PUD. C is incorrect because perforation is the second most common complication of PUD. As in the case of bleeding, the incidence of perforation in the elderly appears to be increasing secondary to increased use of NSAIDs. Perforation of duodenal ulcers has become less common in light of the increased rates of H. pylori eradication with NSAID induced gastric ulcers leading to perforation occurring more commonly. PMHx = s/p EGD (Duodenal Ulcer) D is incorrect because obstruction is the least common ulcer-related complication, occurring in 1–2% of patients. A What is the MOST appropriate medication for his patient may have relative obstruction secondary to ulcer-related condition? inflammation and edema in the prepyloric region. This process A. COX-2 inhibitor often resolves with ulcer healing. A fixed, mechanical B. Tramadol plus methylprednisolone obstruction secondary to scar formation in the prepyloric areas C. NSAIDS plus proton pump inhibitor is also possible which requires endoscopic (balloon dilation) or D. Acetaminophen surgical intervention. Source: Batch 2025 Ratio XI. RATIONALIZATION 4 CORRECT ANSWER: C. Upper Gastrointestinal Endoscopy No. RATIONALIZATION In most circumstances, the standard of care for the initial 1 CORRECT ANSWER: B. Gastroduodenal artery diagnostic evaluation or first line assessment of suspected acute GI bleeding is urgent upper endoscopy and/or Gastric and duodenal mucosa is where ulcers are commonly colonoscopy, as recommended by guidelines from the American seen so the artery that supplies the majority of these parts are College of Gastroenterology and the 2010 International the gastroduodenal artery, a branch of the common hepatic Consensus Recommendations”. It is the most sensitive and artery. specific approach for examining the upper GI tract. A is incorrect because the right gastroepiploic artery is just a A is incorrect because abdominal ultrasound is not the most branch of the gastroduodenal artery and only supplies the recommended diagnostic tool to assess melena. Aside from stomach. this, it has limited visibility to visualize structures. C is incorrect because the celiac artery is a short branch from B is incorrect because upper gastrointestinal series is not the abdominal aorta that branches off to the common hepatic typically the first line test for investigating the cause of melena. artery and the left gastric artery. It cannot directly identify the source of bleeding in the upper GI tract, and it cannot capture active bleeding or provide detailed D is incorrect because the left gastric artery only supplies the information about mucosal abnormalities. Upper GI Series are inner curvature of the stomach. mostly used as a secondary/complementary test to help assess Source: Batch 2025 Ratio structural abnormalities which can contribute to bleeding. 2 CORRECT ANSWER: D. Bleeding peptic ulcer disease D is incorrect because FOBT is used to check for blood in the stool. Requesting FOBT is not needed because bleeding is Bleeding is the most common complication of peptic ulcer obvious. disease. In the setting of upper gastrointestinal bleeding from peptic ulcer, this manifests as melena or black tarry stools as Source: Batch 2025 Ratio shown in the image. Since there is internal bleeding, the patient becomes pale from the loss of intravascular volume and presents with hypotension. AcaComm | Disorders of the Stomach and Duodenum 7 of 8  5 CORRECT ANSWER: B. Tramadol plus methylprednisolone Tramadol is an opioid (analgesic) used to treat Osteoarthritis. Unlike other pain relievers such as non‐steroidal anti‐inflammatory drugs (NSAIDs), it does not cause bleeding in the stomach and intestines, or kidney problems. It also does not affect the cartilage at the end of the bones.” A is incorrect because COX-2 Inhibitors like Celecoxib an NSAID, is an approved treatment for osteoarthritis, however it can cause digestive problems such as ulcers. C is incorrect because NSAIDs, like Meloxicam can also be used, however it can cause stomach and intestinal problems such as bleeding and ulcers. D is incorrect because Acetaminophen in high doses may induce upper Source: Batch 2025 Ratio AcaComm | Disorders of the Stomach and Duodenum 8 of 8