It’s Friday morning and Sal Volpe is sitting in Dr. Lorraine’sexam room, dozing after another night of disrupted sleep. When thedoctor knocks and walks in, she finds the 66-year-old man lookingexhausted and uncomfortable. Sal gets to the reason for his visitimmediately: He’s been suffering from “stomach aches” (dyspepsia)that wake him at night and nag him in between meals during the day.He describes his pain as gnawing, burning (maybe a 4 out of 10 on apain scale) and points to the epigastric region of his abdomen.When he eats, he tells Dr. Lorraine, the pain goes away, but thenhe feels bloated and a little nauseated. The pain usually returns2–4 hours later, depending on what he eats. Sal explains that hehas had some pain relief from the over-the-counter drugPepcid^® (famotadine).

Dr. Lorraine proceeds with the history and physical exam. Shediscovers that Sal has a family history for gastrointestinal cancerand has unintentionally lost 10 pounds since his checkup a yearago. His epigastric area is modestly tender to palpation. Shesuspects a peptic ulcer (gastric or duodenal), but the weight lossand family history make it prudent to eliminate the diagnosis ofstomach (gastric) cancer. “Mr. Volpe, I think you may have astomach or intestinal ulcer,” Dr. Lorraine says. “I suggest weperform an endoscopy to have a look. This involves passing a smalltube with a small camera through your mouth and into your stomach.We can look at the wall of your stomach and small intestine, checkfor an ulcer, and remove a very small piece of tissue to test forinfection. We call this a biopsy. We’ll also test the biopsy forcancer because of your family history. But, I really think we’redealing with an ulcer here and not cancer.”

Later that month, the endoscopy is performed and it confirms Dr.Lorraine’s suspicions. Sal has a duodenal ulcer and infection withthe bacterium Helicobacter pylori (H. pylori).This is not surprising since H. pylori is the cause ofmost peptic ulcer disease, particularly in the duodenum. Treatmentinvolves complete eradication of the H. pylori with twodifferent antibiotics, and a drug that decreases gastric acidsecretion, a so-called proton pump inhibitor (PPI). Dr. Lorraineexplains to Sal, “Mr. Volpe, you do not have stomach cancer, butyou do have a duodenal ulcer caused by the H. pyloribacteria I was telling you about. Too much acid and inflammationfrom this infection is causing your pain. The good news is we canprobably cure your ulcer by killing the bacteria, but you will haveto take three different medications twice a day for 14 days. I’llsee you again in 3 weeks; we can do a simple breath test todetermine if the H. pylori has been successfullyeliminated.”

Short Answer Questions:

1. The structures in the epigastric region share a common nervesupply. Can you name the specific cranial nerve that serves thisregion and the part of the nervous system to which it belongs?
2. In order to understand the disease in Mr. Volpe’s alimentarycanal, one must know the layers that make up its walls. Design achart that identifies the four basic layers of thealimentary canal, the tissues that make up each layer, and thegeneral function of each layer.
3. Dr. Lorraine suspects a peptic ulcer. This is an inflammatorylesion in the stomach or duodenal mucosa, which may extend throughall layers of the alimentary canal wall. Describe thebasic histological (tissue) structure of the mucosa layerin the alimentary canal. Identify the unique features ofthe mucosa in the stomach and in the duodenum, and explain how thisuniqueness determines the function of the stomach and theduodenum.
4. Mr. Volpe asks, “What do the bacteria have to do with theulcer?” Dr. Lorraine tells him that the H. pyloriincreases stomach acid secretion and, at the same time, breaks downthe lining of your stomach and duodenum. What is the source andnormal function of acid in the stomach and what regulates itsproduction
5. Why is Mr. Volpe’s dyspepsia relieved by food, and aggravated2–4 hours after a meal?