Ischemic bowel/Peptic ulcer disease Flashcards
Colonic Ischemia
general
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.
Colonic Ischemia
RF
> 60, female
ASCVD
hypotension
CHF
recent surgery for AAA
hx constipation
hx HTN RX ( esp vasoconstrictive)
Colonic Ischemia
Clin man
LLQ pain
hematochezia (bloody diarrhea): typically self limited
LLQ tenderness- watch for peritoneal signs/fever ( usually absent)
Absent/hypoactive bowel signs
Colonic Ischemia
Dx options
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
colonic ischemia
scalloping/”fingerprinting” seen in left image
colonic ischemia
Tx
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
Acute Mesenteric Ischemia
general
Inadequate perfusion through mesenteric vessels (embolic, thrombotic, low flow state) can lead to gangrene of bowel
Fatal without intervention
Acute Mesenteric Ischemia
RF
Afib
ASCVD
recent MI
valvular disease
elderly
abdominal malignancy
hypercoagulability
Paradoxical venous embolism
Acute Mesenteric Ischemia
clin man
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
Acute Mesenteric Ischemia
Labs
Leukocytosis, elevated lactate ( depending on stage of disease), lactic acidosis
Acute Mesenteric Ischemia
imaging
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
Acute mesenteric ischemia
Tx
Restore flow with anticoagulation/thrombolysis if occlusive ischemia; angioplasty/stenting/bypass
If bowel ischemia need immediate exploratory surgery and if bowel viable poss bypass
Colonic Volvulus
general
Life threatening emergency when colon twists creating colonic obstruction or vascular compromise
Sigmoid colon is most commonly involved
Can be recurrent
colonic volvulus
RF
Elderly, bedridden, constipation, ovarian or pelvic mass, pregnancy, dementia, psychiatric impairment, hx of previous volvulus
colonic volvulus
Clin man
Presentation
Acute, colicky abdominal pain, abdominal distention, obstipation, N/V
Physical Exam:
Largely distended, tympanic abdomen; if rebound tenderness consider peritonitis from perforation
Acute Mesenteric Ischemia
SMA is the most commonly affected
colonic volvulus
labs/xray/CT/barium enema
Leukocytosis
Xray abd: U-shaped distended sigmoid colon
CT: dilated sigmoid colon, “bird beak” appearance
barium enema, c-scope can aid in diagnosis
colonic volvulus
Tx
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
PUD
general
Size of ulcers
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
PUD
common causes
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)
PUD
RF
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
PUD
Patho
Stomach andduodenum:
Normally exposed to an acidic environment
Imbalance between offending agents anddefense mechanismsleads to PUD
PUD
Defense preventing mucosal injury
Mucus-bicarbonate-phospholipid layer
Epithelial layer (repair, which is regulated by prostaglandins)
PUD
Mechanisms by offending agents
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
PUD
S/Sx
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
PUD
Esophagogastroduodenoscopy (EGD)
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
PUD
Indications for Serum gastrin level
Indications:
Multiple ulcers
Ulcers in atypical locations
Ulcers refractory to treatment
Patients with weight loss and significant diarrhea
PUD
Complications
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)
PUD
Perforation
general and Sx
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
PUD
Perforation PE findings
Bowel sounds
Vitals
Bowel sounds are diminished or absent
Diffuse abdominal pain with palpation
Abdominal muscles are rigid
Tachycardia and hypotensive
PUD
Perforation Dx
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!
PUD
Gastric outlet obstruction
general and Sx
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
PUD
Gastric outlet obstruction
Dx
Endoscopy
Determine the site, cause, and degree of obstruction
Stomach must be emptied prior to the procedure
Nasogastric (NG) tube placement with suction
PUD
non pharm tx
Smoking and alcohol cessation
Discontinue NSAIDs
Limit/avoid foods and beverages that can increased mucosal irritation
PUD
Pharm tx
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
PUD
Surgery Tx
Patients requiring surgery has declined dramatically due to the effectiveness of current drug therapy
Procedures to reduce acid secretion and ensure gastric emptying
Proton pump inhibitors
PUD
Complications - Recurrence & Risks
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
PUD
PUD
