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welcome
today we'll be discussing disorders of
the small bowel
so we'll begin with a case we have a 34
year old man who presents to the ed
complaining of dark stools for the last
two days
he has had epigastric pain for two weeks
that improves after eating
and is worst at night he has had nausea
and a feeling of fullness after eating
small amounts
he's not had any difficulty swallowing
or unintentional weight loss
he is a construction worker and takes
naproxen several times a day
for back pain his vitals are notable for
a heart rate of 100
on exam he has mild tenderness to
palpation in the epigastrium
without rebound or guarding rectal exam
shows a small amount of black stool in
the rectal vault
hemoglobin is 9 from a baseline of 11
several months ago what is the best next
step in management
so before we answer that let's go
through some key features here
he has dark stools which should prompt
you to consider a gi bleed
he does have symptoms that are
concerning for either peptic or duodenal
ulcer
disease since he has pain that improves
after eating
nausea and early satiety
he does have chronic nsaid use
and on his exam he has mild tachycardia
when i see a patient who comes in
complaining of dark stools this is often
a very
vague complaint you always want to do a
rectal exam to confirm
that it is actually black stool which is
positive for melano
so in this case his rectal exam was
positive
he also has what we consider a subacute
hemoglobin drop
meaning over several months he then had
his hemoglobin drop
from 11 down to 9.
so before we answer this question let's
take a quick step to review
some steps in gi bleed management i'll
refer you back to the lecture on the
approach to the patient with a
gastrointestinal bleed
for a more in-depth review but we'll go
through a quick
overview as well so
recall that when managing a gi bleed the
most important steps
include establishing adequate iv access
with large bore ivs
or a centrally placed large pore
catheter
you then fluid resuscitate the patient
and offer blood products so packed red
blood cell transfusion if a hemoglobin
is less than seven
or you would consider a higher threshold
if they are actively bleeding
or have cardiovascular disease you may
consider giving platelets if their
platelets are
less than 50 000 and you give
medications including
a proton pump inhibitor you might
consider vasoactive medications if
you're concerned
for a varicel bleed and consider any
reversal agents for anticoagulants that
your patient is taking
the last step is to always consult gi
since they can then do the
diagnostic and therapeutic next steps
so let's review duodenal ulcers now
duodenal ulcers are very similar into
peptic ulcers
they are caused by the same risk factors
so those things include
h pylori infection chronic nsaid use
rare acid hypersecretory states like
zollinger ellison syndrome
and smoking patients will come in with
the same clinical features as they do
with peptic ulcer disease
they may have epigastric pain nausea
vomiting a feeling of early satiety
and unintentional weight loss here on
the right you can see an example
of a duodenal ulcer at the bottom of the
image
the diagnosis must be done with upper
endoscopy
or esophagogastroduodenoscopy what we
refer to as
an egd you should always make sure to
also check for an h pylori infection
since this is easily treated treatment
consists of doing endoscopy
and intervening at that point if it's a
bleeding ulcer
you also need to identify any underlying
risk factors
and treat those and you may also do a
ppi proton pump inhibitor
or h2 blockers
so you might be wondering at this point
gastric and duodenal ulcers are very
similar
some features you can use to distinguish
between the two
are listed here so first patients who
have gastric ulcers
tend to be older or age greater than 40.
patients who present with duodenal
ulcers on the other hand tend to be a
bit younger
in addition the risk factors also differ
a bit between the two
so for gastric ulcers the most common
cause in developed countries is nsaid
use
and with duodenal ulcers h pylori
infection tends to be more common
the location obviously differs with
gastric ulcers they tend to occur
on the lesser curvature of the stomach
whereas duodenal ulcers tend to occur a
few centimeters distal to the pylorus
their clinical features may be similar
but in general gastric ulcers
tend people with gastric ulcers tend to
have eating that worsens with pain
and those with duodenal ulcers tend to
have
their pain get relieved by eating they
may also more commonly present with
nocturnal pain
the follow-up that is required also
differs between the two
because gastric ulcers may have a risk
of progressing to cancer
they may require a follow-up endoscopy
for duodenal ulcers on the other hand
we often do not need to repeat endoscopy
since they have a low risk of
progressing to cancer
so now let's return to our case we have
a 34 year old man
presenting with melana for the last two
days concerning for a gi bleed
he has chronic nsaid use which is a risk
factor for both
peptic and duodenal ulcers although more
commonly peptic ulcers
he also has signs of mild hypovolemia
based on his rapid heart rate
so in a real life situation if you saw
this patient
you would think of both gastric or duono
ulcers on your differential
and the only way to differentiate
between the two would be to then perform
upper endoscopy
to look for the location of the ulcer
for test taking purposes on the other
hand
if you were faced with the scenario you
should look at the clue that he has
pain that improves after eating which is
more specific to a duodenal ulcer
so because of that you should recognize
that he has a duodenal ulcer
leading to a gi bleed and the next steps
would be fluid resuscitation
and performing an egd to look for the
bleeding ulcer
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