Ch. 49 Severe Epigastric Abdominal Pain

Question 1

H. pylori accounts more for than 90% of duodenal ulcers and up to 80% of gastric ulcers. How?

Answer 1

Inflammatory rxn caused by H. pylori invokes hypersecretion of gastrin –> increase in acid secretion –> antral gastritis –> ulcer

(associated dec. of prostaglandins, bicarbonate, somatostatin)

Question 2

How do NSAIDs lead to Peptic Ulcers?

Answer 2

Inhibit both COX-1 and COX-2 production (inhibit secretion of prostagladins and thromboxanes)

• Prostaglandins - regulate inflammatory rxns within gastric mucosa + reduce production of acid by acting upon the parietal cells of stomach (therefore, NSAID use –> unopposed acid secretion and dec. in mucosal defense)

Question 3

Types of gastric ulcers

Type?

Location?

Acid hypersecretion?

Answer 3

1. Type I: Lesser curvature (70%); no
2. Type II: Lesser curvature and duodenum; yes
3. Type III: Prepyloric; yes
4. Type IV: Gastric cardia; no
5. Type V: Any location in stomach; no

Types I, IV, V = disruptions in mucosal protective defense mechanisms

Question 4

How does vomiting change a patient’s acid/base balance?

Answer 4

Loss of K and HCl

Loss of H+ ions –> metabolic alkalosis

If vomiting continues, pt will also start losing Na+ –> Hyponatremia sensed by macula densa of kidneys –> RAAS activation –> Na+ and H2O reabsorption within renal tubules at expense of hydrogen ions (contraction alkalosis)

Question 5

Work Up:

What Laboratory Studies Should Be Sent?

Answer 5

• CBC
• Blood chemistries
• LFTs (to r/o choledocolithasis or cholecystitis)

Blood test abnormalities may include:

• Leukocytosis with left shift
• Elevated CRP
• Decreased albumin
• Elevated BUN and creatinine

Amylase and lipase should be obtained to exclude pancreatitis.

Question 6

Classic finding on upright CXR for pt with suspected PUD

Answer 6

Pneumoperitoneum (hyper-lucent area under one or both hemidiaphragms)

Question 7

If perforated peptic ulcer suspected, what tests are contraindicated?

Answer 7

Barium UGI series (causes barium peritonitis)

Upper endoscopy (insufflation of air may exacerbate perforation)

Question 8

Pharm and surgical tx for perforated peptic ulcer?

Answer 8

2-week abx/PPI regimens:

• abx (gram+, gram-, anaerobes)
• PPI (3x therapy)
  
  • MOC: metronidazole, omeprazole, clarithromycin
  • AOC: ampicillin, omeprazole, clarithromycin
• NG decompression
• Close observation (sepsis)

Surgical repair: cover ulcer with omental patch

Question 9

What is the name of the sign with RLQ pain/peritonitis as a result of succus collecting from a perforated peptic ulcer?

Answer 9

Valentino’s sign

Question 10

Duodenal Ulcers:

1. Most common location?
2. Classic pain response to food intake?
3. Cause?
4. Associated syndrome?
5. When is surgery indicated with a bleeding duodenal ulcer?
   
   1. Artery involved?

Answer 10

1. Most are within 2 cm of the pylorus in the duodenal bulb
2. Food classically relieves duodenal ulcer pain (Duodenum = Decreased with food)
3. Cause: Increased production of gastric acid
4. Zollinger-Ellison syndrome
5. Most surgeons use: >6 u PRBC transfusions, >3 u PRBCs needed to stabilize, or significant rebleed
   
   1. Gastroduodenal a.

Question 11

Why may a duodenal rupture be initially painless?

Why may a perforated duodenal ulcer present as lower quadrant abdominal pain?

Answer 11

Fluid can be sterile, with a nonirritating pH of 7.0 initially

Fluid from stomach/bile drains down paracolic gutters to lower quadrants and causes localized irritation

Question 12

What must be performed in every operation for gastric ulcers?

Answer 12

Biopsy looking for gastric cancer

Question 13

What is the initial treatment for perforated peptic ulcer?

Answer 13

• NPO: NGT (decreases contamination of peritoneal cavity)
• IVF/Foley
• Abx/PPIs
• Surgery

Question 14

What is a Graham Patch?

Answer 14

Piece of omentum incorporated into the suture closure of perforation

(Common option for poor operative candidate with a perforated gastric ulcer)

Question 15

What is the significance of hemorrhage and perforation with duodenal ulcer?

What type of perforated ulcer may present just like acute pancreatitis?

Answer 15

May indicate two ulcers (kissing); posterior is bleeding, anterior is perforated with free air

Posterior perforated duodenal ulcer into the pancreas (i.e., epigastric pain radiating to the back; high serum amylase)

Question 16

What is a truncal vagotomy?

What other procedure must be performed along with a truncal vagotomy?

Answer 16

Resection of 1- to 2-cm segment of each vagal trunk as it enters the abdomen on the distal esophagus, decreasing gastric acid secretion

“Drainage procedure” (pyloroplasty, antrectomy, or gastrojejunostomy), b/c vagal fibers provide relaxation of the pylorus, and, if you cut them, the pylorus will not open

Question 17

Define the following terms:

Vagotomy + pyloroplasty

Vagotomy + antrectomy

Answer 17

1. Vagotomy + pyloroplasty
   
   1. Pyloroplasty performed with vagotomy to compensate for decreased gastric emptying
2. Vagotomy + antrectomy
   
   1. Remove antrum and pylorus in addition to vagotomy; reconstruct as a Billroth I or II