GI1 Case A New Patient Answers

You're the new GI doctor in a DC practice. It's your first day and you meet Mr. Harper. He was referred to you by his primary care, whom he only recently started to see again. He's been having episodes of dark stools that he thought was normal until his wife noticed and commented on the strange color. He says it's been happening for a while now, but it wasn't until he was denied from donating blood recently, for having an iron deficiency, that he decided to get checked out.

You read the brief note sent from his primary care doctor.

"59 yo M p/w 2 year h/o of melena and iron deficiency. He has had increasing episodes of nausea and NBNB vomiting over the last year; once a week. Describes sense of post  prandial fullness.

PMHx: Osteoarthritis.
Meds: Aspirin and PRN Ibuprofen"

What is the top diagnosis you are considering?

Gastritis

You've started to worry that your patient's issue has become a chronic process. What major issue do you notice in your patient's history, could be causing the problem?

H/O NSAID use. Could be taking lots of pain medication for his osteoarthritis flareups. 

What malignant process are you worried about should your patient's problem continue to be unmanaged?

Gastric Adenocarcinoma

You do an endoscopy and you find a 1cm gastric ulcer near in the fundus of the stomach.

Describe what you see

"The ulcer is shallow and sharply demarcated, with surrounding hyperemia. It is probably benign. However, all gastric ulcers should be biopsied to rule out a malignancy. " -Utah Path

You decide to order a urea breath test. (WHY? To detect H. pylori) By chance, you receive the result the same time as your gastric ulcer biopsy you performed during endoscopy. Describe what you see on the following slides.

(IMAGES FROM UTAS)

 Gram Stain and Cx from endoscopy

"Photograph 1 (top left) shows a modified Gram stain demonstrating the spiral bacillus of Helicobacter pylori.
Photograph 2 (top right) shows a Giemsa stain in which the organisms can be seen within the mucus extruding from the foveolar pits.
Photograph 3 (bottom) shows a proliferating colony of Helicobacter pylori obtained by culturing a gastric biopsy.

Note that Helicobacter pylori is strongly associated with active chronic gastritis." -UTAS


What is another clinical test you can use to detect H. pylori? What is another useful feature of this test?

Stool Antigen Test. Also lets you know when H. pylori has been eradicated.

What other diseases are associated with H. pylori?

-Duodenal and Gastric Ulcers
-Gastric Adenocarcinoma
-Low Grade B cell Malignant Lymphoma