Duodenal Ulcer with Case

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.