Pathology and Clinical Science
Case Study 1
Mark presents a history of back pain, and has been using Nurofen Plus for the last five months. He also has intermittent epigastric pain associated with nausea and vomiting, which increases after a fatty or a spicy meal. His vital signs and hematology tests are done. On endoscopy, there are large solitary lesions; one in the stomach and another in the duodenum measuring 2 centimeters and 1.5centimeters respectively. From the history presented, differential diagnosis can be made, which will help in making a definitive diagnosis for his condition.
Digestive System Signs and Symptoms
Mark has various digestive system signs and symptoms. These signs include vomiting and ulcers in the stomach and duodenum. The symptoms or the conditions felt and reported by the patient include nausea, epigastric pain associated with heartburn, bloating, dyspepsia, flatulence, feeling hungry, and an empty feeling in his stomach.
Differential Diagnosis
Peptic ulcers disease. Gastric ulcers and duodenal ulcers contribute to peptic ulcers disease (‘Peptic Ulcer Disease’ 2015, p. 23). Gastric ulcers are ulcerated gastric mucosal lining resulting in a solitary lesion. The ulcers are mainly caused by increased secretion of gastric acid as a result of gastrin cell hyperplasia, H. pylori infection, smoking, prolonged use of NSAIDs, and alcoholism (‘Peptic Ulcer Disease’ 2015, p. 23). Unlike duodenal ulcers, gastric ulcers are more common among advanced age groups because they are more likely to be affected by Helicobacter pylori or prolonged use of NSAIDs (‘Peptic Ulcer Disease’ 2015, p. 25).
Chronic gastritis. It is a prolonged inflammation of the mucosal lining of the stomach. It can be caused by continuous injury to the gastric mucosa, or an infection of the gastric mucosa (‘Peptic Ulcer Disease’ 2015, p. 26).
Gastric carcinoma. The endoscopy revealed a mass measuring 1.5 centimeters on the gastric lining. The gastric ulcers can be as a result of increased gastric acid production or an autoimmune attack on the mucosal lining (Iskandar, et al., 2015, p. 1). Metaplasia can occur resulting in the formation of gastric carcinoma.
Hematology Results
The hematology results give clues to his upper gastrointestinal condition. The hematology results show that the hemoglobin level is reduced; his hematocrit is below the normal range. His Mean Cell Volume is 66fl, which is also below the normal range. According to McFarlane, et al., (2015, p. 38), low hemoglobin and hematocrit levels indicate a reduced number of red blood cells, and this suggests that the patient is slightly anemic. This is most likely attributed to gastrointestinal blood loss and reduced iron absorption. The Mean Cell Volume and Mean Cell Hemoglobin are slightly reduced. This is an indication of microcytic anemia and from the patient’s history; duodenal ulcer can bring about microcytic anemia because of reduced iron absorption in the duodenum. The patient has normal fasting blood glucose. Elevated blood glucose is an indication of bleeding since platelets are increased in number to enhance blood clotting at the site of hemorrhage.
Physical Abdominal Examination
On physical examination, the most likely finding is a distended abdomen. Mark experiences bloating and flatulence, suggesting that the abdomen might be slightly distended as a result of gasses in the stomach and the intestines. Abdominal sounds are likely to be heard, and taps on the abdomen during percussion can probably indicate tenderness.
Investigative Tests
Stool test. Stool sample examination would help in the identification of Helicobacter pylori in the stool of the patient (‘Peptic Ulcer Disease’, 2015, p.23). Laboratory examination of the stool to identify characteristic features of the bacteria would provide a definitive diagnosis of H. pylori-associated peptic ulcers.
Urea Breath Test; Urea breath test is also a test used to investigate Pylori associated ulcers (‘Peptic Ulcer Disease’ 2010, p.23). The patient is given urea, and if the bacteria are present, it breaks down the waste products of urea into carbon dioxide.
Pathophysiology
Peptic ulcers disease stem from an imbalance in the protective factors and those that damage the gastro duodenal mucosal lining (Al Dhahab, et al., 2013, p.195). The mechanism responsible for gastric and duodenal ulcer formation induced by NSAIDs includes enhanced gastrin and parietal cell hyperplasia which increases gastric acid secretion. NSAIDs reduce gastric mucous synthesis by inhibiting arachidonic acid formation (Al Dhahab, et al., 2013, p.195). Prostaglandins are not formed resulting in a diminished mucus protective barrier exposing the gastroduodenal mucosa to erosion by gastric acid. H. pylori are also associated with damage to the integrity of the gastroduodenal mucosa.
Definitive Diagnosis
The definitive diagnosis is peptic ulcers disease and comprises of gastric ulcers and duodenal ulcers. Since the most likely cause of this condition is prolonged use of NSAIDs, treatment is improvement of the gastroduodenal mucus barrier and reduction of acid secretion.
According to Yazdanpanah, et al. (2016, p. 11), zinc sulfate is effective for treatment of gastric ulcers. Acid neutralizing drugs such as Aluminum and Magnesium Hydroxides and Histamine receptor H2 antagonists such as cimetidine are also used to lessen the rate of acid secretion. Proton pump inhibitors are the most potent inhibitors of acid secretion (Al Dhahab, et al., 2013, p.197). They include omeprazole, lansoprazole, and esomeprazole. Cytoprotective agents such as Sodium sucralfate, bismuth-containing salts, and prostaglandin analogs are used to increase mucus protective barrier (‘Peptic Ulcer Disease’ 2015, p.25). Effective antibiotic therapy includes amoxicillin, metronidazole, and clarithromycin (‘Peptic Ulcer Disease’ 2015, p.25).
Non-Pharmacologic Therapy
Nonpharmacologic therapy of this condition includes diet modification. Mark should avoid highly acidic and spicy food. Cessation of alcohol and smoking, surgery to manage complications, which can arise from the disease, and reduction of psychological stress will also be effective treatment options (‘Peptic Ulcer Disease’ 2015, p.26).
Case Study 2
In this case study, George, a 62-year-old, an opal miner, is presented with burning, frequency, and hematuria while urinating. He also complains of bilateral loin pain radiating down into his groin. Analysis done to investigate his condition includes urine dipstick test, x-ray, and full blood count.
Urine Dipstick Findings
Urinalysis is a biochemical technique to examine urine. Urine dipstick is a thin plastic strip with chemicals attached to it, and it is used to detect various abnormalities in urine. The patient is most likely to present with;
Specific gravity above 1.020. This is an indication of a concentrated urine. The urine is concentrated due to the presence of dissolved substances in the urine, which mainly are calcium stones. Concentrated urine is a major predisposing factor to the development of urine stones as seen in the patient
Leucocytes; The urine is most likely to have elevated leukocytes because of hematuria. According to Shatla, et al. (2016, p.6), blood in urine suggests that there is an injury to the urinary tract and this is a significant predisposition to infections. Urinary tract infections are a leading cause of elevated leucocytes which are produced by the body as a defense mechanism against the infectious agents (Shatla, et al., 2016, p.6). In line with this, the patient feels pain radiating to his groin which likely suggests a urinary tract infection.
Renal Calculi Visible on X-ray
Renal stones develop as a result of the concentration of a given substance in urine, and an X-ray can be used to investigate the types of renal stones. According to Grases, et al. (2011, p.409), calcium stones are the kinds of stones visible in this X-ray because calcium stones are radio-opaque thus seen as whitish patches when viewed under a microscope. The type of mineral deposits in these stones is mainly Calcium Phosphate and Calcium Oxalate (Porowski, et al., 2013, p.1079).
Clinical Signs and Symptoms
Change in smell and Color of Urine. the smell of urine often changes during urolithiasis. The natural smell of urine changes to a metallic, mineral smell (Porowski, et al., 2013, p.1079). The difference in smell is attributed to the additional dissolved substances in urine which are not there in normal conditions. Urine color change accompanies the change in smell as a result of the concentration of the urine.
Fever and Chills. Fever and chills also develop in association with renal calculi.
Nausea and vomiting. Nausea and vomiting are also non-specific symptoms which occur in the presence of renal calculi (Porowski, et al., 2013, p.1079).
Causes of Renal Stones
Hereditary. There is a genetic predisposition to formation of renal stones by some patients. Because the majority of kidney stones are formed by calcium, hereditary predisposition to abnormally high levels of calcium puts one at risk of developing renal stones since the kidney is unable to excrete all the calcium (Evan, 2010, p.832).
Diet; According Evan (2010, p.832), diet of an individual is also a significant predisposition to the development of renal calculi. As seen in this case, the patient has been drinking bore water for a long time, and this might have increased his daily calcium consumption.
Medications. Renal calculi can also develop in the setting of increased calcium ions levels in the body as a result of medicines (Evan, 2010, p. 838). Excess calcium containing drugs such as antacids predisposes one to the development of renal calculi. Vitamin A, Vitamin D and parathyroid hormone-containing medications are also associated with increased levels of calcium in the body (Evan, 2010, p. 838).
Diseases. There are some conditions associated with chronic kidney failure and thus associated with the development of kidney stones. Renal Tubular Acidosis and Cystic fibrosis are some of the conditions which might result in renal calculi (Evan, 2010, p. 838).
Geographical location;
The geographic location of the patient is Central Asia a desert with very hard water. Such area predisposes one to the development of calcium stones since there is low water and the water available contains a high concentration of dissolved salts. The hot climate and intake of hard water make these people be dehydrated and thus accumulation of dissolved calcium resulting in the formation of calcium stones (Tasian, et al., 2014, p. 1081)
Treatment
Treatment involves reducing further development of renal calculi and minimizing the effects of renal calculi using antiurolithiatic drugs (Lulat, et al., 2016, p.78). Modular flexible ureteroscopy and holmium laser lithotripsy can be used for treatment (Zejun, et al., 2015, p. 1468).
Renal calculi develop as a result of the accumulation of salts in urine more than the limit which they can be excreted (Zejun, et al., 2015, p. 1468). The renal calculi can be investigated by an X-ray and urinary dipstick test. There are various predisposing factors to the development of renal calculi, and some of the factors include hereditary factors, diet, and geographical location (Zejun, et al., 2015, p. 1468).
Bibliography
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