胃鏡檢查結果分析及治療建議-肝膽腸胃科

上消化道泛內視鏡檢查結果？

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[第一次胃鏡Finding]:
(Esophagus)：mucosab break at EC junction less than 5mm
(Stomach):CLO test was done. Hyperemic mucosa chanage at antrum shallow Gu at antrum s/p (Duodenum)：
narrowing lumen at inferior duodenal angle of duodenum, suspect external compression related, cause?
(Diagnosis)：
1.Reflux Esophagitis, LA Grade （A）（No Biopsy )
2.Superficial Gastritis （ No Biopsy )
3.Gastric Ulcer （ Biopsy Was Done )
Others : narrowing lumen at inferior duodenal angle of duodenum, suspect external compression related, cause?
(Suggestions)：PPI treatment pending pathology report / GI OPD follow up
(切片檢查)
The specimen submitted consists of a tissue fragment measuring 0.2 x 0.1* 0. 1 cm. in size, fixed in formalin.
Grossly, it is tan and elastic. All for section.
Microscopically, the sections show a picture of chronic gastritis. No evidence of malignancy.
Checklist of gastritis
1. Neutrophils activity: Absent.
Chronic inflammation/Mononuclear cells infiltration: Mild.
3. Atrophy of glands: Absent
4.Intestinal metaplasia: Absent.
5.Helicobacter-like microorganism: Not identified.
[第二次胃鏡Finding]:
(Esophagus): sliding hiatal hernia with mucosal breaks at L/3 ＞ 5 mm with confluence ＜ 75 ％ circumference
(Stomach):Gastric shallow ulcers,H1 s/p biopsyx 2 for path . hyperemia noted at antrum;
CLO test was done to prepyloric area
(Duodenum): Negative of bulb and 2nd portion
[Diagnosis]:
1.GERD Gr C with H.H R/o hoase shade gastal type
2.EC junction s/p adhesion relaxation Gastritis, antrum
3.Gastric multiple round ulcers,H1 s/p biopsyx 2 for path with hematin .
4.Duodenalitis
[Recommendation] 1. PPI tx, RAC tx if positive CLO test 2. GI OPD f/u .
想詢問醫生,第一次胃鏡完目前已服用Nexium Tab 40mg 一個月+Pariet EFC Tab 20 mg半個月!但第二次胃鏡結果卻從GERD 卻從GERD Gr A變 Gr C,是不是還需要再注意什麼?另外想詢問hoase shade gastal type 代表的意義是? RAC tx 是指抗生素治療嗎?

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LEO，20~29歲男性，詢問日期：2023/03/01