Peptic Ulcer Disease + Hyperparathyroidism (17)

Question 1

What is an ulcer?

Answer 1

An ulcer is a local defect of the mucous membrane or the skin due to gradual disintegration of the surface epithelial cells OR breach of the continuity of skin, epithelium or mucous membrane caused by sloughing out of inflamed necrotic tissue.

Question 2

What are the risk factors of PUD?

Answer 2

• H. pylori infection
• NSAIDs
• Smoking

Question 3

What is H. pylori?

Answer 3

H. pylori is a gram-negative microaerophilic spiral bacteria found in the stomach.

Question 4

How does H. pylori cause gastritis?

Answer 4

H. pylori produces certain proteases and phospholipases and these together with toxic ammonia produced from the breakdown of urea damage gastric mucosa and cause inflammation.

Question 5

How can H. pylori survive in acidic medium?

Answer 5

H. pylori survives in acidic conditions by producing urease, which catalyzes hydrolysis of urea to yield ammonia, thus elevating the pH of its environment.

Question 6

What is the mechanism by which H. pylori can colonize the stomach?

Answer 6

• Flagella, which allow the bacteria to be motile in viscous mucus
• Urease, which generates ammonia from endogenous urea, thereby elevating local gastric pH around the organisms and protecting the bacteria from the acidic pH of the stomach
• Adhesins, which enhance bacterial adherence to surface foveolar cells
• Toxins, such as that encoded by cytotoxin-associated gene A (CagA), that may be involved in ulcer or cancer development by poorly defined mechanisms.

Question 7

What type of gastric cancer can be caused by H. pylori?

Answer 7

• Adenocarcinoma
• MALT (Mucosal associated lymphoid tissue tumor)

Question 8

How can H. pylori be eradicated?

Answer 8

• 7 days twice daily of full dose of PPI + metronidazole 400 mg + clarithromycin 250mg, or
• 7 days twice daily of full dose of PPI + amoxicillin 1g + clarithromycin 500mg

Question 9

What is the mechanism of action of PPI?

Answer 9

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 10

How can NSAIDs cause PUD?

Answer 10

• Topical irritant effect on the epithelium
• Impairment of the barrier properties of the mucosa
• Suppression of gastric PG synthesis (inhibitors of cyclooxygenase)
• Reduction of gastric mucosal blood flow
• Interference with the repair of superficial injury

Question 11

What are the other causes of hematemesis in this patient?

Answer 11

Hypercalcemia → increased gastrin release → increased HCl production.

Question 12

What are the common causes of hypercalcemia?

Answer 12

• Malignancy
• Hyperparathyroidism (PTH adenoma)
• Renal failure

Question 13

What is hyperparathyroidism?

Answer 13

Hyperparathyroidism is a condition in which the parathyroid glands produce too much parathyroid hormone (PTH).

Question 14

How to localize parathyroid glands?

Answer 14

• Sestamibi scan (pre-operative)
• Frozen section (intra-operative)

Question 15

What is frozen section?

Answer 15

Frozen section is a pathological laboratory procedure to perform rapid microscopic analysis of a specimen.

Question 16

How is the specimen fixed?

Answer 16

The surgical specimen is placed on a metal tissue disc, which is then secured in a chuck and frozen rapidly to about -20 to -30°C. The specimen is embedded in a gel-like medium called OCT and consisting of polyethylene glycol and polyvinyl alcohol. Subsequently, it is cut frozen with the microtome portion of the cryostat, the section is picked up on a glass slide, and stained (usually with hematoxylin and eosin, the H&E stain).

Question 17

Why can’t we use paraffin-based histopathology intraoperatively?

Answer 17

As it takes a week for paraffin to embed through the tissues.

Question 18

Where to find parathyroid gland if you do not see them in the normal position?

Answer 18

The superior mediastinum (as the thymus originates from the third branchial arch, it occasionally drags the inferior glands down to the mediastinum).

Question 19

What is the treatment of hypercalcemia?

Answer 19

• Hydration
• Forced diuresis
• Bisphosphonates: IV pamidronate
• Calcitonin

Question 19

What is the treatment of parathyroid adenoma?

Answer 19

Excision

Question 20

Types of Hyperparathyroidism

Answer 20