{"version":"1.0.0","segments":[{"startTime":1.108,"endTime":3.17,"body":"♪ (music) ♪"},{"startTime":3.17,"endTime":5.467,"body":"(Cathy) Hi. Welcome to Harrison's Podclass"},{"startTime":5.467,"endTime":8.683,"body":"where we discuss important concepts"},{"startTime":5.467,"endTime":8.683,"body":"in internal medicine."},{"startTime":8.683,"endTime":10.935,"body":"- I'm Cathy Handy."},{"startTime":8.683,"endTime":10.935,"body":"- (Charlie) And I'm Charlie Wiener"},{"startTime":10.935,"endTime":15.205,"body":"and we're coming to you"},{"startTime":10.935,"endTime":15.205,"body":"from the Johns Hopkins School of Medicine."},{"startTime":15.869,"endTime":17.915,"body":"Welcome to Harrison's Podclass."},{"speaker":"Today is Episode 14","startTime":17.915,"endTime":22.491,"body":"A 57-year-old with Hematemesis."},{"speaker":"Here's the question","startTime":23.775,"endTime":26.629,"body":"A 57-year-old man is evaluated with an EGD"},{"speaker":"Here's the question","startTime":26.629,"endTime":29.515,"body":"after an episode of acute hematemesis."},{"speaker":"Here's the question","startTime":29.515,"endTime":31.434,"body":"The patient reports"},{"speaker":"Here's the question","startTime":29.515,"endTime":31.434,"body":"a history of tobacco use"},{"speaker":"Here's the question","startTime":31.434,"endTime":33.181,"body":"and hypercholesterolemia,"},{"speaker":"Here's the question","startTime":33.181,"endTime":34.681,"body":"but he's otherwise healthy."},{"speaker":"Here's the question","startTime":34.681,"endTime":36.875,"body":"He's had lower back pain"},{"speaker":"Here's the question","startTime":34.681,"endTime":36.875,"body":"for the past month"},{"speaker":"Here's the question","startTime":36.875,"endTime":41.939,"body":"and has been intermittently using"},{"speaker":"Here's the question","startTime":36.875,"endTime":41.939,"body":"acetaminophen, 1000 mg daily, for relief."},{"speaker":"Here's the question","startTime":41.939,"endTime":46.228,"body":"His endoscopy shows"},{"speaker":"Here's the question","startTime":41.939,"endTime":46.228,"body":"a 3 cm duodenal ulcer."},{"speaker":"Here's the question","startTime":46.228,"endTime":49.241,"body":"So, Cathy, what do you think"},{"speaker":"Here's the question","startTime":46.228,"endTime":49.241,"body":"is the cause of the ulcer?"},{"speaker":"Here's the question","startTime":49.241,"endTime":51.072,"body":"(Cathy) Duodenal ulcers"},{"speaker":"Here's the question","startTime":49.241,"endTime":51.072,"body":"are most commonly due"},{"speaker":"Here's the question","startTime":51.072,"endTime":54.449,"body":"to Helicobacter pylori,"},{"speaker":"Here's the question","startTime":51.072,"endTime":54.449,"body":"or H. pylori infection."},{"speaker":"Here's the question","startTime":54.449,"endTime":58.715,"body":"In the minority of cases, non-steroidal"},{"speaker":"Here's the question","startTime":54.449,"endTime":58.715,"body":"anti-inflammatory drugs, or NSAIDs,"},{"speaker":"Here's the question","startTime":58.715,"endTime":62.98,"body":"can facilitate development"},{"speaker":"Here's the question","startTime":58.715,"endTime":62.98,"body":"or be the only identified cause of ulcers."},{"speaker":"Here's the question","startTime":62.98,"endTime":66.06,"body":"The patient was taking acetaminophen,"},{"speaker":"Here's the question","startTime":62.98,"endTime":66.06,"body":"which is not an NSAID,"},{"speaker":"Here's the question","startTime":66.06,"endTime":69.169,"body":"so I would say that H. pylori-associated"},{"speaker":"Here's the question","startTime":66.06,"endTime":69.169,"body":"peptic ulcer disease"},{"speaker":"Here's the question","startTime":69.169,"endTime":71.823,"body":"would be the most likely cause"},{"speaker":"Here's the question","startTime":69.169,"endTime":71.823,"body":"of the findings here."},{"speaker":"Here's the question","startTime":71.823,"endTime":76.595,"body":"(Charlie) Okay, so this question is asking"},{"speaker":"Here's the question","startTime":71.823,"endTime":76.595,"body":"a bunch of aspects of the duodenal ulcer."},{"speaker":"Here's the question","startTime":76.595,"endTime":78.471,"body":"And the question says,"},{"speaker":"Here's the question","startTime":78.471,"endTime":80.597,"body":"which of the following"},{"speaker":"Here's the question","startTime":78.471,"endTime":80.597,"body":"statements is correct"},{"speaker":"Here's the question","startTime":80.597,"endTime":84.014,"body":"regarding this finding"},{"speaker":"Here's the question","startTime":80.597,"endTime":84.014,"body":"referring to the duodenal ulcer?"},{"speaker":"Here's the question","startTime":84.014,"endTime":87.052,"body":"Option A reads, \"The lesion"},{"speaker":"Here's the question","startTime":84.014,"endTime":87.052,"body":"should be biopsied"},{"speaker":"Here's the question","startTime":87.052,"endTime":89.426,"body":"because duodenal ulcers"},{"speaker":"Here's the question","startTime":87.052,"endTime":89.426,"body":"have an elevated risk"},{"speaker":"Here's the question","startTime":89.426,"endTime":91.156,"body":"of being due to carcinoma.\""},{"speaker":"Here's the question","startTime":91.156,"endTime":93.695,"body":"Option B reads, \"First line therapy"},{"speaker":"Here's the question","startTime":93.695,"endTime":97.12,"body":"should be discontinuation"},{"speaker":"Here's the question","startTime":93.695,"endTime":97.12,"body":"of the acetaminophen.\""},{"speaker":"Here's the question","startTime":97.12,"endTime":98.895,"body":"Option C reads,"},{"speaker":"Here's the question","startTime":98.895,"endTime":103.351,"body":"\"The patient is not at risk"},{"speaker":"Here's the question","startTime":98.895,"endTime":103.351,"body":"for any associated cancers.\""},{"speaker":"Here's the question","startTime":103.351,"endTime":106.619,"body":"Option D reads, \"Poor socioeconomic status"},{"speaker":"Here's the question","startTime":106.619,"endTime":110.037,"body":"is a risk factor for the development"},{"speaker":"Here's the question","startTime":106.619,"endTime":110.037,"body":"of this condition.\""},{"speaker":"Here's the question","startTime":110.037,"endTime":112.211,"body":"And finally, option E says,"},{"speaker":"Here's the question","startTime":112.211,"endTime":116.244,"body":"\"Enterogastritis is rarely found"},{"speaker":"Here's the question","startTime":112.211,"endTime":116.244,"body":"with this condition.\""},{"speaker":"Here's the question","startTime":116.244,"endTime":118.494,"body":"Why don't you take these"},{"speaker":"Here's the question","startTime":116.244,"endTime":118.494,"body":"one by one, Cathy?"},{"speaker":"Here's the question","startTime":118.494,"endTime":121.381,"body":"(Cathy) So the case, if we recall,"},{"speaker":"Here's the question","startTime":118.494,"endTime":121.381,"body":"is a 57-year-old man"},{"speaker":"Here's the question","startTime":121.381,"endTime":124.054,"body":"with a duodenal ulcer"},{"speaker":"Here's the question","startTime":121.381,"endTime":124.054,"body":"which, again, like we said before,"},{"speaker":"Here's the question","startTime":124.054,"endTime":126.704,"body":"was most likely"},{"speaker":"Here's the question","startTime":124.054,"endTime":126.704,"body":"due to H. pylori infection."},{"speaker":"Here's the question","startTime":126.704,"endTime":129.399,"body":"So, option A suggests"},{"speaker":"Here's the question","startTime":126.704,"endTime":129.399,"body":"that the lesion should be biopsied"},{"speaker":"Here's the question","startTime":129.399,"endTime":132.595,"body":"because of an elevated risk"},{"speaker":"Here's the question","startTime":129.399,"endTime":132.595,"body":"of underlying carcinoma."},{"speaker":"Here's the question","startTime":132.595,"endTime":135.549,"body":"So, that's not necessarily the case"},{"speaker":"Here's the question","startTime":132.595,"endTime":135.549,"body":"for duodenal ulcers."},{"speaker":"Here's the question","startTime":135.549,"endTime":138.022,"body":"Routine H. pylori-associated"},{"speaker":"Here's the question","startTime":135.549,"endTime":138.022,"body":"duodenal ulcers"},{"speaker":"Here's the question","startTime":138.022,"endTime":140.332,"body":"are not typically related to a malignancy."},{"speaker":"Here's the question","startTime":140.332,"endTime":142.888,"body":"It would be different, though,"},{"speaker":"Here's the question","startTime":140.332,"endTime":142.888,"body":"if the patient had a gastric ulcer;"},{"speaker":"Here's the question","startTime":142.888,"endTime":146.322,"body":"and, again, the location of the ulcer"},{"speaker":"Here's the question","startTime":142.888,"endTime":146.322,"body":"is where the difference lies here."},{"speaker":"Here's the question","startTime":146.322,"endTime":148.841,"body":"So, gastric ulcers"},{"speaker":"Here's the question","startTime":146.322,"endTime":148.841,"body":"are much more likely to be malignant."},{"speaker":"Here's the question","startTime":148.841,"endTime":152.558,"body":"So if the ulcer was found in the stomach,"},{"speaker":"Here's the question","startTime":148.841,"endTime":152.558,"body":"a biopsy would be indicated."},{"speaker":"Here's the question","startTime":152.558,"endTime":155.811,"body":"But since here we have a duodenal ulcer,"},{"speaker":"Here's the question","startTime":152.558,"endTime":155.811,"body":"option A is not true."},{"speaker":"Here's the question","startTime":155.811,"endTime":159.029,"body":"Option B asks about stopping"},{"speaker":"Here's the question","startTime":155.811,"endTime":159.029,"body":"acetaminophen use."},{"speaker":"Here's the question","startTime":159.029,"endTime":161.601,"body":"That's also not necessary,"},{"speaker":"Here's the question","startTime":159.029,"endTime":161.601,"body":"so acetaminophen use"},{"speaker":"Here's the question","startTime":161.601,"endTime":164.907,"body":"is not associated with"},{"speaker":"Here's the question","startTime":161.601,"endTime":164.907,"body":"an increased risk of duodenal ulcers."},{"speaker":"Here's the question","startTime":164.907,"endTime":167.349,"body":"Sometimes people"},{"speaker":"Here's the question","startTime":164.907,"endTime":167.349,"body":"who are taking acetaminophen"},{"speaker":"Here's the question","startTime":167.349,"endTime":169.73,"body":"because of pain are also taking NSAIDs,"},{"speaker":"Here's the question","startTime":169.73,"endTime":172.272,"body":"so it would be important"},{"speaker":"Here's the question","startTime":169.73,"endTime":172.272,"body":"to ask about that specifically,"},{"speaker":"Here's the question","startTime":172.272,"endTime":175.106,"body":"but we wouldn't need to stop"},{"speaker":"Here's the question","startTime":172.272,"endTime":175.106,"body":"acetaminophen use."},{"speaker":"Here's the question","startTime":175.106,"endTime":177.401,"body":"(Charlie) Okay, so option B"},{"speaker":"Here's the question","startTime":175.106,"endTime":177.401,"body":"is also not true."},{"speaker":"Here's the question","startTime":177.401,"endTime":178.99,"body":"How about option C?"},{"speaker":"Here's the question","startTime":178.99,"endTime":182.789,"body":"(Cathy) Option C asks about cancers"},{"speaker":"Here's the question","startTime":178.99,"endTime":182.789,"body":"associated with the duodenal ulcer."},{"speaker":"Here's the question","startTime":182.789,"endTime":185.369,"body":"This is a little subtle"},{"speaker":"Here's the question","startTime":182.789,"endTime":185.369,"body":"because H. pylori infection"},{"speaker":"Here's the question","startTime":185.369,"endTime":188.519,"body":"is associated with duodenal ulcers"},{"speaker":"Here's the question","startTime":185.369,"endTime":188.519,"body":"but also with some malignancies,"},{"speaker":"Here's the question","startTime":188.519,"endTime":192.017,"body":"such as gastric cancer"},{"speaker":"Here's the question","startTime":188.519,"endTime":192.017,"body":"and mucosa-associated lymphoid tissue,"},{"speaker":"Here's the question","startTime":192.017,"endTime":193.623,"body":"or MALT lymphoma."},{"speaker":"Here's the question","startTime":193.623,"endTime":195.955,"body":"All in all, while there is some truth"},{"speaker":"Here's the question","startTime":193.623,"endTime":195.955,"body":"to this statement,"},{"speaker":"Here's the question","startTime":195.955,"endTime":197.896,"body":"simply the presence of a duodenal ulcer"},{"speaker":"Here's the question","startTime":197.896,"endTime":200.569,"body":"does not increase the risk"},{"speaker":"Here's the question","startTime":197.896,"endTime":200.569,"body":"of an associated malignancy,"},{"speaker":"Here's the question","startTime":200.569,"endTime":203.387,"body":"so I'm hoping"},{"speaker":"Here's the question","startTime":200.569,"endTime":203.387,"body":"one of the other options is better."},{"speaker":"Here's the question","startTime":203.387,"endTime":205.724,"body":"(Charlie) Okay, well,"},{"speaker":"Here's the question","startTime":203.387,"endTime":205.724,"body":"let's look at option D."},{"speaker":"Here's the question","startTime":205.724,"endTime":207.596,"body":"That says that duodenal ulcer"},{"speaker":"Here's the question","startTime":207.596,"endTime":210.007,"body":"is associated"},{"speaker":"Here's the question","startTime":207.596,"endTime":210.007,"body":"with poor socioeconomic status."},{"speaker":"Here's the question","startTime":210.007,"endTime":211.211,"body":"What do you think of that one?"},{"speaker":"Here's the question","startTime":211.211,"endTime":214.163,"body":"(Cathy) Okay, I like this one,"},{"speaker":"Here's the question","startTime":211.211,"endTime":214.163,"body":"and this choice is clearly correct."},{"speaker":"Here's the question","startTime":214.163,"endTime":218.386,"body":"Duodenal ulcers and H. pylori infection"},{"speaker":"Here's the question","startTime":214.163,"endTime":218.386,"body":"are closely correlated with advancing age,"},{"speaker":"Here's the question","startTime":218.386,"endTime":221.435,"body":"low socioeconomic status,"},{"speaker":"Here's the question","startTime":218.386,"endTime":221.435,"body":"and low education levels."},{"speaker":"Here's the question","startTime":221.435,"endTime":223.651,"body":"So, this choice is clearly correct."},{"speaker":"Here's the question","startTime":223.651,"endTime":226.207,"body":"(Charlie) Okay. Therefore, option E,"},{"speaker":"Here's the question","startTime":226.207,"endTime":229.514,"body":"that states that enterogastritis"},{"speaker":"Here's the question","startTime":226.207,"endTime":229.514,"body":"is rarely found with this condition,"},{"speaker":"Here's the question","startTime":229.514,"endTime":230.54,"body":"is also false."},{"speaker":"Here's the question","startTime":230.54,"endTime":232.225,"body":"Tell me why."},{"speaker":"Here's the question","startTime":232.225,"endTime":234.125,"body":"(Cathy) After initial infection"},{"speaker":"Here's the question","startTime":232.225,"endTime":234.125,"body":"with H. pylori,"},{"speaker":"Here's the question","startTime":234.125,"endTime":235.735,"body":"enterogastritis is common."},{"speaker":"Here's the question","startTime":235.735,"endTime":237.076,"body":"So, during the EGD,"},{"speaker":"Here's the question","startTime":237.076,"endTime":240.327,"body":"the endoscopist will usually"},{"speaker":"Here's the question","startTime":237.076,"endTime":240.327,"body":"also assess the antral epithelium."},{"speaker":"Here's the question","startTime":240.327,"endTime":242.173,"body":"(Charlie) While not asked"},{"speaker":"Here's the question","startTime":240.327,"endTime":242.173,"body":"in this question,"},{"speaker":"Here's the question","startTime":242.173,"endTime":244.668,"body":"what would you do next"},{"speaker":"Here's the question","startTime":242.173,"endTime":244.668,"body":"to treat this patient?"},{"speaker":"Here's the question","startTime":244.668,"endTime":246.838,"body":"(Cathy) We need to address"},{"speaker":"Here's the question","startTime":244.668,"endTime":246.838,"body":"the ulcer and the infection,"},{"speaker":"Here's the question","startTime":246.838,"endTime":248.05,"body":"which are obviously related."},{"speaker":"Here's the question","startTime":248.05,"endTime":250.608,"body":"So, our goals would be"},{"speaker":"Here's the question","startTime":248.05,"endTime":250.608,"body":"to suppress gastric acid production"},{"speaker":"Here's the question","startTime":250.608,"endTime":253.077,"body":"and to treat the H. pylori infection."},{"speaker":"Here's the question","startTime":253.077,"endTime":255.74,"body":"To do this, usually we use"},{"speaker":"Here's the question","startTime":253.077,"endTime":255.74,"body":"three to four drug regimens,"},{"speaker":"Here's the question","startTime":255.74,"endTime":259.333,"body":"which include acid suppressive therapy"},{"speaker":"Here's the question","startTime":255.74,"endTime":259.333,"body":"and a combination of antibiotics."},{"speaker":"Here's the question","startTime":259.333,"endTime":260.54,"body":"The three-drug regimen"},{"speaker":"Here's the question","startTime":260.54,"endTime":263.067,"body":"of clarithromycin,"},{"speaker":"Here's the question","startTime":260.54,"endTime":263.067,"body":"a proton pump inhibitor,"},{"speaker":"Here's the question","startTime":263.067,"endTime":266.499,"body":"and amoxycillin or metronidazole,"},{"speaker":"Here's the question","startTime":263.067,"endTime":266.499,"body":"is a commonly used regimen."},{"speaker":"Here's the question","startTime":266.499,"endTime":267.705,"body":"Some geographic areas"},{"speaker":"Here's the question","startTime":267.705,"endTime":269.852,"body":"may have higher rates"},{"speaker":"Here's the question","startTime":267.705,"endTime":269.852,"body":"of clarithromycin resistance,"},{"speaker":"Here's the question","startTime":269.852,"endTime":271.45,"body":"so sometimes quadruple therapy,"},{"speaker":"Here's the question","startTime":271.45,"endTime":275.452,"body":"which usually consists of bismuth,"},{"speaker":"Here's the question","startTime":271.45,"endTime":275.452,"body":"a PPI, metronidazole, and tetracycline,"},{"speaker":"Here's the question","startTime":275.452,"endTime":277.215,"body":"is also recommended."},{"speaker":"Here's the question","startTime":277.215,"endTime":279.154,"body":"(Charlie) Great."},{"speaker":"Here's the question","startTime":277.215,"endTime":279.154,"body":"So, the teaching point here"},{"speaker":"Here's the question","startTime":279.154,"endTime":280.314,"body":"is that duodenal ulcers"},{"speaker":"Here's the question","startTime":280.314,"endTime":282.875,"body":"are most commonly caused"},{"speaker":"Here's the question","startTime":280.314,"endTime":282.875,"body":"by H. pylori infection,"},{"speaker":"Here's the question","startTime":282.875,"endTime":285.28,"body":"which has been associated"},{"speaker":"Here's the question","startTime":282.875,"endTime":285.28,"body":"with advancing age"},{"speaker":"Here's the question","startTime":285.28,"endTime":287.629,"body":"and low socioeconomic status."},{"speaker":"Here's the question","startTime":287.629,"endTime":290.771,"body":"Treatment requires"},{"speaker":"Here's the question","startTime":287.629,"endTime":290.771,"body":"simultaneous suppression of acid"},{"speaker":"Here's the question","startTime":290.771,"endTime":294.101,"body":"and treatment of the H. pylori infection."},{"speaker":"Here's the question","startTime":294.101,"endTime":296.798,"body":"(Cathy) For more information,"},{"speaker":"Here's the question","startTime":294.101,"endTime":296.798,"body":"we refer you to the Harrison's chapter"},{"speaker":"Here's the question","startTime":296.798,"endTime":298.021,"body":"on peptic ulcer disease,"},{"speaker":"Here's the question","startTime":298.021,"endTime":301.265,"body":"and also you can check out"},{"speaker":"Here's the question","startTime":298.021,"endTime":301.265,"body":"the American College of Gastroenterology"},{"speaker":"Here's the question","startTime":301.265,"endTime":305.275,"body":"2017 Clinical Guide on treatment"},{"speaker":"Here's the question","startTime":301.265,"endTime":305.275,"body":"of H. pylori Infection."},{"speaker":"Here's the question","startTime":305.275,"endTime":308.155,"body":"(Charlie) That's published in"},{"speaker":"Here's the question","startTime":305.275,"endTime":308.155,"body":"the American Journal of Gastroenterology,"},{"speaker":"Here's the question","startTime":308.155,"endTime":312.318,"body":"2017, volume 112, page 212."},{"speaker":"Here's the question","startTime":312.318,"endTime":314.282,"body":"♪ (music) ♪"}]}