Ischemic bowel/Peptic ulcer disease

Question 1

Colonic Ischemia

general

Answer 1

Mesenteric ischemia of colon leads to inflammation and sloughing of the intestinal mucosa
Most common areas splenic flexure and rectosigmoid junction

splenic flexture has poor vascularization.

Question 2

Colonic Ischemia

RF

Answer 2

> 60, female
ASCVD
hypotension
CHF
recent surgery for AAA
hx constipation
hx HTN RX ( esp vasoconstrictive)

Question 3

Colonic Ischemia

Clin man

Answer 3

LLQ pain
hematochezia (bloody diarrhea): typically self limited

LLQ tenderness- watch for peritoneal signs/fever ( usually absent)
Absent/hypoactive bowel signs

Question 4

Colonic Ischemia

Dx options

Answer 4

CTA or MRA: intestinal ischemia; bowel wall edema; “thumbprinting”: segmental bowel wall thickening

Colonoscopy: ischemic changes to mucosa ( gold standard) , edematous/friable tissue, can bx. Do NOT perform if suspected bowel perforation or peritoneal signs

Question 5

colonic ischemia

Answer 5

scalloping/”fingerprinting” seen in left image

Question 6

colonic ischemia

Tx

Answer 6

Treatment:
IV fluid hydration
Stable BP
avoid further hypotension/low flow state
will usually resolve with supportive care

Consider empiric broad spectrum antibiotics
Coverage of Gram (-) and anaerobes

Question 7

Acute Mesenteric Ischemia

general

Answer 7

Inadequate perfusion through mesenteric vessels (embolic, thrombotic, low flow state) can lead to gangrene of bowel

Fatal without intervention

Question 8

Acute Mesenteric Ischemia

RF

Answer 8

Afib
ASCVD
recent MI
valvular disease
elderly
abdominal malignancy
hypercoagulability
Paradoxical venous embolism

Question 9

Acute Mesenteric Ischemia

clin man

Answer 9

Presentation:
Acute severe abdominal pain with unremarkable physical exam
N/V +/- GIB
If have chronic ischemia may have postprandial abdominal pain, “food fear” and weight loss

Physical exam:
+/- peritoneal signs if perforation

Question 10

Acute Mesenteric Ischemia

Labs

Answer 10

Leukocytosis, elevated lactate ( depending on stage of disease), lactic acidosis

Question 11

Acute Mesenteric Ischemia

imaging

Answer 11

Abdominal CT is often unremarkable ( can help r/o perforation, diverticulitis, obstruction, appendicitis, abscess)

CTA is gold standard: narrowing of proximal visceral vessels

MRA: increase cost, time

Question 12

Acute mesenteric ischemia

Tx

Answer 12

Restore flow with anticoagulation/thrombolysis if occlusive ischemia; angioplasty/stenting/bypass

If bowel ischemia need immediate exploratory surgery and if bowel viable poss bypass

Question 13

Colonic Volvulus

general

Answer 13

Life threatening emergency when colon twists creating colonic obstruction or vascular compromise
Sigmoid colon is most commonly involved
Can be recurrent

Question 14

colonic volvulus

RF

Answer 14

Elderly, bedridden, constipation, ovarian or pelvic mass, pregnancy, dementia, psychiatric impairment, hx of previous volvulus

Question 15

colonic volvulus

Clin man

Answer 15

Presentation
Acute, colicky abdominal pain, abdominal distention, obstipation, N/V
Physical Exam:
Largely distended, tympanic abdomen; if rebound tenderness consider peritonitis from perforation

Question 16

Acute Mesenteric Ischemia

Answer 16

SMA is the most commonly affected

Question 17

colonic volvulus

labs/xray/CT/barium enema

Answer 17

Leukocytosis

Xray abd: U-shaped distended sigmoid colon

CT: dilated sigmoid colon, “bird beak” appearance

barium enema, c-scope can aid in diagnosis

Question 18

colonic volvulus

Tx

Answer 18

Sigmoid volvulus: Decompression vis sigmoidoscopy then consider surgical resection

Cecal volvulus: do not try to reduce/decompress- straight to surgery (higher risk for perforation and ischemia)

If peritonitis or ischemic bowel- IVF, analgesia, antibx, and surgical resection
Life-threatening

Question 19

PUD

general
Size of ulcers

Answer 19

Ulcerations (> 5 mm in diameter) of the stomach or duodenum that penetrate through to the muscularis
Stomach – gastric ulcer
Duodenum – duodenal ulcer (more common)
Can occur at any age

Question 20

PUD

common causes

Answer 20

Disruption of normal mucosal defenses and repair
H. pylori infection
80-90% of duodenal ulcers
70-80% of gastric ulcers
Use of NSAIDs and aspirin
>50% of peptic ulcers (gastric > duodenal ulcers)

Question 21

PUD

RF

Answer 21

NSAID and/or ASA use
H. pylori infection
Cigarette smoking
Impairs ulcer healing and increases the incidence of recurrence
Risk correlates the number of cigarettes smoked daily
Alcohol
Stress (severe illness-related, psychologic)
Diet (food storage)
Genetic predisposition

Question 22

PUD

Patho

Answer 22

Stomach andduodenum:
Normally exposed to an acidic environment
Imbalance between offending agents anddefense mechanismsleads to PUD

Question 23

PUD

Defense preventing mucosal injury

Answer 23

Mucus-bicarbonate-phospholipid layer
Epithelial layer (repair, which is regulated by prostaglandins)

Question 24

PUD

Mechanisms by offending agents

Answer 24

Increasedgastric acidsecretion:

H. pylori gastritis or inflammation: ↑gastric acid, inhibitssomatostatin, ↓ mucus

NSAID inhibition ofCOX 1→ ↓ prostaglandins (↓ mucus, ↓ mucosalblood flow, ↓ epithelial proliferation)

NSAIDinhibition ofCOX 2→ delays healing

Impaired duodenal bicarbonate secretion (inpatients with duodenal ulcers)

Effects of other etiologies or risk factors:
Smoking→ ↑ acidsecretion, ↓ prostaglandins

Question 25

# PUD S/Sx

Answer 25

Dependent on the location of the ulcer and age of the patient Older patients – few or no symptoms Symptoms: Pain Chronic and recurrent Localized to the epigastrium; may radiate to the back Described as burning, gnawing, or sensation of hunger Other symptoms: nausea/vomiting, early satiety, bloating, belching, GI bleeding Gastric ulcer: **Eating exacerbates rather than relieving pain** (presence of food and ↑ hydrochloric acid) Duodenal ulcer: Cause more consistent pain **Pain 2-5 hours after eating and pain that awakens the patient at night**

Question 26

# PUD Esophagogastroduodenoscopy (EGD)

Answer 26

PUD should be suggested by the patient’s history **Most accurate** diagnostic test Biopsy or cytologic brushing of lesions to distinguish between simple ulceration and ulcerating cancer Malignant gastric ulcer > malignant duodenal ulcer Allows for diagnosis of H. pylori infection

Question 27

# PUD Indications for Serum gastrin level

Answer 27

Indications: Multiple ulcers Ulcers in atypical locations Ulcers refractory to treatment Patients with weight loss and significant diarrhea

Question 28

# PUD Complications

Answer 28

Hemorrhage: Most common complication Symptoms: hematemesis, melena, weakness, orthostasis, syncope Penetration: Ulcers can penetrate the wall of the stomach leading to adhesions Symptoms: persistent, intense pain that is often referred (back) Perforation Ulcers perforate into the peritoneal cavity Duodenal ulcer > gastric ulcer Gastric outlet obstruction Results from scarring, spasm, or inflammation from an ulcer (duodenal ulcer near the pyloric sphincter)

Question 29

# PUD Perforation | general and Sx

Answer 29

Ulcers perforate into the peritoneal cavity Duodenal ulcer > gastric ulcer Symptoms: Acute abdominal pain Sudden, intense, continuous epigastric pain → spreads throughout the abdomen → prominent in the right lower quadrant with referred pain to one or both shoulders Increased pain with deep breathing

Question 30

# PUD Perforation PE findings Bowel sounds Vitals

Answer 30

Bowel sounds are diminished or absent Diffuse abdominal pain with palpation Abdominal muscles are rigid Tachycardia and hypotensive

Question 31

# PUD Perforation Dx

Answer 31

X-ray (upright views of the chest and abdomen) or CT scan showing free air under the diaphragm or in the peritoneal cavity Failure to detect free air does not exclude the diagnosis of perforation!

Question 32

# PUD Gastric outlet obstruction | general and Sx

Answer 32

Results from scarring, spasm, or inflammation from an ulcer (duodenal ulcer near the pyloric sphincter) Persistent bloating or fullness after eating Recurrent, large-volume vomiting often **6 hours after eating**

Question 33

# PUD Gastric outlet obstruction Dx

Answer 33

**Endoscopy** Determine the site, cause, and degree of obstruction Stomach must be emptied prior to the procedure Nasogastric (NG) tube placement with suction

Question 34

# PUD non pharm tx

Answer 34

Smoking and alcohol cessation Discontinue NSAIDs Limit/avoid foods and beverages that can increased mucosal irritation

Question 35

# PUD Pharm tx

Answer 35

Eradication of H. pylori See triple and quadruple therapy from the gastritis lecture Acid-suppressive drugs PPIs H2 blockers Antacids Sucralfate Prostaglandins Used for patients at high risk for NSAID-induced ulcer

Question 36

# PUD Surgery Tx

Answer 36

Patients requiring surgery has declined dramatically due to the effectiveness of current drug therapy Procedures to reduce acid secretion and ensure gastric emptying

Question 37

# Proton pump inhibitors

Question 38

# PUD Complications - Recurrence & Risks

Answer 38

Factors affecting recurrence: Failure to eradicate H. pylori Continued NSAID use Smoking Rates: < 10% recurrence of gastric and duodenal ulcers with eradication of H. pylori 50% recurrence of gastric and duodenal ulcers without eradication of H. pylori **Gastric cancer** Occurs at a 3-6x increased rate in patients with H. pylori-associated ulcers

Question 39

# PUD

Question 40

# PUD