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 at the ED
complaining of dark stools for the last 2 days.
He has had epigastric pain for the 2 weeks that
improves after eating and is worse 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 melena.
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 bore catheter.
You then fluid resuscitate the patient
and offer blood products.
So packed red blood cell transfusion
if a hemoglobin is less than 7
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 variceal bleed,
and consider any reversal agents for
anticoagulants that your patient is taking.
The last step is to always consult GI so that they can
then do the diagnostic and therapeutic next steps.
So, let's review duodenal ulcers now.
Duodenal ulcers are very
similar to peptic ulcers.
They are caused by the same risk factors.
So those things include H. pylori infection,
chronic NSAID use,
regular acid hypersecretory states
like Zollinger-Ellison syndrome
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
- 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 consist 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 to 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,
people with gastric ulcers tend to
have eating that worsens with pain.
and those with duodenal ulcers tends 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 melena for the last 2 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,
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
duodenal 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 a 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 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.