Name:
A 57-Year-Old with Hematemesis
Description:
A 57-Year-Old with Hematemesis
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Duration:
T00H05M21S
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Upload Date:
2025-07-17T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
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CATHY: Hi. Welcome to Harrison's Podclass where we discuss important concepts in internal medicine. I'm Cathy Handy.
CHARLIE: And I'm Charlie Wiener
CHARLIE: and we're coming to you from the Johns Hopkins School of Medicine. Welcome to Harrison's Podclass. Today is Episode 14: A 57-year-old with Hematemesis. Here's the question: A 57-year-old man is evaluated with an EGD after an episode of acute hematemesis. The patient reports a history of tobacco use and hypercholesterolemia, but he's otherwise healthy. He's had lower back pain for the past month and has been intermittently using acetaminophen, 1000 mg daily, for relief.
CHARLIE: His endoscopy shows a 3 cm duodenal ulcer. So, Cathy, what do you think is the cause of the ulcer?
CATHY: Duodenal ulcers are most commonly due to Helicobacter pylori, or H. pylori infection. In the minority of cases, non-steroidal anti-inflammatory drugs, or NSAIDs, can facilitate development or be the only identified cause of ulcers. The patient was taking acetaminophen, which is not an NSAID, so I would say that H. pylori-associated peptic ulcer disease would be the most likely cause of the findings here.
CHARLIE: Okay, so this question is asking a bunch of aspects of the duodenal ulcer. And the question says, which of the following statements is correct regarding this finding referring to the duodenal ulcer? Option A reads, "The lesion should be biopsied because duodenal ulcers have an elevated risk of being due to carcinoma." Option B reads, "First line therapy should be discontinuation of the acetaminophen." Option C reads, "The patient is not at risk for any associated cancers." Option D reads, "Poor socioeconomic status is a risk factor for the development of this condition." And finally, option E says, "Enterogastritis is rarely found with this condition." Why don't you take these one by one, Cathy?
CATHY: So the case, if we recall, is a 57-year-old man with a duodenal ulcer which, again, like we said before, was most likely due to H. pylori infection. So, option A suggests that the lesion should be biopsied because of an elevated risk of underlying carcinoma. So, that's not necessarily the case for duodenal ulcers. Routine H. pylori-associated duodenal ulcers are not typically related to a malignancy. It would be different, though, if the patient had a gastric ulcer; and, again, the location of the ulcer is where the difference lies here.
CATHY: So, gastric ulcers are much more likely to be malignant. So if the ulcer was found in the stomach, a biopsy would be indicated. But since here we have a duodenal ulcer, option A is not true. Option B asks about stopping acetaminophen use. That's also not necessary, so acetaminophen use is not associated with an increased risk of duodenal ulcers. Sometimes people who are taking acetaminophen because of pain are also taking NSAIDs, so it would be important to ask about that specifically, but we wouldn't need to stop acetaminophen use.
CHARLIE: Okay, so option B is also not true. How about option C?
CATHY: Option C asks about cancers associated with the duodenal ulcer. This is a little subtle because H. pylori infection is associated with duodenal ulcers but also with some malignancies, such as gastric cancer and mucosa-associated lymphoid tissue, or MALT lymphoma. All in all, while there is some truth to this statement, simply the presence of a duodenal ulcer does not increase the risk of an associated malignancy, so I'm hoping one of the other options is better.
CHARLIE: Okay, well, let's look at option D. That says that duodenal ulcer is associated with poor socioeconomic status. What do you think of that one?
CATHY: Okay, I like this one, and this choice is clearly correct. Duodenal ulcers and H. pylori infection are closely correlated with advancing age, low socioeconomic status, and low education levels. So, this choice is clearly correct.
CHARLIE: Okay. Therefore, option E, that states that enterogastritis is rarely found with this condition, is also false. Tell me why.
CATHY: After initial infection with H. pylori, enterogastritis is common. So, during the EGD, the endoscopist will usually also assess the antral epithelium.
CHARLIE: While not asked in this question, what would you do next to treat this patient?
CATHY: We need to address the ulcer and the infection, which are obviously related. So, our goals would be to suppress gastric acid production and to treat the H. pylori infection. To do this, usually we use three to four drug regimens, which include acid suppressive therapy and a combination of antibiotics. The three-drug regimen of clarithromycin, a proton pump inhibitor, and amoxycillin or metronidazole, is a commonly used regimen. Some geographic areas may have higher rates of clarithromycin resistance, so sometimes quadruple therapy, which usually consists of bismuth, a PPI, metronidazole, and tetracycline, is also recommended.
CHARLIE: Great. So, the teaching point here is that duodenal ulcers are most commonly caused by H. pylori infection, which has been associated with advancing age and low socioeconomic status. Treatment requires simultaneous suppression of acid and treatment of the H. pylori infection.
CATHY: For more information, we refer you to the Harrison's chapter on peptic ulcer disease, and also you can check out the American College of Gastroenterology 2017 Clinical Guide on treatment of H. pylori Infection.
CHARLIE: That's published in the American Journal of Gastroenterology, 2017, volume 112, page 212. ♪ (music) ♪
