PGY VS

1
EBM

• PGY ???/VS ???

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Basic imformation

• Chart No. 27312156
• Name ?x?
• Age 42 y/o
• Gender male

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Chief complain

• Tarry stool passage(3-4 times) for 5 days

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Present illness

• Suffered from tarry stool passage(3-4 times) for
  5 days
• Mild dizziness, mild epigastric dullness
• Vomiting with food after intaking
• He denied any special food or NSAID drugs taking
  before this episode
• No respiratory symptoms, no abdominal pain

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Past history

• 1. Medical history
• Hypertension --------denied
• Diabetes mellitus ---denied
• Chronic hepatitis B--denied
• Chronic hepatitis C--denied
• 2. Surgical history nil

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Personal history

• 1. Smoking about 1 PPD, for 10 years
• 2. Alcohol drinking for 10 years ( ??)
• 3. Betel nut nil
• 4. Herbal medication nil

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Physical examination

• 1. General appearance acutely ill, well
  development nourished
• 2. Consciousness clear
• 3. Peripheral perfusion distal extremity ---
  warm, pink, no cyanosis
• Finger tail refilling time -- normal
• 4. Skin color --- normal color, no icteria, no
  rash, no ecchymosis
• 5. HEENT
• Head normal appearance, no trauma
• Eyes sclera-------- normal color, no icteria
• conjunctiva--- pale, no ulceration
• 6. Neck supple, no stiffness, no
  lymphadenopathy, no mass
• Thyroid gland no nodules, no goitor, no
  bruit

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• 7. Chest
• normal quality of expansion, symmetrically
• normal clear breathing sounds, no rales, no
  wheezing, no rhonchi, no crackles
• 8. Heart
• normal regular rhythm no murmur
• 9. Abdomen
• flat, no flank bulging, no operation scar, no
  striae,
• normal active bowel sounds, no bruit, no friction
  rub
• dullness, no knocking pain, no shifting dullness
• soft, no tenderness, no Murphy's sign,
• no hepatomegaly, no splenomegaly, no palpable
  mass
• 10.Extremities no pitting edema, no swelling, no
  flapping tremor, no muscle wasting

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Lab
10
CXR
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PES

• Esophagus Erosions(gt5mm) with fresh blood at
  distal end
• Herniated sac at E-C junction
• Stomach Linear ulcer at cardia. CLOtest was
  done. The body, fundus and
• antrum were negative
• Duodenum negative to 2nd portion
• Diagnosis
• 1. Erosive esophagitis, LA(B)
• 2. Sliding hiatal hernia
• 3. Gastric ulcer, A2 at cardia
• 4. CLOtest( - )

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Impression

• 1. Erosive esophagitis
• 2. Sliding hiatal hernia
• 3. Gastric ulcer
• 4. Impairment of liver function r/o alcohol liver
  disease

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Abdominal sonography

• 1. Slightly coarsening liver echo. Advise
  correlate with liver function test to
• DDX Chronic liver parenchymal disease or
  alcoholic liver disease.
• No obvious focal mass of visible liver
  parenchyma.
• 2. The gallbladder is of normal wall thickness,
  and no stone depicted.
• 3. No marked dilatation of PV, IHD and CBD.
• 4. The visible pancreas is unremarkable
  (difficult to evaluate the pancreas tail
• due to bowel gas blockage)
• 5. The spleen is unremarkable.
• 6. The bilateral kidneys shows normal
  echogenicity.
• There is no hydronephrosis and no renal stone.
• IMP
• Chronic liver parenchymal disease or alcoholic
  liver disease.

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• PICO

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Problem and PICO

• Title Can H pylori eradication prevent gastric
  cancer?

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PICO Question

• PICO Question Can H pylori eradication prevent
  gastric cancer?
• P Patient with H.pylori infection had gastric
  cancer
• I With H. pylori eradication therapy
• C without H. pylori eradication therapy
• O Prevent gastric cancer occurance

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Database and search key words

• DatabasePubMed
• Keywords H.pylori eradication AND Gastric
  cancer prevention
• Limits English, Randomized Controlled Trial,
  Humans

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Search result
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Evidence title

• Helicobacter pylori Eradication to Prevent
  Gastric Cancer in a High-Risk Region of China
• JAMA. 2004291187-194.
• Benjamin Chun-Yu Wong, MD Shiu Kum Lam, MD Wai
  Man Wong, MD etc, China Gastric Cancer Study
  Group

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Abstract

• Objective  To determine whether treatment of H
  pylori infection reduces the incidence of gastric
  cancer.
• Design, Setting, and Participants  Prospective,
  randomized, placebo-controlled, population-based
  primary prevention study of 1630 healthy carriers
  of H pylori infection from Fujian Province,
  China, recruited in July 1994 and followed up
  until January 2002. A total of 988 participants
  did not have precancerous lesions (gastric
  atrophy, intestinal metaplasia, or gastric
  dysplasia) on study entry.

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Abstract

• Intervention  Patients were randomly assigned to
  receive H pylori eradication treatment a 2-week
  course of omeprazole, 20 mg, a combination
  product of amoxicillin and clavulanate potassium,
  750 mg, and metronidazole, 400 mg, all twice
  daily (n 817) or placebo (n 813).
• Main Outcome Measures  The primary outcome
  measure was incidence of gastric cancer during
  follow-up, compared between H pylori eradication
  and placebo groups. The secondary outcome measure
  was incidence of gastric cancer in patients with
  or without precancerous lesions, compared between
  the 2 groups.

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Abstract Results 

• Among the 18 new cases of gastric cancers that
  developed, no overall reduction was observed in
  participants who received H pylori eradication
  treatment (n 7) compared with those who did not
  (n 11) (P .33).
• In a subgroup of patients with no precancerous
  lesions on presentation, no patient developed
  gastric cancer during a follow-up of 7.5 years
  after H pylori eradication treatment compared
  with those who received placebo (0 vs 6 P
  .02).
• Smoking (hazard ratio HR, 6.2 95 confidence
  interval CI, 2.3-16.5 Plt.001) and older age
  (HR, 1.10 95 CI, 1.05-1.15 Plt.001) were
  independent risk factors for the development of
  gastric cancer in this cohort.

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Results 
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Conclusion

• The incidence of gastric cancer development at
  the population level was similar between
  participants receiving H pylori eradication
  treatment and those receiving placebo during a
  period of 7.5 years in a high-risk region of
  China.
• In the subgroup of H pylori carriers without
  precancerous lesions, eradication of H pylori
  significantly decreased the development of
  gastric cancer.
• Further studies to investigate the role of H
  pylori eradication in participants with
  precancerous lesions are warranted.