Peptic Ulcer Disease Treatment and Management
There are many ways of dealing with psychosomatic patients. First, identify the disorder Do not miss the possible diagnosis of an affective or anxiety disorder. Treatment of somatization is directed toward teaching the patient to cope with the psychological problems. Be aware that somatization operates unconsciously the patient really is suffering. Above all, the patient should never be told that his or her problem is ''in your head.'' Anxiety, fear, and depression are the main psychological problems associated with psychosomatic illness. The list of associated common symptoms and illnesses is long and includes chest pain, headaches, peptic ulcer disease, ulcerative colitis, irritable bowel syndrome, nausea, vomiting, anorexia nervosa, urticaria, tachycardia, hypertension, asthma, migraine, muscle tension syndromes, obesity, rashes, and dizziness. Answers to an open-ended question such as ''What's been happening in your life '' often provide insight into the problems.
Dietary factors such as coffee, tea, cola, beer, and a highly spiced diet may cause dyspepsia, but they have not been shown to independently increase PUD risk. Although caffeine increases gastric acid secretion and alcohol ingestion causes acute gastritis, there is inconclusive evidence to confirm that either of these substances are independent risk factors for peptic ulcers.
Our consideration shows that, contrary to the causal mechanism view, prior knowledge of noncausality neither precludes nor refutes observation-based causal discovery. Thagard (2000) gave a striking historic illustration of this fact. Even though the stomach had been regarded as too acidic an environment for viruses to survive, a virus was inferred to be a cause of stomach ulcer. Prior causal knowledge may render a novel candidate causal relation more or less plausible but cannot rule it out definitively. Moreover, prior causal knowledge is often stochastic. Consider a situation in which one observes that insomia results whenever one drinks champagne. Now, there may be a straightforward physiological causal mechanism linking cause and effect, but it is also plausible that the relation is not causal it could easily be that drinking and insomnia are both caused by a third variable - for example, attending parties (cf. Gopnik et al., 2004).
Two dopamine agonists are used for the management of hyperprolactinemia, bromocriptine, and cabergoline (Table 46-5).39,45 Because these two dopamine agonists are ergot derivatives, they are contraindicated in combination with potent cytochrome P-450 subfamily IIIA polypeptide 4 (CYP3A4) inhibitors, including protease inhibitors (e.g., ritonavir and indinavir), azole antifungals (e.g., ketoconazole and itraconazole), and some macrolide antibiotics (e.g., erythromycin and clarithromycin). Furthermore, ergot derivatives can cause constriction of peripheral and cranial blood vessels. These medications are also contraindicated in patients with uncontrolled hypertension, severe ischemic heart disease, or peripheral vascular disorders. Caution should be exercised with concomitant use of other ergot derivates and in patients with impaired renal or hepatic function, dementia, concurrent antihypertensive therapy, or a history of psychosis, peptic ulcer disease, or cardiovascular disease.
Outcome assessments can be biased despite effective blinding. In particular, increased diagnostic activity could lead to increased diagnosis of true but harmless cases of disease. For example, many stomach ulcers give no symptoms and have no clinical relevance, but such cases could be detected more frequently on gastroscopy in patients who receive a drug that causes unspecific stomach discomfort and therefore leads to more gastroscopies. Similarly, if a drug causes diarrhoea, this could lead to more digital rectal examinations, and, therefore, also to the detection of more harmless cases of prostatic cancer. Obviously, assessment of beneficial effects can also become biased through such a mechanism. Interventions may also lead to different diagnostic activity, for example if the experimental intervention is a nurse visiting a patient at home, and the control intervention is no visit.
Corlew and associates36 reported a more carefully explored series of 47 patients with primary HPT who either refused surgery or were not offered this option, some of whom were considered poor surgical risks. The diagnosis was accurately established in these patients by measurement of albumin-corrected serum calcium and intact PTH. The patients were classified into three groups on the basis of their levels of serum calcium one fourth had serum calcium levels higher than 2.78 mmol L. Sixteen of the 47 patients (34 ) either died or suffered from complications that the authors considered to be possibly related to primary HPT, such as peptic ulcer disease (8 patients), with bleeding in some cases renal failure (5 patients) renal calculus (1 patient) hypercalcemic crisis (1 patient) and ventricular conduction defect (1 patient). With the exception of the patient with hypercalcemic crisis, who initially belonged to the group with the lowest serum calcium levels, the serum calcium levels did...
Multiple endocrine neoplasia type 1 (MEN1) is an autosomal dominant syndrome characterized by the predisposition to develop both peptic ulcer disease and a wide variety of endocrine tumors usually in adolescence and adulthood. Specifically, hyperplasia and or tumors (most often adenomas) of the parathyroid, pancreatic islet cells, anterior pituitary, and adrenal cortical glands are classically described in affected individuals who have MEN1 (1,2). MEN1 is a highly penetrant disorder whose onset is generally during adult life with the occurrence of at least one, but most often more than one, of the aforementioned tumors. The age-related penetrance of this disorder based on analysis in 63 unrelated kindreds is 7, 52, 87, 98, 99, and 100 by 10, 20, 30, 40, 50, and 60 yr, respectively (3). The disorder is estimated to occur in approx 1 in 30,000 to 1 in 50,000 individuals. Most cases are associated with a positive family history of the disorder, but new germline mutations have been...
Peptic ulcer dyspepsia is rare in people under the age of 20, but by age 30, 2 percent of the males and 0.5 percent of the females in a population have developed the condition. For men, the incidence increases steadily with age, reaching a peak of around 20 percent in the sixth decade of life. The incidence for women remains low, about 1 percent, until menopause, after which it climbs as rapidly as in men. A morbidity rate of nearly 14 percent has been re ported in women in the age group 70 to 79. Death from peptic ulcer occurs three times as often in men as women.
Although the most common, peptic ulcer is hardly the only organic source of dyspepsia. Esophagitis hiatus hernia gastritis carcinoma of the stomach, colon, or pancreas Crohn's disease disease of the biliary tract chronic nephritis or any of several other conditions, including pregnancy, can produce indigestion. In approximately half of the cases of dyspepsia, however, no lesion can be found, and symptoms arise from derangements of motor, secretory, or absorptive functions, especially delayed gastric motility, esophageal reflux, and hyperacidity. This functional indigestion has been related to physical stress (aerophagia, fatigue, dietary indiscretion) and, more commonly, to nervous stress. Anxiety, anger, frustration, and other indications of emotional turmoil can significantly impair digestive function in sensitive or tense individuals (a similar psychic component - chronic tension and repression of emotion - has been implicated in peptic ulcer). Because the symptoms of functional...
During the first half of the twentieth century, that same stress of coping with civilization seems to have brought about an abrupt increase in dyspepsia of organic origin as well. Between the two world wars, peptic (particularly duodenal) ulcer grew from a rarely encountered condition to a significant cause of disability, reaching a high point in the 1950s, then declining sharply to the present. This pattern has suggested that ulcer dyspepsia is less a disease of civilization than a condition of adjustment to civilization the first generations to confront the pressures of urban-industrial life are buffeted more heavily than those born after the turbulent transition period. Functional dyspepsia, of course, might be expected to decrease for the same reason, yet its domain has been diminished still more rapidly by the X-ray and the endoscope, improved diagnostic techniques having transferred many cases of nervous indigestion to peptic ulcer's column. Advances in understanding of the...
NSAID use is associated with an increased risk of GI ulcers or hemorrhage, fluid retention, exacerbation of existing hypertension, and decreased renal function in certain patient populations.7,1 9 Factors that place a patient at a higher risk of GI-re-lated adverse reactions include (a) history of peptic ulcer disease, (b) high doses of NSAIDs, (c) concomitant use of other medications with an increased risk of GI hemorrhage or ulcers (e.g., anticoagulants, corticosteroids, use of multiple NSAIDs), (d) age greater than 75 years, and (e) serious underlying diseases.1 If a patient has an increased risk of NSAID-induced adverse reactions, gastroprotection should be considered by coinitiation of a proton pump inhibitor, histamine-2 receptor blocker, or misoprostol. Misoprostol is effective in reducing the occurrence of gastric and duodenal ulcers. However, its tolerability is limited by adverse effects, specifically diarrhea. Histamine-2 receptor blockers effectively prevent duodenal...
In the United States, approximately 10 of the adult male population is affected by peptic ulcer disease. Five percent of the population older than 40 years has diverticular disease. Colorectal cancer is the third common malignant neoplasm (11 of all cancers) affecting American men and women. It is the second most common cause of cancer deaths in men (10 ) and the third most common cause in women (11 ). In 2007, approximately 158,410 new cases of cancer of the colon and rectum were diagnosed, and there were 52,870 deaths from colorectal cancer.
Socioeconomic status is known to modify the relationship between exposure and outcome for a wide variety of conditions. This applies to many infectious diseases that afflict low to middle-income countries all over the world (such as tuberculosis, malaria and diarrhoea). However, socioeconomic status can also affect causation of several chronic degenerative diseases. For example, the OR for developing peptic ulcer disease from H. pylori infection in Denmark is 1.6 95 CI 0.8, 3.4 in higher socioeconomic classes, compared to 4.1 95 CI 1.8, 9.2 in lower socioeconomic classes'12'. It also affects the relationship between smoking, alcohol, diet and oesophageal cancer'13', smoking and chronic obstructive lung disease'14', diabetes and stroke'15', and many other diseases.
Hood and greater female symptom reporting in adolescence. Most children with chronic or recurrent abdominal pain, probably over 90 , do not suffer from explanatory physical disease, such as peptic ulcer or Crohn's disease (American Academy of Pediatrics Subcommittee on Chronic Abdominal Pain 2005), and are considered to suffer generically from functional abdominal pain (FAP). Traditional physical disease, with demonstrable structural, infectious, inflammatory, or biochemical findings, is especially unusual in the absence of red flags such as weight loss, gastrointestinal bleeding, fever, anemia, or persistent vomiting. Helicobacter pylori infection and celiac disease are not etiological in most cases, and despite suspicions about food allergies, lack of dietary fiber, and lactose malabsorption, results of dietary intervention such as fiber supplementation and lactose-free diets have been disappointing (Huertas-Ceballos et al. 2008a).
Diverticular disease and perforated peptic ulcer. The best investigation is an erect chest radiograph, which will show free gas under one hemi-diaphragm, especially above the liver on the right. If this is not possible, then an antero-posterior left lateral decubitus projection (right side raised) is a suitable alternative, or a lateral dorsal decubitus (supine) can be obtained. Whichever projection is used, the patient should be left for 20 minutes in that position to allow the air to rise, otherwise the diagnosis may be missed. The outcome is an image showing a crescent or bubble of gas in the most non-dependent part of the peritoneal cavity.
The biggest disadvantage of the mechanical heart valves is that most patients need to take an anticoagulant, also referred to as a blood thinner, to prevent blood clots from forming on the valve itself. The most common anticoagulant is coumadin, otherwise known as warfarin. Patients who take coumadin need to get their blood tested periodically. When coumadin treatment is first started, the blood is tested every day or two, but after a few weeks, it is usually tested every couple of months to make sure the level of anticoagulation is appropriate. If the anticoagulation is too great, the patient is more prone to develop bleeding problems, which can include bleeding into the stomach, intestines, brain, or kidneys. A person with bleeding ulcers would be prone to bleed more. If you were cut, you would have a problem with abnormal bleeding. The coumadin treatment can be reversed in an emergency situation if necessary.
An effective intervention has well-recognized adverse effects, which can make it difficult for the patient to continue therapy. Evidence is needed on whether reducing the intensity of the intervention (e.g. lower dose or duration) will help avoid the adverse effects, or whether there is a treatment strategy that can prevent adverse effects (e.g. proton pump inhibitor for peptic ulcers caused by aspirin).
Although diseases of other organ systems (e.g., cardiovascular disease) may appear to be more dramatic illnesses with higher rates of morbidity and mortality, the overall impact of gastrointestinal (GI) disorders is often underestimated from both a biopsychosocial and a resource standpoint. Typically, diseases of the GI tract are misdiagnosed, mistreated, misunderstood, or missed altogether, ultimately leading to substantial psychological morbidity and tremendous direct and indirect expense. Digestive diseases cost an estimated 91 billion annually in U.S. health care costs, lost days from work, and premature deaths. More than 70 million Americans are diagnosed each year with disorders of the digestive tract, including gastroesophageal reflux disease, peptic ulcer disease, inflammatory bowel disease, GI cancers, motility
Once a rule is discovered, scientists can extrapolate from the rule to formulate theories of the observed and yet to be observed phenomena. One example is using inductive reasoning in the discovery that a certain type of bacterium is a cause of many ulcers (Thagard, 1999). In a fascinating series of articles, Thagard documents the reasoning processes that Marshall and Warren went through in proposing this novel hypothesis. One key reasoning process was the use of induction by generalization. Marshall and Warren noted that almost all patients with gastric enteritis had a spiral bacterium in their stomachs and formed the generalization that this bacterium is the cause of many stomach ulcers. There are numerous other examples of induction by generalization in science, such as Tycho Brahe induction about the motion of planets from his observations, Dalton's use of induction in chemistry, and the discovery of prions as the source of mad cow disease. Many theories of...
The most frequent reason why patients (other than routine preventive care, eye-glasses and so forth) come to see their physician is pain. It may be slight it may be described as burning, as with peptic ulcer disease, but ultimately it comes down to discomfort, dis-ease, etc. And often it is outright pain. Addressing the underlying disease can often and most successfully relieve such pain the pain of peptic ulcer disease, hernia or bursitis can be well addressed by dealing with the underlying disease in medically obvious ways. While the disease is being dealt with, however, the fact that the patient's complaint was pain must not be forgotten if relief by taking care of the specific problem can be expected to take more than a short time and if the pain is truly troublesome, then treating the complaint of pain while treating the disease should not be forgotten. That, for medical reasons, may not always be possible but when it is, even for a short time, it demonstrates to the patient that...
Stomach ulcers and duodenal ulcers, commonly referred to as peptic ulcers, occur because pepsin, which aids in digesting proteins, acts on the cells of the stomach wall. Digestion of stomach wall cells is aided by the presence of hydrochloric acid, which is also secreted by the cells lining the stomach.
Women have lower rates of alcohol abuse and dependency than their male counterparts, 1.5 overall and 1.5 in older adult women (Mouton and Espino, 1999) (Box 49-7). Women generally enter treatment later than men and have more psychiatric symptoms. Women seem to develop many pathologic effects of alcohol more rapidly than men (Blume and Zilberman, 2005), including fatty liver, hypertension, anemia, malnutrition, GI hemorrhage, and peptic ulcer requiring surgery (Zweben, 2009). For women, five to seven drinks daily is sufficient to cause significant disease progression.
Analgesics and NSAIDs are first-line therapy in mild to moderate headache attacks. If patients are prone to stomach ulcers, acetaminophen should be used. If these drugs fail, combination analgesics can be used. More severe attacks should be treated with ergotamine, DHE, or sumatriptan. Ergotamine tartrate use should be limited to twice weekly, because of the risk of rebound headaches caused by more frequent dosing. Sumatriptan is effective but expensive, and up to 40 percent of patients have recurrent headaches with this drug. Some clinicians believe that patient-administered sumatriptan and DHE have the best efficacy-to-adverse-effect ratio of all the acute-treatment medications and are the most cost effective because their use results in fewer emergency visits. Because nausea and vomiting are symptoms that are commonly associated with
There is good evidence that in about 80 of patients the clinical manifestations improve after successful parathyroidectomy.8'9,10'46'47 Thus, fatigue, exhaustion and weakness, polydipsia, polyuria and nocturia, bone and joint pain, constipation, nausea, and depression improve in some patients.8 I0'46'47 This is also true for associated conditions. In these patients, new kidney stones usually stop forming, osteoporosis stabilizes or improves, peptic ulcer disease often resolves, and pancreatitis becomes less likely.4647 Thus, both neuropsychiatry and somatic problems improve in most, but not all, patients (Figs. 40-1 to 40-4).10-48 Increased fracture risk and weakness also improve after successful parathyroidectomy in most, but certainly not all, patients.1948 Objective increase in muscular strength has also been documented after successful parathyroidectomy.49 Patients can also resume a regular diet with or without calcium supplementation and hypercalcemia is not a concern when...
Note the exact time at which the pain started and what the patient was doing at that time. Sudden, severe pain awakening a patient from sleep may be associated with acute perforation, inflammation, or torsion of an abdominal organ. A stone in the biliary or renal tract also causes intense pain. Note acuteness of the pain. Acute rupture of a fallopian tube by an ectopic pregnancy, perforation of a gastric ulcer, peritonitis, and acute pancreatitis cause such severe pain that fainting may result. Note the nature of the pain. Pain caused by a perforated gastric ulcer is often described as ''burning'' dissecting aneurysm as ''tearing'' intestinal obstruction as ''gripping'' pyelone-phritis as ''dull, aching'' and biliary or renal colic as ''crampy, constricting.'' The time of occurrence and factors that aggravate or alleviate the symptoms (e.g., meals or defecation) are particularly important. Periodic epigastric pain occurring 1 to 1 hour after eating is a classic symptom of gastric...
The renal symptoms of hypercalcemic crisis are polyuria and polydipsia. The neurologic symptoms are less characteristic and include depression, anxiety, and psychosis. Gastrointestinal symptoms are nausea, vomiting, constipation, peptic ulcer, and pancreatitis. Gastric acid secretion and pancreatic enzyme secretion are increased.10 Cardiac symptoms also are nonspecific. A shortened QT interval and tachycardias may be observed. The mechanism of hypertension attributable to PHPT is unclear.10 Hypercalcemic crisis is a constellation of the preceding signs and symptoms, including psychological disturbances (ranging from drowsiness to stupor to coma), renal insufficiency, and cardiac dysrhythmias (bradyarrhythmias, bundle branch blocks, complete heart blocks, and cardiac arrest).9 (The preceding signs and symptoms are mild and usual, but the signs with italic letters are severe and not common.) Hypercalcemia of malignancy must be considered in cases with a history of, for example, breast...
Notwithstanding the huge number of transport proteins present in the human body, relatively few of them are targets for the action of drugs. It might even be argued that transport proteins are relatively overlooked as drug targets in spite of their critical physiological functions and some real success stories, such as, inhibitors of the gastric ATP-driven proton pump, used against peptic ulcers, and inhibitors of monoamine transporters, used against depression anxiety disorders (see Chapter 18). In this chapter, we focus on the monoamine transporters and then on the neurotransmitter transporters belonging to the SLC6 family (also named neurotransmitter sodium symporters or Na- Cl-dependent transporters) (Table 14.1). Indeed, the SLC6 transporters represent important targets for several drugs including not only medicines used against depression anxiety but also against
Document healing of peptic ulcers by endoscopy. The absence of symptoms does not indicate the adequacy of pharmacologic antisecretory control.33 The diagnosis of Z-E syndrome is established by documenting gastric acid hypersecretion and hypergastrinemia. With rare exception, a basal acid output (BAO) greater than 15 mEq hour and a fasting serum gastrin greater than 500 pg mL are diagnostic. There may be some overlap in the values of gastric acid output in a few patients with ordinary peptic ulcer disease and patients with gastrinoma, but when a fasting serum gastrin is measured, the diagnosis is generally clear.58 If the fasting serum gastrin is normal or in the equivocal range (100 to 500 pg mL), a secretin injection test for gastrin response should identify the patients who harbor a gastrinoma.59 Patients with pernicious anemia or chronic gastritis have been referred to our institution with a diagnosis of Z-E syndrome because of an elevated serum gastrin, often greater than 1000 pg...
Indomethacin was used traditionally, but its relative cyclooxygenase-1 (COX-1) selectivity theoretically increases its gastropathy risk. Thus other generic NSAIDs may be preferred. Adverse effects of NSAIDs include gastropathy (primarily peptic ulcers), renal dysfunction, and fluid retention.14 NSAIDs generally should be avoided in patients at risk for peptic ulcers, those taking warfarin, and those with renal insufficiency or uncontrolled hypertension or heart failure.
As food passes into the esophagus, an obstructing lesion can produce dysphagia, or difficulty swallowing. Gastroesophageal reflux can lead to heartburn. Upon entry of partially digested food into the stomach, the stomach relaxes. A failure of this relaxation may lead to early satiety or pain. The stomach functions as a food reservoir, secreting gastric juice and providing peristaltic activity with its muscular wall. Between 2 and 3 L of gastric juice is produced daily by the stomach lining and affects the digestion of proteins. The semifluid, creamy material produced by gastric digestion of food is called chyme. Secretion of gastric juice may produce pain if a gastric ulcer is present. Intermittent emptying of the stomach occurs when intragastric pressure overcomes the resistance of the pyloric sphincter. Emptying is normally complete within 6 hours after eating. Any obstruction to gastric emptying may produce vomiting.
The accessory duct of Santorini is usually smaller than the main pancreatic duct. It is formed from the persistence of the proximal portion of the duct from the embryologic dorsal pancreas. It usually drains the anterosuperior portion of the pancreatic head, communicates with the main pancreatic duct, and in 70 of the population opens into the duodenum through the minor papilla, which is 2 cm cranial and slightly anterior to the major papilla. The minor papilla is most often directly posterior to the gastroduodenal artery and thus is at risk for injury during surgery for peptic ulcer disease. Variations in the pancreatic ductal anatomy are common and include absence of a minor papilla in 30 , no connection between the accessory and main pancreatic ducts in 10 , and variable degrees of suppression in the development of the accessory or main pancreatic ducts.7 To avoid injury to the accessory pancreatic duct in patients undergoing gastrectomy or peptic ulcer surgery, duodenal dissection...
This disorder has many features in common with FAP type l. Upper and lower extremities are affected, but usually there is no associated carpal tunnel syndrome. Peripheral neuropathy can be severe, but the autonomic neuropathy is less prominent. Peptic ulceration may occur, and renal involvement results in hypertension and uremia. Amyloid deposition also occurs in the liver, adrenal glands, and testes. This type of FAP is associated with apolipoprotein Al-derived amyloid, and a substitution of arginine for glycine has been found in nucleotide 26 of the gene.
Peptic Ulcer Disease Eradication of H. pylori infection in patients with a duodenal or gastric ulcer reduces symptom recurrence. Ulcer prophylaxis with an H2RA or PPI should be considered in patients at high risk for NSAID-associated PUD, including those with a history of PUD, elderly patients, and patients taking corticosteroids or anticoagulants. Peptic ulcer disease (PUD) is the most common cause of upper gastrointestinal bleeding (UGIB) and a leading cause of dyspepsia (Box 38-2), with a cumulative lifetime prevalence of 8 to 14 (Fig. 38-5). Although up to 70 of patients with gastric and duodenal ulcers are 25 to 64 years old, the peak prevalence of complicated ulcer disease requiring hospitalization is age 65 to 74 (Saad and Scheiman, 2004). GERD (with and without esophagitis) Functional (nonulcer dyspepsia) Peptic ulcer disease Modified from Saad R, Scheiman JM. Diagnosis and management of peptic ulcer disease. Clin Fam Pract 2004 6 569-587. Figure 38-5 Gastric ulcer. (Courtesy...
Placebo effects have been shown to relieve postoperative pain, induce sleep or mental awareness, bring about drastic remission in both symptoms and objective signs of chronic diseases, initiate the rejection of warts, and other abnormal growths, and so on (Weil, 1983). Placebo affects headaches, seasickness, and coughs, as well as have beneficial effects on pathological conditions such as rheumatoid and degenerative arthritis, blood cell count, respiratory rates, vasomotor function, peptic ulcers, hay fever, and hypertension (Cousins, 1979). There can also be undesirable side effects, such as nausea, headaches, skin rashes, allergic reactions, and even addiction, that is, a nocebo effect. This is almost akin to voodoo death threats or when patients are mistakenly told that their illness is hopeless both are said to cause death soon after.
A 48-year-old man with a history of hypertension, peptic ulcer disease (gastric ulcer 1 year ago), and morbid obesity presents to the emergency department complaining of excruciating pain in his left big toe and both ankles. This is similar to a painful episode he had with his left toe and ankle 6 months ago. On examination, his left great toe and both ankles are red, swollen, and warm to the touch. He describes the pain as throbbing and rates it as a 10 10 (where 10 is the worst pain he has ever experienced). He admits to drinking a six pack of beer on weekends. He weighs 150 kg (330 lb) and is 5 ft, 9 in. (175 cm) tall. Medications include chlorthalidone 25 mg day and panto-prazole 40 mg day. Serum creatinine is 1.0 mg dL (88 mol L).
A recent endoscopic study found erosive gastritis in 11 and gastric ulcer in 1 of 16 runners completing a 10-km race 15 . Ischemia, mediated perhaps by gastric acid, has been the most frequently proposed etiol NSAID medications, while inconsistently associated with GI blood loss in runners, may contribute to gastritis and gastric ulcers, and less commonly to small bowel or colon lesions and GI bleeding. Aspirin has been shown to enhance increased intestinal permeability associated with running 19 . It is always important to review the use of these medications in the athlete with gastrointestinal complaints.
The form of peptic ulcer disease, occurs in around 5 43 . Grade II to IV hematologic toxicity is seen in 5 to 15 44 . Studies of men from early radiation populations have raised concerns of cardiac toxicity and excess risk for death from cardiac events. Risk for events was increased by a factor of 1.8 to 2.4 44,45 . Although the magnitude of these estimates may not pertain to modern radiotherapy practice, this remains an issue when considering adjuvant treatment.
One third to one half of the patients with NMFH experience nephrolithiasis. One fifth of the patients have severe osteoporosis, and osteitis fibrosa cystica with brown tumors is more common. Other nonspecific symptoms or signs that occur more frequently in the patients with primary HPT, including hypertension, fatigue, weakness, pancreatitis, or peptic ulcer, may also be common in patients with NMFH, but currently there is insufficient information to know with certainty. Four patients in the UCSF series were asymptomatic initially, but two of these initially asymptomatic patients experienced hypercalcemic crises when the disease persisted after the initial parathyroidectomy at another medical center.
All surgical procedures have risks, and the common ones are infection, bleeding, pain, and anesthetic complications. Larger surgical procedures, which involve lengthier operative times and decreased postoperative mobility, have the risk of blood clots in the legs (deep venous thrombosis), pulmonary embolus, pneumonia, and stress-related stomach ulcers. Complications of radical prostatectomy include hernia, significant bleeding requiring blood transfusion, infection, anesthetic-related complications, impotence, urinary incontinence, bladder neck contracture, deep venous thrombosis, rectal injury, and death.
Thus steroids can improve the quality of life in some cancer patients. At least one study, conducted in Britain, has shown that selected patients on corticosteroids live longer as well. However, caution must be exercised with these medications. In particular, patients with peptic ulcers or poorly controlled high blood pressure are not good candidates for treatment with steroids.
Messenger system with which they interact. M -, M3- and Ms-receptors couple to phospholipase C via a Gq-protein to generate IP3. M2- and M4-receptors uncouple adenylate cyclase via interaction with a Gj-protein and decrease the formation of cAMP, activate K+ channels and inhibit Ca2+ channels. Apart from pirenzepine (a specific Mj-antagonist which is used to decrease gastric acid secretion in patients with peptic ulcer disease), currently available drugs acting on cholinergic transmission are thought to act non-specifi-callv at muscarinic receptor subtypes. However, antimuscarinic drugs, e.g. atropine and hyoscine, differ in their clinical spectra (see below), suggesting that they may have differing effects at different muscarinic receptor subtypes and that more specific drugs might be useful clinically.
PGs inhibit gastric acid secretion and have numerous mucosal protective effects, the most important of which include the stimulation of both mucus and phospholipid production, promotion of bicarbonate secretion, and increased mucosal cell turnover. Damage to the mucosal defense system is the primary method by which H. pylori or NSAIDs cause peptic ulcers.
While visiting a drugstore in Seoul with his interpreter, Woods (see the first section of this chapter) examined many roots and herbs that were all said to be good for the stomach This suggests, of course, that digestive disorders were common. Gastritis seemed to be the major disease in the category of stomach diseases, although Avison thought that common complaints of chronic indigestion included many cases of stomach ulcers.
The general appearance of the patient often furnishes valuable information as to the nature of the condition. Patients with renal or biliary colic writhe in bed. They squirm constantly and can find no comfortable position. In contrast, patients with peritonitis, who have intense pain on movement, characteristically remain still in bed because any slight motion worsens the pain. They may be lying in bed with their knees drawn up to help relax the abdominal muscles and reduce intra-abdominal pressure. Patients who are pale and sweating may be suffering from the initial shock of pancreatitis or a perforated gastric ulcer.
Optimum treatment recommendations for patients with Z-E syndrome have undergone continuing change during the 40 years since Zollinger and Ellison reported on their first two patients, both of whom required a TG to control the complications of recurring peptic ulcer disease. These changes in Z-E syndrome management have come with a better understanding of the natural history and pathophysiology of Z-E syndrome, the RIA for gastrin, new imaging technologies that preoperatively and intraoperatively localize gastrinomas, and, perhaps most important, new drugs that inhibit gastric acid secretion.88
Most patients diagnosed with primary hyperparathyroidism today do not have the classic or historical clinical manifestations of this disorder such as osteitis fibrosa cystica, nephrolithiasis, nephrocalcinosis, peptic ulcer disease, gout, or pseudogout. The pentad of symptoms painful bones, kidney stones, abdominal groans, psychic moans, and fatigue overtones is more common, although most patients have few dramatic symptoms. The symptoms and other associated complications of primary hyperparathyroidism are listed in Table 40-3. Several investigators have documented that manifestations such as fatigue, weakness, exhaustion, polydipsia, polyuria, nocturia, joint pain, bone pain, constipation, depression, anorexia, nausea, heartburn, and several associated conditions such as nephrolithiasis and hematuria occur more often in patients with primary hyperparathyroidism than in those with thyroid nodules.8 10 Furthermore, only symptoms of fatigue, bone pain, and weight loss seemed to...
Patients previously operated on for gastrinoma but with progression of hypergastrinemia should also be evaluated periodically to search for a gastrinoma that might be amenable to curative excision because these tumors can grow and cause death. A CT scan and selective abdominal angiography might be done at 1- to 2-year intervals in selected patients. I have successfully excised a large extra-pancreatic gastrinoma from a Z-E syndrome patient who presented with a new abdominal mass and a serum gastrin level of 1.5 million pg mL 20 years after a TG. At the first operation, a duodenal wall gastrinoma was removed along with a TG, which was done to control bleeding ulcers. The patient was in good health during the 20 years since her TG until the discovery of an abdominal mass. After successful removal of the gastrinoma, the patient's serum gastrin and secretin provocative tests have been normal for 5 years. This case illustrates that some Z-E syndrome patients may
Thoracic radiculopathy may be due to disc herniation or metabolic abnormalities of the nerve root (i.e. diabetes). Patients present with bandlike chest pain. Thoracic radiculopathy is not a common diagnosis, and other possible serious pathology should be excluded (malignancy, compression fracture, infection, angina, aortic aneurysm, peptic ulcer disease). Nonsurgical treatment options for thoracic radiculopathy include medication (NSAIDs, analgesics, oral steroids), modalities, TENS, spinal nerve root blocks, spinal stabilization exercises, strengthening of back and abdominal muscles, orthoses, and postural retraining.
The main pathways for pharmacological control of gastric acid secretion are shown in Fig. 9.32. The synthesis of antagonists to the H2 histamine receptors provided the first revolution in the treatment of gastric ulcers (the second revolution being the discovery that eradication of Helicobacter pylori infection results in long-term ulcer remission). H2 antagonists such as cime-tidine and ranitidine can antagonise acid secretion initiated not only by histamine, but also by gastrin and acetylcholine, and thus decrease both basal secretion of HC1 and secretion stimulated by food intake. They promote healing of duodenal ulcers, and are also useful in the treatment of heartburn
Recurrent vomiting is common in the early years. Several gastrointestinal abnormalities have been identified megaesophagus, pylorospasm, gastric ulcer, jejunal distention, and megacolon. Corneal abrasions may occur secondary to corneal insensitivity, whereas neuropathic or Charcot's joints may occur secondary to pain insensitivity. About half of the patients develop kyphosis, scoliosis, or both. Pulmonary complications, profound hypotension, and prolonged respiratory depression from the administration of anesthesia have been reported. y
Y a tightness, heaviness, or pressure y a burning, crushing, or squeezing feeling over a general area in the front portion of the chest y the feeling that somebody has just piled heavy weights on your chest or that your chest is in a vise (it can sometimes almost take your breath away) y a dull, aching pain, usually located just to the left of the breastbone or sternum over the heart y discomfort that radiates from the chest to the back or the neck and even up to the jaw and teeth (sometimes there is only jaw pain that comes and goes with exertion, or sometimes the angina radiates from the chest over the heart, or down one arm or the other, usually the left arm) y in some patients, angina will actually present as a pain or discomfort in the upper abdomen and even cause nausea. When this occurs, it can mimic gall bladder disease, esophageal disease, or stomach ulcers
Second, advances in fields such as microbiology, pathology, and molecular biology have uncovered many physical agents of disease. These advances caused old beliefs to be replaced with new biochemical, bacteriological and genetic explanations. Gastric ulcers are a good example. Thought for decades to be caused by stress-induced excess gastric acid, most ulcers are now known to be caused by the bacterium Helicobacter pylori, and these can be totally eliminated with antibiotics. Stress or other emotions play no role in causing gastric ulcers. Yet even though cause by a bacterium, stress can influence the severity of symptoms.
Derived from Greek roots meaning difficult digestion, dyspepsia has long served as a synonym for indigestion, one of the most common - and etiologically varied - of human miseries. It has also been regularly employed to label symptoms of diverse organic disorders, with the result that some gastroenterologists find the word uselessly elastic. Most practitioners, however, have reached a consensus to use dyspepsia to denote either the ailment of functional indigestion or the symptoms of peptic ulcer.
Misoprostol (Cytotec), a synthetic PGEj FDA approved for prevention of gastric ulcers, has been used off-label for cervical ripening and labor induction. Several protocols have been developed. It is a potent uterotonic agent that may be associated with increased incidence of uterine rupture. Miso-prostol is best not used in women with prior cesarean section or uterine surgery.
Indomethacin also prolongs pregnancy, but it has not been independently associated with decreased neonatal morbidity. 4 It may be of particular benefit in women with hydramnios.34 Indomethacin should be avoided in women with a history of renal or hepatic impairment, aspirin or nonsteroidal anti-inflammatory drug (NSAID) allergy, peptic ulcer disease, other bleeding disorders, or after 32 weeks of pregnancy. Reports of increased risk of maternal postpartum hemorrhage, and neonatal complications (e.g., premature closure of the ductus arteriosus, necrotizing enterocolitis,
Because this is a very potent drug that dissolves clots anywhere in the body, bleeding is one possible side effect of tPA. Therefore, patients must be carefully selected to have minimal risk for bleeding. It cannot be used In patients who have had a recent stroke, in patients with severe high blood pressure, or in patients with bleeding stomach ulcers. However, when it is given to carefully selected patients in the first six to twelve hours after the onset of a heart attack, it can definitely improve their outcome.
Evacuation problems and other gastrointestinal sequelae such as ileus, gastric ulcers, reflux, di-verticulosis, hemorrhoids, and nausea, loss of appetite, incontinence, hours spent attempting to evacuate the bowel, and impactions. Approximately one in four patients with SCI require a hospitalization for such complications.39
If clots continue to develop or if patients cannot take an anticoagulant because they have a bleeding disorder or bleeding ulcers, they may need a filter inserted in the inferior vena cava. Blood clot filters come in different shapes, and all are inserted through a catheter. They prevent larger clots from getting through the vena cava and traveling to the lungs, where they can cause shortness of breath. If the clot is big enough, it may actually block the blood flow to the lungs and could be fatal. When a blood clot goes to the lungs, this is called a pulmonary embolus. Most blood clots that travel to the lungs can be dissolved with drugs, but sometimes they need to be removed surgically.
The logical, imaginative, and iterative approach to new drugs based on hormone-receptor systems sketched out above stands in marked contrast to the industrial approach we experienced 40 years ago and to the direction in which the industry is now moving compulsively at hectic speed. In the past, industrial research was criticized for its practice of random screening and for its generation of me-too drugs. Of course, the biological screening was not random far from it, as the screening tests were chosen with great care to reflect identified medical needs. Pharmacologists tried to reflect the importance of meeting medical needs by using experimental pathology paradigms for screening tests. Thus, assays were often based on experimentally induced animal pathology such as sterile inflammatory responses to foreign bodies such as cotton-wool, or turpentine, or arthritis induced by antigen-adjutant presentation, or stomach ulcers induced by histamine or aspirin, or convulsions induced by...
Restricted to gastrointestinal therapy. Since the 1970s, two Bi(III) compounds have been most commonly used worldwide bismuth subsalicylate (BSS) for the prevention and treatment of diarrhea and dyspepsia, and colloidal bismuth subcitrate (CBS Figure 10.16) for the treatment of peptic ulcers. Most ulcers are associated with the bacterium, Helicobacter pylori. In the 1990s, a new Bi(III)-containing drug was developed, ranitidine bismuth citrate (RBC), which combines the antisecretory action of ranitidine with the bactericidal properties of bismuth. Although the use of bismuth containing drugs for years was declining, they are now again becoming increasingly popular as combination pharmaceuticals due to developed antibiotics resistance by H. pylori.
In rats, inhibits formation of gastric ulcers caused Gastric ulcer prevention May cause bronchospasm on first exposure caution with asthma Not for topical use on damaged skin Caution in irritable bowel, stomach ulcers (with excess use), acid reflux in peptic ulcer disease), increased sebum, dizziness, arrhythmias, Chronic use at high doses causes skin effects, gout, peptic ulcer, eye
Pain relief, biostimulation, tooth whitening Tumour removal In oral surgery, gynaecology, bleeding peptic ulcers, fissure sealing, caries, dentine hypersensitivity, dentine, enamel and bone cutting, varicose veins (long pulse), analgesia (low power laser) Ureter and bladder surgery, lithotripsy, myocardial revascularisation, dacrocystorhinostomy Skin resurfacing, caries removal, enamel, dentine and bone cutting Tumour removal in gynaecology, ENT and oral surgery, denture-induced hyperplasia, skin resurfacing, gingival surgery, implant exposure, fissure sealing, caries, scaling of root surfaces, dentine, enamel and bone cutting_
Thyroid storm is a poorly defined clinical syndrome. The synonyms include thyroid crisis, thyrotoxic storm, and thyrotoxic crisis. Thyroid surgery, once the most common pathogenesis of thyroid storm, has become a rare cause of this disorder. Even senior surgeons have seen only a few such patients. This is attributable to recognition of these patients, to administration of appropriate antithyroid drugs, and to the popularity of radioactive iodine therapy for treating patients with thyrotoxicosis. Nonthyroid surgery, major trauma, infection, and image studies with iodinated contrast medium in patients with unrecognized thyrotoxicosis may act as precipitating factors of thyroid storm. For unequivocal cases of thyroid storm at our medical center, pneumonia, perforation of a peptic ulcer, iodinated contrast medium, and coexistent hyperparathyroidism with extreme hypercalcemia (serum calcium 15 mg dL) were considered pr cipitants. Known pr cipitants of thyroid storm are listed in Table...
The term tobaccosis in this essay denotes, collectively, all diseases resulting from the smoking, chewing, and snuffing of tobacco and from the breathing of tobacco smoke. They include cancers of the mouth, nasopharynx, larynx, trachea, bronchi, lungs, esophagus, stomach, liver, pancreas, kidney, bladder, prostate, and cervix, as well as leukemia. They also include atherosclerosis of the cardiovascular system - coronary heart disease (with ischemia and infarction), cardiomyopathy, aortic and other aneurysms, cerebrovascular hemorrhages and blockages renal failure and peripheral vascular disease emphysema and chronic obstructive pulmonary diseases peptic ulcer disease and regional ileitis cirrhosis of the liver immunological deficiencies and failures of endocrine and metabolic functions and fetal diseases and perinatal disabilities.
A spiral, urease-producing bacterium, Helicobacter pylori is associated with almost 90 of duodenal ulcers. Testing is indicated in patients with either active or previously documented peptic ulcer disease, in the evaluation of dyspepsia who have no alarm features, and for patients with a history of gastric MALT (mucosa-associated lymphoid tissue) lymphoma (MALToma) (Chey and Wong, 2007). Several tests can be performed during endoscopy. Rapid urease testing of a biopsy specimen has sensitivity over 90 and specificity over 95 , with results available within 1 to 24 hours. The sensitivity of rapid urease tests is reduced by drugs that treat
Several authors have published reports on laparoscopic renal biopsy by both transperitoneal (12,13) and retroperitoneal (8,14,18-20) approaches, including biopsies in children involving minor technical modifications (21). The largest series is reported by Shetye et al. (8) in which 74 patients underwent retroperitoneal laparoscopic renal biopsy over a nine-year period from 1991 to 2000. These authors obtained adequate tissue in 96 of their cases, which is similar to 100 rates of recovery from other published series (13,14). Shetye et al. reported an overall complication rate of 13.5 , the most common complication being bleeding, which was observed in 3 of 74 (4 ) patients (8). Only one bleed was significant, involving a 2000 mL blood loss. These authors also reported one death seven days following uneventful biopsy in a patient with a lupus flare who was treated with high-dose steroids after the renal biopsy and subsequently died of a perforated gastric ulcer after refusing...
GRFoma is anticipated when a patient has acromegaly and a pancreatic mass. Liver metastases and peptic ulcer disease should also be considered.66 68 The diagnosis can be confirmed by performing a plasma assay for GRF and a CT scan of the abdomen to identify a pancreatic or liver tumor. Octreotide therapy can relieve the signs and symptoms of acromegaly. Surgical resection should be attempted in these patients because complete resection may be curative, and debulking may decrease symptoms and prolong survival.