Peptic Ulcer

Question 1

Stem: patient with known peptic ulcer disease, presented with hematemesis, OGD done showed bleeding gastric ulcer. Labs showed hypercalcemia. PMH: osteoarthritis on NSAID, smooker, CKD on dialysis.

Q1. What is the definition of an ulcer!

Answer 1

Local defect in the mucus membrane or skin due to disintegration of surface epithelial cells.

Question 2

Q2. What are the major risk factors of peptic ulcers?
How can NSIADs cause PUD?

Answer 2

NSAIDs / H.pylori inf / smoking
…
irritating the epitheluim /
interfere with healing of mm /
decrease blood supply to mm /
Inhibit Cox-1 leading to suppression of PG synthesis
NB; Cox-2 which is anti-inflammatory

Question 3

Q3. What’s H.pylori?

Answer 3

Gram negative microaerophilic spiral bacteria found in the stomach

Question 4

Q4. After taking a gastric biopsy during endoscopy, what test can be done to the biopsy to confirm H.Pylori infection?

Answer 4

CLO test (Campylobacter-Like-Organism)

Question 5

Describe how it’s done. CLO

Answer 5

Biopsy taken by endoscopy and put in a media contain urea and an indicator (Phenol red), urease production by H.Pylori converts urea to ammonia raising the PH and changing the color of the indicator from yellow to red (+ve test)
Other tests Stool Ag test / Urease breath test

Question 6

Q4. How does H.Pylori manage to survive in the gastric acidic medium?

Answer 6

Produce Urease catalyze urea to ammonia and increase ph and decrease stomach acidity

Question 7

Q. Other tests to Dx H.pylori ag?

Answer 7

Detection of ag in stool analysis /
Urea breath test /
Serology for Ab /
take biopsy for microbial culture

Question 8

Q5. How can H.Pylori colonize the stomach and induce gastritis?

Answer 8

Flagella help its motility /
Uresae elevate ph /
adhesins adherence to faveolar cells /
toxins CagA involved in ulcer or cancer

Question 9

Q6. What’s the type of cells in the gastric antral mucosa?

Answer 9

Simple Colum. With goblet cells

Question 10

What are the types of gastric cancer caused H.Pylori infection? Which immune endocrine disease is associated with it?

Answer 10

Adenocarcinoma / Mucosal associated lymphoid tissue tumor MALTOMA
Hashimoto Thyroiditis

Question 11

Q7. How to treat symptomatic H. Pylori infection?

Answer 11

7 days of PPI Full dose/ Metro 400 mg / Clarith 250mg
or 7 ds of PPI full / Amox 1gm / Clarith 500 mg

Question 12

Q8. What’s the mechanism of action of proton pump inhibitors?

Answer 12

PPI binds irreversibly to H+/K+ ATPase enzyme (proton pump) on gastric parietal cells and blocks secretion of H+ ,which combine with Cl in the stomach lumen to form HCL.

Question 13

Q9. What are the actions of gastric HCL?

Answer 13

Antimicrobial action / Activate pepsinogen to pepsin / Promote pancreatic enzymes / Enhances absorption of Ca and iron / Help secreation of CCK and secrtine.

Question 14

Q10. What are the other possible causes of hematemesis in this patient?

Answer 14

Hypercalcemia increases release of gastrin and increase HCL which increase liability of bleeding from stomach

Question 15

Q11. What are the common causes of hypercalcemia?

Answer 15

Malignancy / Renal Failure / HyperPTH

Question 16

Q12. The patient had a history of recurrent (Flank pains) renal stones, what’s the possible cause?

Answer 16

HyperCa

Question 17

Q13. What’s the commonest cause of primary hyperparathyroidism? What’s the meaning of adenoma?

Answer 17

Solitary adenoma in 80% of cases
benign tumor originating from epithelial cells and has glandular pattern or tumor arising from gland itself

Question 18

Q14. How can the pararthyroid glands be localized. Where can they be found if not in their normal location?

Answer 18

Pre-op by sestamibi scan / Intra-op by frozen section
In sup mediastinum / because they follow the thymus gland originating the 3rd branchial pouch

Question 19

Q15. What’s frozen section and it is performed in simple words?

Answer 19

FROZEN SECTION:
the surgeon takes a small piece of fresh tissue or tumor for Analysis,
the pathologist freezes this sample and sections are immediately cut,
the sections are stained and reported immediately by phoned back to theatre

Question 20

Q16.Why parafin based histopathology is not convenient for intraopertive pathological testing?

Answer 20

Takes long time for stain to be imbedded in tissue

Question 21

Q17. What’s the treatment of parathyroid adenoma?

Answer 21

Excision

Question 22

The patient underwent excisin of the 4 parathroid glands. You were given the following pathology report.
. 1 gland 0.2 g chief cells.
. The other 3 glands ranging from 0.08 to 0.09 g composed of oxyphilic and fat cells.
Q18. What’s your interpretation?

Answer 22

Parathyroid adenoma in one gland / the other 3 are involuted (Atrophied)

Question 23

Q19. What’s the histological features of parathyroid adenoma. And how does this compare to hyperplasia?

Answer 23

Polygonal chief cells which are uniform with small central nuclei and islets of oxyphil cells and rare type called oxyphil adenoma. Composed of non-neoplastic compressed normal tissue at periphery separated by fibrous capsule
PT hyperplasia is commonly from chief cells and less commonly water clear cells.

Question 24

Q20. What are the types of hyperparathyroidism?

Answer 24

1ry – >Due to solitary adenoma / 2ry– > due to decrease Ca in CRF /
3ry – > following correction of any underlying renal disorder

Question 25

Q21. how to treat acute hypercalcemia?

Answer 25

Hydration / Forced diuresis / Bisphosphonate / Calcitonin

Question 26

Q. How to preserve Tissue sample?

Answer 26

By Formalin (preserve the specimen)