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CMT-dos > Ischemic bowel/Peptic ulcer disease > Flashcards

Ischemic bowel/Peptic ulcer disease Flashcards

1
Q

Colonic Ischemia

general

A

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.

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2
Q

Colonic Ischemia

RF

A

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

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3
Q

Colonic Ischemia

Clin man

A

LLQ pain
hematochezia (bloody diarrhea): typically self limited

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

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4
Q

Colonic Ischemia

Dx options

A

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

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5
Q

colonic ischemia

A

scalloping/”fingerprinting” seen in left image

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6
Q

colonic ischemia

Tx

A

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

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7
Q

Acute Mesenteric Ischemia

general

A

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

Fatal without intervention

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8
Q

Acute Mesenteric Ischemia

RF

A

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

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9
Q

Acute Mesenteric Ischemia

clin man

A

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

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10
Q

Acute Mesenteric Ischemia

Labs

A

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

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11
Q

Acute Mesenteric Ischemia

imaging

A

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

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12
Q

Acute mesenteric ischemia

Tx

A

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

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

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13
Q

Colonic Volvulus

general

A

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

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14
Q

colonic volvulus

RF

A

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

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15
Q

colonic volvulus

Clin man

A

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

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16
Q

Acute Mesenteric Ischemia

A

SMA is the most commonly affected

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17
Q

colonic volvulus

labs/xray/CT/barium enema

A

Leukocytosis

Xray abd: U-shaped distended sigmoid colon

CT: dilated sigmoid colon, “bird beak” appearance

barium enema, c-scope can aid in diagnosis

18
Q

colonic volvulus

Tx

A

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

19
Q

PUD

general
Size of ulcers

A

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

20
Q

PUD

common causes

A

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)

21
Q

PUD

RF

A

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

22
Q

PUD

Patho

A

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

23
Q

PUD

Defense preventing mucosal injury

A

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

24
Q

PUD

Mechanisms by offending agents

A

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

25
Q

PUD

S/Sx

A

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

26
Q

PUD

Esophagogastroduodenoscopy (EGD)

A

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

27
Q

PUD

Indications for Serum gastrin level

A

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

28
Q

PUD

Complications

A

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)

29
Q

PUD

Perforation

general and Sx

A

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

30
Q

PUD

Perforation PE findings
Bowel sounds
Vitals

A

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

31
Q

PUD

Perforation Dx

A

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!

32
Q

PUD

Gastric outlet obstruction

general and Sx

A

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

33
Q

PUD

Gastric outlet obstruction
Dx

A

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

34
Q

PUD

non pharm tx

A

Smoking and alcohol cessation

Discontinue NSAIDs

Limit/avoid foods and beverages that can increased mucosal irritation

35
Q

PUD

Pharm tx

A

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

36
Q

PUD

Surgery Tx

A

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

37
Q

Proton pump inhibitors

A
38
Q

PUD

Complications - Recurrence & Risks

A

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

39
Q

PUD

A
40
Q

PUD

A

CMT-dos (95 decks)

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