00:00
Welcome, today we'll be discussing
disorders of the small bowel.
00:05
So we'll begin with a case.
00:07
We have a 34-year-old man who presents at the ED
complaining of dark stools for the last 2 days.
00:13
He has had epigastric pain for the 2 weeks that
improves after eating and is worse at night.
00:19
He has had nausea and a feeling of
fullness after eating small amounts.
00:23
He's not had any difficulty swallowing
or unintentional weight loss.
00:28
He is a construction worker and takes
naproxen several times a day for back pain.
00:33
His vitals are notable
for a heart rate of 100.
00:36
On exam, he has mild tenderness to palpation in
the epigastrium, without rebound or guarding.
00:43
Rectal exam shows a small amount of
black stool in the rectal vault.
00:48
Hemoglobin is 9 from a
baseline of 11 several months ago.
00:53
What is the best next
step in management?
So before we answer that, let's
go through some key features here.
00:59
He has dark stools which should
prompt you to consider a GI bleed.
01:05
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.
01:15
He does have chronic NSAID use.
01:19
And on his exam, he has mild tachycardia.
01:22
When I see a patient who comes
in complaining of dark stools,
this is often a very vague complaint.
01:28
You always want to do
a rectal exam to confirm
that it is actually black stool
which is positive for melena.
01:35
So in this case, his
rectal exam was positive.
01:39
He also has what we consider
a subacute hemoglobin drop.
01:43
Meaning, over several months he then had
his hemoglobin drop from 11 down to 9.
01:49
So, before we answer this question, let's take a quick
step to review some steps in GI bleed management.
01:56
I'll refer you back to the lecture on the approach
to the patient with a gastrointestinal bleed
for a more in-depth review.
02:03
But we'll go through a
quick overview as well.
02:07
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.
02:20
You then fluid resuscitate the patient
and offer blood products.
02:26
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.
02:36
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.
02:55
The last step is to always consult GI so that they can
then do the diagnostic and therapeutic next steps.
03:03
So, let's review duodenal ulcers now.
03:05
Duodenal ulcers are very
similar to peptic ulcers.
03:09
They are caused by the same risk factors.
03:11
So those things include H. pylori infection,
chronic NSAID use,
regular acid hypersecretory states
like Zollinger-Ellison syndrome
and smoking.
03:23
Patients will come in with the same clinical
features as they do with peptic ulcer disease.
03:27
They may have epigastric pain,
nausea/vomiting, a feeling of early satiety
and unintentional weight loss.
03:34
Here on the right you can see an example of a
duodenal ulcer at the bottom of the image.
03:41
The diagnosis must be
done with upper endoscopy
or esophagogastroduodenoscopy
- what we refer to as an EGD.
03:50
You should always make sure to also check for an
H. pylori infection since this is easily treated.
03:57
Treatment consist of doing endoscopy
and intervening at that
point if it's a bleeding ulcer.
04:03
You also need to identify any underlying
risk factors and treat those.
04:08
And you may also do a PPI (Proton
Pump Inhibitor) or H2 blockers.
04:14
So, you might be wondering at this point,
gastric and duodenal ulcers are very similar.
04:20
Some features you can use to distinguish
between the two are listed here.
04:25
So first, patients who have gastric ulcers
tend to be older or age greater than 40.
04:32
Patients who present with duodenal ulcers
on the other hand tend to be a bit younger.
04:38
In addition to risk factors, also
differ a bit between the two.
04:41
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.
04:52
The location obviously differs.
04:54
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.
05:04
Their clinical features may be similar
but in general, gastric ulcers,
people with gastric ulcers tend to
have eating that worsens with pain.
05:14
and those with duodenal ulcers tends to
have their pain get relieved by eating.
05:20
They may also more commonly
present with nocturnal pain.
05:24
The follow up that is required
also differs between the two.
05:28
Because gastric ulcers may
have a risk of progressing to cancer,
they may require a follow-up endoscopy.
05:35
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.
05:43
So now let's return to our case.
05:45
We have a 34-year-old man
presenting with melena for the last 2 days,
concerning for a GI bleed.
05:51
He has chronic NSAID use which is a risk
factor for both peptic and duodenal ulcers,
although more commonly,
peptic ulcers.
05:59
He also has signs of mild hypovolemia
based on his rapid heart rate.
06:03
So in a real life situation,
if you saw this patient,
you would think of both gastric or
duodenal ulcers on your differential.
06:11
And the only way to
differentiate between the two
would be to then perform upper endoscopy
to look for the location of the ulcer.
06:19
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.
06:30
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.