Stomach (Robbins 5th Ed., p. 770-778) or (Robbins 6th Ed., p. 789-797)
1. List the causes of an acute gastric ulcer.
2. Describe the gross and microscopic features of an acute gastric ulcer.
3. Describe the major complication of an acute gastric ulcer.
4. Describe the microscopic characteristics of chronic gastritis associated with chronic infection secondary to Helicobacter pylori.
5. Describe the causes of a chronic ulcer.
6. Describe the gross and microscopic features of a chronic peptic ulcer.
7. Describe the role of gastric acid/pepsin, infection with H. pylori, and mucosal defenses in the pathogenesis of peptic ulcers (Robbins 5th Ed., Figure 17-18, p. 776) or (Robbins 6th Ed., Figure 18-16, p. 794).
8. List the complications of a chronic gastric ulcer.
Small Intestine
1. Describe the following aspects of ischemic bowel disease (Robbins 5th Ed., p. 787-788) or (Robbins 6th Ed., p. 820-823, 825-826):
a. Definition
b. Vascular causes
c. Mechanical causes
d. Gross and microscopic features (Robbins 5th Ed., p. 788) or (6th Ed., p. 821-822)focus on bold-faced text in pink boxes)
e. Clinical features (age, mortality, abdominal signs)
f. Complications (gangrene, perforation, peritonitis)
2. Describe the following aspects of neoplasms of the small intestine (Robbins 5th Ed., p. 818-819) or (Robbins 6th Ed., p. 835-837):
a. Carcinoid tumors:1. Most common sites in GI tract
2. Gross and microscopic features
3. Clinical features
4. Complication -- carcinoid syndromeb. List the features of the carcinoid syndrome.
1. (Robbins 5th Ed., p. 770-778, 787-788, 818-819) or (Robbins 6th Ed., p. 789-797, 820-823, 825-826, 835-837)
2. Images 1-4 relate to the case; the rest are related to other objectives
W.K. is a 72-year-old white man with a history of homelessness, chronic obstructive pulmonary disease, chronic alcohol abuse, chronic dementia, and multiple episodes of upper GI bleeding. He was admitted to the hospital with complaints of lightheadedness, syncope, and abdominal pain.
The patient was an elderly thin, white man in no acute distress. On admission the patient's blood pressure was 96/72, pulse - 104, respiratory rate - 24, and a temperature of 98.9 F. The conjunctivae were pale. The chest and heart examination were unremarkable. The abdominal examination demonstrated mild epigastric pain to palpation. The rectal and prostate examination were unremarkable; however, black hemoccult-positive stool was present. The remainder of the physical exam was unremarkable.
On admission the following lab results were noted:
|
TEST RESULT |
NORMAL VALUE |
|
|
Hemoglobin |
4.1 gm/dl |
12.5-18.0 gm/dl |
|
Hematocrit |
12.9% |
40-54% |
|
Albumin |
2.6 gm/dl |
3.9-4.8 gm/dl |
|
WBC |
11,000/mm3 |
5,000-10,000/mm3 |
|
Ethanol |
less than 10 mg/dL |
less than 10 mg/dL |
EKG was unremarkable, as were a chest x-ray and x-rays of kidneys, ureters, and bladder.
The patient was admitted to the Medical Intensive Care Unit, where a naso-gastric tube lavage demonstrated coffee ground gastric contents that were hemoccult-positive. He was transfused with six units of packed red blood cells, which increased his hematocrit to 38% (normal 40-54%). An upper endoscopy was performed and demonstrated 2 large gastric ulcers; one measured 5x5 cm and the other one measured 2x3 cm. Biopsies were taken of the ulcers and surrounding mucosa. The biopsies showed necrotic debris consistent with an ulcer, and the surrounding mucosa showed acute and chronic inflammation and organisms consistent with Helicobacter pylori. There was no evidence of malignancy. The patient was treated with acid suppressive therapy and antibiotics and was discharged five days after admission. He was given instructions not to take aspirin or drink alcohol.
The patient was re-admitted two weeks later with a history of abdominal pain, weight loss, constipation, and fever. Lab data revealed a urinary tract infection due to Klebsiella, which was treated with antibiotic therapy. The hemoglobin was 8.2g/dL (normal 12.5-18.0g/dL) and hematocrit was 27.5% (normal 40-54%). He was transfused with 2 units of packed red blood cells and discharged one week later on antibiotics and acid suppressive therapy. He was readmitted for two additional episodes of GI bleeding. Over a two year period he received a total of 20 units of packed red blood cells. He was taken to surgery for a vagotomy and antrectomy with Billroth I Reconstruction. He was discharged to a nursing home 2 weeks after surgery.