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Lab Examination Findings

6/22/2025, 11:50:26 AMMale25-34

Examination Results **Duodenum - Second Section** **Diagnosis Overview:** The second portion of the duodenum presents no significant abnormalities; the small bowel lining appears normal. Tests for Giardia, parasites, and signs of villous atrophy returned negative results. **Microscopic Analysis:** A thorough microscopic evaluation was conducted. **Duodenum - Duodenal Bulb** **Diagnosis Overview:** Observations revealed hyperplasia of Brunner's glands along with congestion and swelling of the villi; aside from these findings, the small bowel mucosa is otherwise normal. No evidence of Giardia, parasites, or villous atrophy was found. **Microscopic Analysis:** A detailed microscopic examination has been carried out. **Stomach - Antrum and Body** **Diagnosis Overview:** The findings indicate acute erosive gastritis, possibly due to medications, NSAIDs, or bile reflux injury. Testing for H. pylori using standard staining procedures was negative. **Microscopic Analysis:** A microscopic assessment has been performed. The patient is a 43-year-old male with a history of alcohol use spanning 20 years. The tests took place in January 2025, and he has been sober since December 12, 2024.

Family MedicineInternal MedicinePreventive Medicine

Answers (1)

Cony

6/22/2025, 11:50:39 AM

OpenHealth AI

The examination findings indicate a generally normal small bowel with specific concerns in the duodenum and stomach, predominantly acute erosive gastritis. Here's a breakdown of the results and actionable steps you can take.

Summary of Findings:

  1. Duodenum: The second section shows normal findings, but there is hyperplasia (enlargement) of Brunner's glands and swelling of villi in the duodenal bulb.
  2. Stomach: Acute erosive gastritis has been identified, likely linked to medication use, particularly NSAIDs, or bile reflux. Testing for H. pylori was negative.

Explanation:

  • Brunner's Gland Hyperplasia: This is generally a benign condition where the glands produce excess mucous, typically in response to excess acid.
  • Erosive Gastritis: This is an inflammation of the stomach lining that can cause pain and digestive issues. It may be aggravated by certain medications, particularly non-steroidal anti-inflammatory drugs (NSAIDs) or high alcohol consumption.

Next Steps:

  1. Medication Review: If you're currently taking NSAIDs or any medications known to irritate the stomach, consult with a healthcare provider about alternatives or protective agents like proton pump inhibitors (PPIs).

  2. Diet Adjustments: Adopt a bland diet to minimize stomach irritation. Foods like bananas, rice, and applesauce can be soothing. Avoid spicy, acidic, or fatty foods that could exacerbate gastritis.

  3. Hydration: Drink plenty of fluids, preferably water, to help flush out the system and support stomach lining healing.

  4. Avoid Irritants: Since you have a history of alcohol use, it's essential to maintain sobriety to reduce any further stress or damage to your gastrointestinal tract.

  5. Symptom Monitoring: Keep track of any symptoms such as stomach pain, nausea, or changes in appetite. If you notice worsening symptoms or new issues arise, consider seeking further medical advice.

  6. Follow-Up Care: Regular check-ins with a healthcare provider for ongoing gastrointestinal health management are advisable, especially given your history and recent findings.

By focusing on these actionable steps, you can work towards improving your gastrointestinal health and managing any discomfort related to the findings. If you have any more specific questions or concerns about your condition, don't hesitate to reach out for further assistance.

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