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Clinical Case Study
Peptic Ulcer Disease: A Case on the Digestive System


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It's Friday morning and Sal Volpe is sitting in Dr. Lorraine's exam room, dozing after another night of disrupted sleep. When the doctor knocks and walks in, she finds the 66-year-old man looking exhausted and uncomfortable. Sal gets to the reason for his visit immediately: He's been suffering from "stomach aches" (dyspepsia) that wake him at night and nag him in between meals during the day. He describes his pain as gnawing, burning (maybe a 4 out of 10 on a pain scale) and points to the epigastric region of his abdomen. When he eats, he tells Dr. Lorraine, the pain goes away, but then he feels bloated and a little nauseated. The pain usually returns 2–4 hours later, depending on what he eats. Sal explains that he has had some pain relief from the over-the-counter drug Pepcid® (famotadine).

Dr. Lorraine proceeds with the history and physical exam. She discovers that Sal has a family history for gastrointestinal cancer and has unintentionally lost 10 pounds since his checkup a year ago. His epigastric area is modestly tender to palpation. She suspects a peptic ulcer (gastric or duodenal), but the weight loss and family history make it prudent to eliminate the diagnosis of stomach (gastric) cancer. "Mr. Volpe, I think you may have a stomach or intestinal ulcer," Dr. Lorraine says. "I suggest we perform an endoscopy to have a look. This involves passing a small tube with a small camera through your mouth and into your stomach. We can look at the wall of your stomach and small intestine, check for an ulcer, and remove a very small piece of tissue to test for infection. We call this a biopsy. We'll also test the biopsy for cancer because of your family history. But, I really think we're dealing with an ulcer here and not cancer."

Later that month, the endoscopy is performed and it confirms Dr. Lorraine's suspicions. Sal has a duodenal ulcer and infection with the bacterium Helicobacter pylori (H. pylori). This is not surprising since H. pylori is the cause of most peptic ulcer disease, particularly in the duodenum. Treatment involves complete eradication of the H. pylori with two different antibiotics, and a drug that decreases gastric acid secretion, a so-called proton pump inhibitor (PPI). Dr. Lorraine explains to Sal, "Mr. Volpe, you do not have stomach cancer, but you do have a duodenal ulcer caused by the H. pylori bacteria I was telling you about. Too much acid and inflammation from this infection is causing your pain. The good news is we can probably cure your ulcer by killing the bacteria, but you will have to take three different medications twice a day for 14 days. I'll see you again in 3 weeks; we can do a simple breath test to determine if the H. pylori has been successfully eliminated."

Short Answer Questions

  1. As Dr. Lorraine is listening to Mr. Volpe's complaints she automatically visualizes the organs in the epigastric region that are the potential source of his problems. Where is the epigastric region and what organs associated with digestion are located in that area?
  2. The structures in the epigastric region share a common nerve supply. Can you name the specific cranial nerve that serves this region and the part of the nervous system to which it belongs?
  3. In order to understand the disease in Mr. Volpe's alimentary canal, one must know the layers that make up its walls. Design a chart that identifies the four basic layers of the alimentary canal, the tissues that make up each layer, and the general function of each layer.
  4. Dr. Lorraine suspects a peptic ulcer. This is an inflammatory lesion in the stomach or duodenal mucosa, which may extend through all layers of the alimentary canal wall. Describe the basic histological (tissue) structure of the mucosa layer in the alimentary canal. Identify the unique features of the mucosa in the stomach and in the duodenum, and explain how this uniqueness determines the function of the stomach and the duodenum.
  5. Mr. Volpe asks, "What do the bacteria have to do with the ulcer?" Dr. Lorraine tells him that the H. pylori increases stomach acid secretion and, at the same time, breaks down the lining of your stomach and duodenum. What is the source and normal function of acid in the stomach and what regulates its production?
  6. Dr. Lorraine also explains to Mr. Volpe that H. pylori impairs the normal buffering effect in his duodenum. What does she mean by the "buffering effect?" How does the duodenum accomplish this, and in what way does this protect the duodenum?
  7. The medication Pepcid® that Mr. Volpe took for partial relief of his dyspepsia is called an H2 (histamine) receptor antagonist, or H2 blocker. That means it prevents histamine release. What is the normal function of histamine in the stomach and how might this help Mr. Volpe's hyperacidity problem?
  8. H. pylori weakens the duodenal mucosa making it more susceptible to gastric juice. Besides the high acidity, why are the contents of gastric juice so hostile to the exposed duodenal wall?
  9. Why is Mr. Volpe's dyspepsia relieved by food, and aggravated 2-4 hours after a meal?
  10. One year after Mr. Volpe's therapy, Dr. Lorraine performs a follow-up endoscopy and is delighted to see a healed and healthy duodenum. Describe what she sees through the lens of her endoscope as she looks at the lining of the duodenum.





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