BAUYA/MAGDARAOG/MEJICA/NEMENZO/VADIVEL

CASE PRESENTATION
SALIENT FEATURES:
RECURRENT EPIGASTRIC PAIN — GNAWING,
CONSTIPATION
NON-RADIATING, NOT RELIEVED BY ANTACIDS
EPIGASTRIC PAIN INITIALLY RELIEVED BY FOOD INTAKE BP 80/60MMHG
AGGRAVATED BY ALCOHOL INTAKE HR 119BPM
VOMITING (+) RIGIDITY OF ABDOMEN
KNOWN CASE OF HYPERTENSION (+) DIRECT TENDERNESS OF ABDOMEN
ALCOHOL BEVERAGE DRINKER ABSENT BOWEL SOUNDS
35-PACK-YEAR SMOKER BLOATING & BELCHING

RECURRENT HUNGER PANGS FAINT PERIPHERAL PULSES

 CLINICAL PROFILE PHYSICAL FINDINGS
EPIGASTRIC PAIN

ACUTE GASTRITIS CHOLECYSTITIS FUNCTIONAL GASTRIC

PANCREATITIS GENERALIZED PERITONITIS DYSPEPSIA CANCER
PROBABLY FROM
PERFORATED PEPTIC ULCER DISEASE,
R/O ACUTE PANCREATITIS

PATHOPHYSIOLOGY
 CLINICAL PROFILE
Patient C.E., 63 year old, Male
Generalized Abdominal Pain

Recurrent epigastric pain initially

Known case of hypertension
relieved by food intake
since 2008 with poor
compliance of medications
Gnawing, Non-Radiating with
PRS of 7/10

Alcohol beverage drinker

Worsened after intake of alcohol

35-pack-year smoker
Vomiting composed of previously ingested food

Antacids taken but offered no relief

 PHYSICAL FINDINGS
ENDOMORPH WITH BMI OF 32
FACIAL GRIMACE & GUARDING ABSENT BOWEL SOUNDS

HYPOTENSIVE (80/60MMHG) (+) RIGIDITY OF ABDOMEN

TACHYCARDIA (119BPM) (+) TENDERNESS OF ABDOMEN
DRY LIPS AND TONGUE
FLAT NECK VEINS, FAINT PULSES
 CLINICAL PROFILE PHYSICAL FINDINGS
EPIGASTRIC PAIN

ACUTE PANCREATITIS GASTRITIS CHOLECYSTITIS FUNCTIONAL DYSPEPSIA GASTRIC

GENERALIZED PERITONITIS CANCER
PROBABLY FROM
PERFORATED PEPTIC ULCER DISEASE,
R/O ACUTE PANCREATITIS

PATHOPHYSIOLOGY
 ACUTE PANCREATITIS

AGE: 63 Y.O. PT’S PAIN IS GNAWING IN CHARACTER

OBESITY (BMI 32) NON-RADIATING PAIN
COMORBID DISEASE (HYPERTENSION) (-) CULLEN’S SIGN
ALCOHOL BEVERAGE DRINKER (-) TURNER’S SIGN
EPIGASTRIC PAIN
VOMITING
HYPOTENSION
TACHYCARDIA
ABDOMINAL TENDERNESS
ABSENT BOWEL SOUNDS
 CLINICAL PROFILE PHYSICAL FINDINGS
EPIGASTRIC PAIN

ACUTE PANCREATITIS GASTRITIS CHOLECYSTITIS FUNCTIONAL GASTRIC

GENERALIZED PERITONITIS DYSPEPSIA CANCER
PROBABLY FROM
PERFORATED PEPTIC ULCER DISEASE,
R/O ACUTE PANCREATITIS

PATHOPHYSIOLOGY
 GASTRITIS

GNAWING EPIGASTRIC PAIN NORMAL BOWEL SOUNDS

NAUSEA AND VOMITING NO LOSS OF APPETITE
BLOATING NO MELENA/HEMATOCHEZIA
NO HEMATEMESIS
BELCHING
ADVANCED AGE (63 YRS. OLD)
ALCOHOL BEVERAGE DRINKER
 CLINICAL PROFILE PHYSICAL FINDINGS
EPIGASTRIC PAIN

ACUTE PANCREATITIS GASTRITIS CHOLECYSTITIS FUNCTIONAL GASTRIC

GENERALIZED PERITONITIS DYSPEPSIA CANCER
PROBABLY FROM
PERFORATED PEPTIC ULCER DISEASE,
R/O ACUTE PANCREATITIS

PATHOPHYSIOLOGY
 CHOLECYSTITIS

EPIGASTRIC PAIN COLICKY ABDOMINAL PAIN

NAUSEA & VOMITING NO FEVER
BLOATING NO REBOUND TENDERNESS
ABDOMINAL TENDERNESS (-) MURPHY’S SIGN
OBESITY (BMI 32)
35-PACK-YEAR SMOKER
 CLINICAL PROFILE PHYSICAL FINDINGS
EPIGASTRIC PAIN

ACUTE PANCREATITIS GASTRITIS CHOLECYSTITIS FUNCTIONAL DYSPEPSIA GASTRIC

GENERALIZED PERITONITIS CANCER
PROBABLY FROM
PERFORATED PEPTIC ULCER DISEASE,
R/O ACUTE PANCREATITIS

PATHOPHYSIOLOGY
 FUNCTIONAL DYSPEPSIA

RECURRENT EPIGASTRIC PAIN ADVANCED AGE

EARLY SATIETY NO LOSS OF APPETITE
BLOATING TENDERNESS
BELCHING ABDOMINAL RIGIDITY
NAUSEA & VOMITING NO HISTORY OF USE OF PSYCHOTROPIC MEDICATIONS
ALCOHOLIC BEVERAGE AND COFFEE DRINKER NO SIGNS OF ANXIETY OR DEPRESSION
 CLINICAL PROFILE PHYSICAL FINDINGS
EPIGASTRIC PAIN

ACUTE PANCREATITIS GASTRITIS CHOLECYSTITIS FUNCTIONAL DYSPEPSIA GASTRIC

GENERALIZED PERITONITIS CANCER
PROBABLY FROM
PERFORATED PEPTIC ULCER DISEASE,
R/O ACUTE PANCREATITIS

PATHOPHYSIOLOGY
 GASTRIC
CANCER

UPPER ABDOMINAL PAIN NO WEIGHT LOSS

NAUSEA & VOMITING NO LOSS OF APPETITE
GENDER: MALE NO MELENA/HEMATOCHEZIA
BLOATING NO WEAKNESS OR FATIGUABILITY
CONSTIPATION
35-PACK-YEAR SMOKER
 CLINICAL PROFILE PHYSICAL FINDINGS
EPIGASTRIC PAIN

ACUTE PANCREATITIS GASTRITIS CHOLECYSTITIS FUNCTIONAL DYSPEPSIA GASTRIC

GENERALIZED PERITONITIS CANCER
PROBABLY FROM
PERFORATED PEPTIC ULCER DISEASE,
R/O ACUTE PANCREATITIS

PATHOPHYSIOLOGY
 PATHOPHYSIOLOGY
ADVANCE AGE (63 YEARS OLD) H. PYLORI INFECTION ALCOHOL & SMOKING

reduced mucosal production of urease irritation of gastric and

integrity and production that catalyses the intestinal mucosa
of protective mucus hydrolysis of urea to
ammonia

increased concentration
of ammonia in the
susceptibility to the gastric lumen
damaging effects of HCl
acid and pepsin impairment of
mitochondrial and
cellular respiration and
metabolism of mucosal
cell

mucosal damage and ulceration

 mucosal damage and ulceration

BLOATING EPIGASTRIC PAIN CONSTIPATION & NAUSEA AND VOMITING

ulceration penetrates the muscular ABSENT BOWEL SOUNDS
layer of the stomach

leakage of gastric acid into

ENDOSCOPY: DEMONSTRATES PERFORATED ULCER erosion of the blood
the peritoneal cavity vessels supplying the area

gastric acid irritates the internal bleeding

peritoneum
decrease in circulating
blood volume
PERITONITIS

ABDOMINAL RIGIDITY & ABSENT BOWEL FACIAL GRIMACE & FAINT PERIPHERAL PULSES HYPOTENSION TACHYCARDIA
TENDERNESS SOUNDS GUARDING (80/60MMHG) (119BPM)

XRAY: ACCUMULATION OF PERITONEAL FLUID

CBC: INCREASED HEMATOCRIT
ABDOMINAL IMAGING: PRESENCE OF FREE INTRAPERITONEAL AIR
 ADVANCE AGE (63 YEARS OLD) H. PYLORI INFECTION ALCOHOL

reduced mucosal integrity and irritation of gastric and intestinal

production of protective mucus production of urease that catalyses mucosa
the hydrolysis of urea to ammonia

increased concentration of ammonia

in the gastric lumen

impairment of mitochondrial and

susceptibility to the damaging cellular respiration and metabolism
effects of HCl acid and pepsin of mucosal cell

mucosal damage and ulceration

BLOATING EPIGASTRIC PAIN NAUSEA AND VOMITING

ulceration penetrates the muscular layer of the stomach

ENDOSCOPY: DEMONSTRATES PERFORATED ULCER

leakage of gastric acid into the peritoneal erosion of the blood vessels supplying
cavity the area

gastric acid irritates the peritoneum internal bleeding

PERITONITIS decrease in circulating blood volume

ABDOMINAL ABSENT BOWEL FACIAL

RIGIDITY&TENDERNESS SOUNDS GRIMACE&GUARDING
XRAY: ACCUMULATION OF PERITONEAL FLUID FAINT PERIPHERAL PULSES
HYPOTENSION TACHYCARDIA
ABDOMINAL IMAGING: PRESENCE OF FREE INTRAPERITONEAL AIR (80/60MMHG) (119BPM)
CBC: LEUKOCYTOSIS CBC: DECREASED HEMOGLOBIN AND HEMATOCRIT
 GENERALIZED PERITONITIS
PROBABLY FROM
PERFORATED PEPTIC ULCER DISEASE,
R/O ACUTE PANCREATITIS
THANK YOU FOR LISTENING!

BAUYA / MAGDARAOG / MEJICA / NEMENZO / VADIVEL