Case D 14
A 43-year-old man presents to his gastroenterologist with symptoms of peptic ulcer disease. He states that he has a midepigastric burning pain that is relieved by eating food and worse on an empty stomach. The patient has been on numerous antacid medications without relief. He has had recurrent peptic ulcers for the last five years, with minimal relief with the usual treatments. A fasting gastrin level is drawn and found to be extremely elevated. After further tests are done, the patient is diagnosed with a gastrin-secreting tumor in the pancreas.
1. Explain how elevated gastrin levels could cause ulcers.
2. What cells are stimulated to secrete acid by gastrin?
3. How (decrease/increase/no effect) would ingesting antacids with and after a meal so that gastric pH does not decrease below pH 6 affect the secretion of gastrin, secretin, and pancreatic bicarbonate?
Case D 15
A 43-year-old woman presents to the emergency department with the acute onset of abdominal pain. Her pain is located in the right upper quadrant (RUQ) and radiates to the right shoulder. She reports nausea and vomiting but no fever or chills. The RUQ pain is worse after she eats fatty meals. On examination the patient has severe right upper quadrant tenderness. Her white blood cell count is elevated, as are her liver function tests and alkaline phosphatase. The amylase and lipase levels are normal. An abdominal ultrasound reveals an enlarged gallbladder with multiple stones and gallbladder wall thickening. She is admitted to the hospital and undergoes a cholecystectomy.
1. Why would fatty foods aggravate the patient's right upper quadrant pain?
2. Why does the patient report pain in the right shoulder?
3. What is the stimulus for the secretion of cholecystokinin (CCK)?
4. What effect does CCK have on gastric emptying? On the gallbladder?
5. Why do gallstones lead to pain?