CASE RECORD FORM
Survey of Prevalence of Peptic Ulcer Disease and
Helicobacter pylori Infection over the Past Decade
(Write in block letters, numbers, or tick box)
Study ID number: ........... ________________________________________________________________________ Initials of patient's Name:..................................... Medical Number:................................ Date of Endoscopy :......../......../......... Date of Birth:......./......../.......... Age at Endoscopy .......... Male (1) F emale (2)
Other endoscopies 1)......./......./..........; 2)....../......./.........; 3)......../......../...........
_________________________________________________________________________ 1. Major indication for Endoscopy
Epigastric pain (1)
Discomfort (2)
Nausea and/or vomiting (3)
Reflux (Heartburn, regurgitation, etc.) (4)
Dysphagia (5)
Anaemia (6)
Foreign bodies (7)
Others (8) (specified).........................................
2. Drugs being used over the prior 3 months
None or unknown (0)
Antibiotic (1) (specified)....................................................................
Proton Pump Inhibitor (2) (specified)....................................................................
H2 Blocker (3) (specified)....................................................................
NSAID (4) (specified)....................................................................
Other (5) (specified)....................................................................
3. Drugs being used over the prior 12 months (not include in above question)
None or unknown (0)
Antibiotic (1) (specified)....................................................................
Proton Pump Inhibitor (2) (specified)....................................................................
H2 Blocker (3) (specified)....................................................................
NSAID (4) (specified)....................................................................
Other (5) (specified)....................................................................
4. Endoscopic Diagnosis
Within Normal Limit (0)
Oesophagitis (1) Grade: .......... Los Angeles Savary-Miller
1
Hiatus Hernia (2)
Barrett’s Oesophagus (3)
Gastritis (4) Site: Antral (1) Body (2) Antral+Body (3) Gastric Polyps (5) Number: ........... Size: ....................cm
Site: Prepyloric (1) Antral (2) Incisura (3)
Body (4) Fundus (5)
Gastric Ulcer (6) Number: ............. Size: ....................cm
Site: Prepyloric (1) Antral (2) Incisura (3)
Body (4) Fundus (5)
Gastric Carcinoma (7) Stage: E arly (1) Later (2)
(confirmed) Site: Prepyloric (1) Antral (2) Incisura (3)
Body (4) Fundus (5)
Duodenitis (8) Specified: Erythema (1) Erosions (2) Duodenal Ulcer (9) Number: ........... Size: .............cm
Site: Pyloric(1) Bulbar region (2) Post-bulbar (3) Foreign Bodies (10) (specified) ...................................................................
Other (11) (specified) ...................................................................
No diagnosis (12) (reasons) .....................................................................
5. CLO-test Not Done (ND) Negative (0) Positive (1)
6. Histology Not Done (0) Done (1)
Site: Antral (1) Incisura (2) Body (3) Fundus (5) Helicobacter-like Organisms No Data (ND) Absent (0) Present (1)
Number: Small (1) Moderate (2) Large (3) Chronic Gastritis Absent (0) Present (1)
Grade: Mild (1) Moderate (2) Marked (3) Active Gastritis Absent (0) Present (1)
Grade: Mild (1) Moderate (2) Marked (3) Intestinal Metaplasia Absent (0) Present (1)
Grade: Mild (1) Moderate (2) Marked (3) Lymphoid Aggregates Absent (0) Present (1)
Grade: Mild (1) Moderate (2) Marked (3) 7. Other Comments.............................................................................................................
2
4. CLO-test:
1 Not Done
2 Negative
3 Positive
5. Drugs used in the last 3 months:
1 Antibiotic
2 H2 Blocker
3 NSAID or aspirin
4 Proton Pump Inhibitor
5 None or unknown
6 Other (specify) .............................................
6. Drugs used between 3 to 12 months ago (but not in the last 3 months):
1 Antibiotic
2 H2 Blocker
3 NSAID or aspirin
4 Proton Pump Inhibitor
5 None or unknown
6 Other (specify) .............................................
7. Other General Comments
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The results of this retrospective study were published:
Xia HH, Phung N, Altiparmak E, Berry A, Matheson M, Talley NJ. Reduction of peptic ulcer disease and Helicobacter pylori infection but increase of reflux esophagitis in Western Sydney between 1990 and 1998. Dig Dis Sci. 2001 Dec;46(12):2716-23.
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