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Case 270

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A female patient, aged 59, presented with a 3-day history of melena and a 2-hour history of hematemesis. She refers epigastric pain and hyporexia on the last 30 days. Her previous history is: ex-smoker (46 pack-years), hypertension, type 2 diabetes and peripheral artery disease (including a left forefoot amputation 1 year ago). She refers the use of 4 tablets of nimesulide a day in the last 4 months for pain relief in the amputated stump. An upper gastrointestinal endoscopy with biopsy was performed and it is shown below.

According to the clinic history and the findings on the exams presented, what is the most likely diagnosis?

a) Gastric adenocarcinoma

25%

b) Gastric peptic ulcer related to H. pylori

25%

c) Gastric peptic ulcer related to NSAIDs

25%

d) Gastrointestinal stromal tumor (GIST)

25%
   

Image analysis

Image 1: Endoscopic picture revealing an extensive ulcer (red mark), located on the lesser curvature of the stomach, with borders slightly elevated, irregular shape and its floor covered with fibrin and coagulated blood (blue marks).

 

Image 2: Gastric biopsy showing gastritis – characterized by the presence of diffuse inflammatory infiltrate (blue marks), besides intestinal metaplasia – characterized by the presence of goblet cells (red marks), what is commonly found with gastritis. No suggestive findings of cancer are present.

 

 

Image 3: Gastric biopsy showing an extensive necrotic area (in red), composed by cellular debris and strongly dyed by eosin.

 

Image 4: Gastric biopsy showing normal gastric glands (red marks), with no finding suggesting cancer, besides diffuse inflammatory infiltrate and intestinal metaplasia.

Highlights

- Gastritis is a common histologic diagnosis in endoscopic biopsies. Peptic ulcers are commonly found associated with gastritis;

- Gastritis and peptic ulcers have 3 main etiologies: chronic infection by H. pylori, auto-immune damage and chemical damage, as with NSAIDs;

- Working the differential diagnosis between peptic ulcers and other ulcers is mandatory, as with gastric carcinomas. A biopsy is fundamental for the differentiation;

- The most frequent complications of the Peptic Ulcer Disease are Upper Gastrointestinal Bleeding (UGB) and perforation;

- The work-up for UGB consists of endoscopic evaluation and the treatment is based on eradicating the underlying cause. Intravenous proton-pump inhibitors and suspension of the NSAID are indicated on this case.

References

- Goldman L, Schafer AI. Cecil – Tratado de medicina interna. 24ª edição. São Paulo: Elsevier; 2014.

- Filho GB. Bogliolo Patologia. 8ª edição. Rio de Janeiro: Guanabara Koogan; 2011.

- Ballinger A, Smith G. COX-2 inhibitors vs. NSAIDs in gastrointestinal damage and prevention. Expert Opinion on Pharmacotherapy. 2001;2(1):31-40.

- Vasapolli R, Malfertheiner P, Kandulski A. Helicobacter pylori and non-malignant upper gastrointestinal diseases. Helicobacter. 2016;21:30-33.

- Vakil, NB. Overview of the complications of peptic ulcer disease. Shilpa G, editor. UpToDate, 2017. Available on https://www.uptodate.com/contents/overview-of-the-complications-of-peptic-ulcer-disease.

- Saltzman, JR. Overview of the treatment of bleeding peptic ulcers. Anne CT, editor. UpToDate, 2017. Available on https://www.uptodate.com/contents/overview-of-the-treatment-of-bleeding-peptic-ulcers.

Authors

Thiago de Oliveira Heringer, 5th year medical student at UFMG.

Email: thiheringer[at]gmail.com

Supervisors

Ênio Roberto Pietra Pedroso, professor on the Intern Medicine department of the Medicine Faculty of UFMG.

Reviewers 

Lucas Raso, Thiago Ruiz, Giovanna Carvalho, Lucas Resende, Joice Carneiro and Professor Viviane Parisotto.

Translated by

Arthur de Paula Melgaço, 5th year medical student at UFMG.

Email: artmelgaco[at]gmail.com

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