PARAPHRASE ONLY

CASE 5 GASTROESOPHAGEAL REFLUX DISEASE (GERD) PART 1 – CRITICAL READING 1. Summary of the case study Jack Nelson, a 48-year-old male, presented with severe indigestion, which was confirmed as gastroesophageal reflux disease (GERD) through intraesophageal pH monitoring and a barium esophagram. The patient’s symptoms worsened over the past year, accompanied by significant weight gain (35 pounds) due to reduced physical activity caused by a right knee arthroplasty five years ago and increased caloric intake, particularly stress-related eating. His diet and lifestyle contribute to his condition, with a history of hypertension and a family history of coronary artery disease. His current medications include atenolol, aspirin, multivitamin, and ibuprofen. He was advised to decrease his aspirin intake, discontinue ibuprofen, and start omeprazole therapy. 2. Problem/issue Setting of the Study The study focuses on diagnosing and managing GERD in a patient with several contributing factors: a sedentary lifestyle, poor diet, stress-related eating, and a family history of heart disease. His weight gain and poor dietary choices exacerbated his symptoms. His problem has become worse despite his efforts to control it with over-the-counter antacids like Tums (antacid). His medical and surgical history, along with the use of aspirin and ibuprofen, complicates the condition further. The issue is how to manage GERD effectively while addressing underlying factors. PART 2 – CRITICAL THINKING 1. Resolution of the Issue/Problem The physician’s plan to resolve Mr Nelson’s GERD included the following steps: First, medication adjustments by reducing aspirin intake from 325mg to 75mg daily to minimize its gastro irritative effects and discontinuing ibuprofen due to its potential to aggravate GERD. Second, pharmacological treatment by starting omeprazole 30mg daily to reduce stomach acid production. Additionally, conduct more diagnostic tests like ambulatory 48-hour pH monitoring and a barium esophagram, along with endoscopy and biopsy to rule out H. pylori infection. Also, a nutritional consultation is a must to address his diet, focusing on reducing his intake of fatty, fried foods and large meals that worsen his GERD symptoms. 2. Agreement with the Resolution With the involved multifaceted approach addressing both his medical and lifestyle factors, I agree with the resolution. The reduction of aspirin and discontinuation of ibuprofen is appropriate as they exacerbate GERD symptoms. Omeprazole, a proton pump inhibitor, is an effective choice for reducing stomach acid and providing symptom relief. Nutritional counseling is also essential to modify dietary habits that contribute to GERD. 3. Recommendations as Alternative Solutions • Alternative drug: If omeprazole is unsuccessful or produces negative effects, additional options for treatment might be investigated, such as other pharmacological options such as H2 receptor antagonists (e.g., ranitidine). • Increase Physical Activity: Introduce a gradual, structured exercise plan to help with weight loss and overall fitness. Activities like walking, swimming, or low-impact aerobics can be beneficial. • Stress Management: Incorporate stress-reduction techniques such as mindfulness meditation, yoga, or therapy to address stress-related eating. • Dietary Modifications: Emphasize smaller, more frequent meals rather than large meals, and avoid known GERD triggers like caffeine, alcohol, chocolate, spicy foods, and acidic foods. • Lifestyle Changes: Elevate the head of the bed to prevent nighttime reflux and advise not to eat within three hours of bedtime. • Follow-up and Monitoring: Regular follow-ups to monitor the effectiveness of the treatment plan and make necessary adjustments, including possible changes in medication if symptoms persist or side effects occur. • Others: Should medicinal care be inadequate, consideration may be given to investigating surgical alternatives such as fundoplication. References Liang, S. W., Wong, M. W., Yi, C. H., Liu, T. T., Lei, W. Y., Hung, J. S., Lin, L., Rogers, B. D., & Chen, C. L. (2022). Current advances in the diagnosis and management of gastroesophageal reflux disease. Tzu chi medical journal, 34(4), 402–408. https://doi.org/10.4103/tcmj.tcmj_323_21 Maret-Ouda, J., Markar, S. R., & Lagergren, J. (2020). Gastroesophageal Reflux Disease: A Review. JAMA, 324(24), 2536–2547. https://doi.org/10.1001/jama.2020.21360 CASE 6 PEPTIC ULCER DISEASE PART 1 – CRITICAL READING 1. Summary of the Case Study This case study focuses on a 3-year-old girl who developed a peptic ulcer after taking ibuprofen for a fever. She was admitted to the hospital with symptoms including coffeeground vomiting (indicating gastrointestinal bleeding), abdominal pain, and fever. Her family had a history of peptic ulcers, increasing her risk. Initial lab tests revealed anemia and further examination through endoscopy identified a non-bleeding ulcer in her stomach near the pylorus. Helicobacter pylori tests were negative. She was treated with esomeprazole, a proton pump inhibitor, for two months, leading to the resolution of her symptoms and healing of the ulcer as confirmed by follow-up endoscopy. 2. Problem/Issue Setting of the Study The study highlights the problem of peptic ulcer disease (PUD) developing in children following short-term use of NSAIDs like ibuprofen. This is unusual because PUD is less common in children than in adults and is typically associated with long-term NSAID use or other risk factors like H. pylori infection. In this case, the patient had a family history of ulcers, which likely contributed to her susceptibility. The issue at hand is the need to understand and mitigate the risks associated with NSAID use in pediatric patients, particularly those with a family history of gastrointestinal issues. PART 2 – CRITICAL THINKING 1. Resolution of the Issue/Problem The issue was addressed by the following: First, by stopping the administration of ibuprofen to prevent further irritation of the gastrointestinal tract. Second, treating the ulcer with esomeprazole (10 mg/day), a proton pump inhibitor that reduces stomach acid and allows the ulcer to heal. Also, administer fluids intravenously to compensate for fluid loss due to vomiting and maintaining hydration. And conducting a follow-up endoscopy after two months of treatment to ensure the ulcer had healed, and there were no further complications. 2. Agreement with the Resolution I agree with the resolution as it appropriately addressed the immediate and underlying issues. Stopping NSAIDs and using a proton pump inhibitor are standard treatments for NSAID- induced peptic ulcers. The effectiveness of the treatment was confirmed by the normalization of hemoglobin levels and the healing observed in the follow-up endoscopy. This approach effectively managed both the symptoms and the root cause of the problem. 3. Recommendations as Alternative Solutions • Preventive Measures: Before prescribing NSAIDs to children, especially those with a family history of ulcers, consider the use of alternative pain and fever management options such as acetaminophen, which has a lower risk of causing ulcers. Thoroughly assess the child’s medical and family history to identify potential risks. • Education for Parents and Caregivers: Inform parents and caregivers about early warning signs of gastrointestinal issues by NSAIDS, such as persistent stomach pain, nausea, vomiting, or blood in vomit or stool. Provide guidelines on how to manage fever and pain without relying heavily on NSAIDs. • Dietary Adjustments and Physical Activity: Encourage a balanced diet with foods that are gentle on the stomach, like bananas, rice, applesauce, and toast. Promote physical activity appropriate for the child’s age and health condition to improve overall well-being and digestive health. • Regular Medical Check-Ups: Regular monitoring can ensure that the child’s diet and lifestyle modifications are effective in preventing future issues. • Nonpharmacologic: Using non-pharmacological techniques, such as tepid sponging and sufficient drinking, to reduce fever, particularly in kids with a history of digestive problems. References Kavitt, R. T., Lipowska, A. M., Anyane-Yeboa, A., & Gralnek, I. M. (2019). Diagnosis and Treatment of Peptic Ulcer Disease. The American journal of medicine, 132(4), 447–456. https://doi.org/10.1016/j.amjmed.2018.12.009 Malik, T. F., Gnanapandithan, K., & Singh, K. (2023). Peptic Ulcer Disease. In StatPearls. StatPearls Publishing. CASE 7 DIARRHEA PART 1 – CRITICAL READING 1. Summary of the Case Study A 22-year-old woman presented with severe abdominal cramps and persistent bloody and mucoid diarrhea for two months. She also experienced significant weight loss and fatigue. Initially treated for gastritis without improvement, she was later hospitalized twice for rehydration and further investigation but remained undiagnosed. Upon current admission, she continued to pass 10-20 liquid stools daily, with ongoing malaise and a total weight loss of 8 kg over two months. Laboratory tests showed anemia, elevated CRP, and abnormal liver function tests. An endoscopy and colonoscopy revealed severe ulcerative colitis, characterized by extensive ulceration and inflammation of the colon. 2. Problem/Issue Setting of the Study The main issue in this study is the diagnosis and management of severe ulcerative colitis in a young adult. Ulcerative colitis is a chronic inflammatory bowel disease that causes longlasting inflammation and ulcers in the digestive tract, primarily affecting the colon and rectum. The condition can lead to significant morbidity, characterized by frequent bloody diarrhea, abdominal pain, weight loss, and fatigue. The patient’s prolonged symptoms and severe presentation underscore the need for accurate diagnosis and effective treatment strategies. PART 2 – CRITICAL THINKING 1. Resolution of the Issue/Problem The patient’s ulcerative colitis was managed initially with medical treatment including rehydration, corticosteroids (Solucortef), and anti-inflammatory medications (Asacol, Flagyl). Despite these interventions, her symptoms persisted. Further medical management involved cyclosporine, omeprazole, and enoxaparin, but no significant improvement was observed. Ultimately, surgical intervention was deemed necessary. The patient underwent a laparoscopic total colectomy and ileostomy. Post-surgery, she was scheduled for ileal-anal pouch surgery to eliminate the need for a permanent ostomy bag. 2. Agreement with the Resolution I agree with the resolution because it followed a logical and evidence-based approach to managing severe ulcerative colitis. Initially, medical management was appropriately attempted with various medications to control inflammation and manage symptoms. When these treatments failed to provide relief, surgical intervention was necessary to prevent further complications and improve the patient’s quality of life. The decision to perform a total colectomy and later an ileal-anal pouch surgery aligns with standard care practices for refractory ulcerative colitis. 3. Recommendations as Alternative Solutions • Early and Aggressive Medical Therapy: an early referral for specialized treatment to a gastroenterologist might have sped up the diagnosis procedure. Consider early use of biologic agents such as infliximab or adalimumab in severe cases of ulcerative colitis to prevent progression to surgery. • Nutritional Support: this could include enteral nutrition or dietary modifications to ensure adequate caloric and nutrient intake while minimizing gastrointestinal irritation. • Regular Monitoring and Adjustments: Regular monitoring of inflammatory markers, stool frequency, and overall health can help tailor therapy and prevent severe flares. • Patient Education and Support: Provide thorough education on ulcerative colitis, including its chronic nature, potential complications, and management strategies. Support groups and counseling can also help the patient cope with the emotional and psychological aspects of living with a chronic illness. • Integrative Therapies: Explore integrative therapies such as stress management techniques, acupuncture, or probiotics as adjuncts to conventional treatment. References Gajendran, M., Loganathan, P., Jimenez, G., Catinella, A. P., Ng, N., Umapathy, C., Ziade, N., & Hashash, J. G. (2019). A comprehensive review and update on ulcerative colitis. Disease-amonth : DM, 65(12), 100851. https://doi.org/10.1016/j.disamonth.2019.02.004 Sokic-Milutinovic, A., Pavlovic-Markovic, A., Tomasevic, R. S., & Lukic, S. (2022). Diarrhea as a Clinical Challenge: General Practitioner Approach. Digestive diseases (Basel, Switzerland), 40(3), 282–289. https://doi.org/10.1159/000517111 CASE 8 CONSTIPATION PART 1 – CRITICAL READING 1. Summary of the Case Study The study investigates patients presenting with chronic constipation, a condition marked by infrequent bowel movements and difficulty passing stools, often leading to significant discomfort and decreased quality of life. The study involves a detailed diagnostic process, evaluating potential etiologies such as colonic inertia, pelvic floor dysfunction, and dietary factors. It outlines the stepwise management of constipation, emphasizing individualized treatment plans tailored to the patient’s specific symptoms and underlying causes. 2. Problem/Issue Setting of the Study The central issue addressed in the study is the multifactorial nature of chronic constipation and the challenges it poses in diagnosis and treatment. Chronic constipation can result from intrinsic factors like colonic motility disorders, such as slow transit constipation and pelvic floor dyssynergia, as well as extrinsic factors including dietary habits, medications (e.g., opioids, anticholinergics), and systemic diseases (e.g., hypothyroidism, diabetes). The study highlights the necessity for a comprehensive clinical evaluation, which includes thorough patient history, physical examination, and diagnostic tests like anorectal manometry, balloon expulsion test, and colonic transit studies to pinpoint the specific subtype of constipation. PART 2 – CRITICAL THINKING 1. Resolution of the Issue/Problem The study followed a stepwise approach to treatment, starting with the least invasive options and progressing to more intensive interventions. The initial management included dietary modifications, such as increasing dietary fiber and fluid intake. Fiber supplementation aimed to increase stool bulk and frequency, with recommendations for foods high in fiber like fruits, vegetables, and whole grains. Pharmacological treatments were then introduced. Osmotic laxatives, such as polyethylene glycol and lactulose, were used to draw water into the colon, softening stools and making them easier to pass. Stimulant laxatives, including bisacodyl and senna, were prescribed for short-term use to stimulate bowel movements by increasing muscle contractions in the intestines. When standard laxatives failed, newer medications like lubiprostone, a chloride channel activator, and linaclotide, a guanylate cyclase-C agonist, were considered for their ability to enhance intestinal fluid secretion and transit. For patients with pelvic floor dysfunction, biofeedback therapy was used to retrain the pelvic floor muscles, improving coordination during defecation. In cases refractory to medical and noninvasive treatments, surgical interventions were considered. Total abdominal colectomy with ileorectal anastomosis (TAC-IRA) involved removing the colon and connecting the small intestine to the rectum, which was considered for patients with severe slow-transit constipation. Other surgical techniques, like subtotal colectomy with antiperistaltic colorectal anastomosis, were explored, especially for patients with slow-transit constipation combined with obstructive defecation. 2. Agreement with the Resolution The comprehensive, evidence-based approach taken in the case study is agreeable. It appropriately starts with conservative measures and advances to more invasive treatments as necessary. This method ensures that all less invasive options are exhausted before considering surgery, aligning with current clinical guidelines and best practices for managing chronic constipation. 3. Recommendations as Alternative Solutions • Pharmacological alternatives for treating chronic constipation include prucalopride, a selective 5-HT4 receptor agonist that enhances bowel motility, and elobixibat, a bile acid transporter inhibitor that increases bile flow into the colon to help stimulate bowel movements. • Nonpharmacological alternatives involve encouraging regular physical activity, as daily exercise can stimulate intestinal motility and improve overall digestive health, and implementing behavioral interventions like cognitive-behavioral therapy (CBT) to address underlying psychological factors contributing to constipation. • Surgical alternatives include minimally invasive procedures such as laparoscopic colectomy, which offers shorter recovery times and fewer complications compared to open surgery, and sacral nerve stimulation, which involves implanting a device that stimulates the nerves controlling the lower digestive tract to improve bowel function in refractory cases. • Integrative approaches also offer potential benefits, with some studies suggesting that acupuncture may help alleviate symptoms of chronic constipation, and probiotics supplementation can improve gut flora balance, aiding in regular bowel movements. References: Bharucha, A. E., Wouters, M. M., & Tack, J. (2017). Existing and emerging therapies for managing constipation and diarrhea. Current opinion in pharmacology, 37, 158–166. https://doi.org/10.1016/j.coph.2017.10.015 Diaz, S., Bittar, K., Hashmi, M. F., & Mendez, M. D. (2023). Constipation. In StatPearls. StatPearls Publishing.

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