PANRE/PANCE – Gastroenterology part 2 – PUD, Mallory Weiss Tear, Bowel Obstruction and Fecal Impaction

by Isabella on June 9, 2012

So before we move on with our study session, lets recap yesterday’s “lecture” about GERD….here’s my quick recap:

Thank you to my adorable husband Simon for bringing my comic idea to life!

So lets continue discussing GI conditions as we study for our big test.  Today I will discuss PUD (Peptic Ulcer disease), Mallory Weiss Tear and Bowel obstruction. Ok, lets start….

Peptic Ulcer Disease – PUD

  • PUD is essentially any ulceration and damage to the gastric or duodenal mucosa
  • Causes of PUD:
    • Most common cause of PUD is HPylori – Hpylori is linked to increased risk of gastric malignancy and must be treated
    • alcohol, NSAIDS, certain food, and stress
  • Symptoms of PUD:
    • Patients usually complain of an epigastric/LUQ gnawing pain that radiates through the abdomen to the back.  Pain usually gets worse a few hours after meals
      • Duodenal ulcer pain sometimes improves post meals
    • Nausea, burping, and heartburn
  • Diagnosis:
    • HPylori is more accurately diagnosed with a stool antigen test ( HpSAg) than a breath urea test
    • Endoscopy: allows to visualize the stomach and differentiate gastritis from ulceration and allows biopsy of tissue to r/o gastric carcinoma
  • Treatment: 
    • Conservative treatment should always be discussed with patients which includes: smoking cessation, dietary changes, NSAID reduction or avoidance and alcohol cessation
    • Hpylori negative: PPI daily x 4 weeks
    • HPylori postive: initiate triple or quadruple therapy for 14 days
      • Triple Therapy: Amoxicillin 500 mg, ii tabs po bid x 14 days, Clarithromycin 500mg, i po bid x 14 days, Prilosec 20 mg, i po bid x 14 days.
        • in PCN allergic patients, substitute with metronidazole 500 mg bid
        • PPI weakens Hpylori  (hpylori thrives in highly acidic environments PPI increases PH level)
        • Amoxicillin bacteriostatic, Clarithromycin bactericidal
      • Quadruple Therapy:  peptobismol, tetracycline, metronidazole, PPI

Mallory-Weiss Tear:

  • Mallory-Weiss tear is an UGIB caused by a longtitudinal tear in the gastric mucosa that usually occurs in the gastroesophageal junction
  • Causes:
    • retching and vomiting usually that is usually caused by excessive alcohol consumption
  • Population:
    • incidence is higher in males 40-50 yo
  • Diagnosis: confirmed with endoscopy
  • Treatment: usually self resolving  within 24-48 hours, or injection of epinephrine to stop the bleeding

Bowel Obstruction:

  • Obstruction occurs when flow of intestinal contents is interrupted, leading to blockage
  • Causes:
    • Small bowel: most common cause are adhesions, as well as hernia, neoplasm and IBD
    • Large Bowel: most common cause are neoplasms, as well as hernias, fecal impaction, volvulus, and intussusception
  • Symptoms/Signs:
    • Patient will usually present complaining of colicky abdominal pain, nausea, vomiting, not passing gas or having a BM
    • on exam: Bowel sounds are high pitched early on, and then are not present later on, abdomen is tender and distended, patient may be febrile
  • Diagnosis:
    • plain upright abdominal film – test of choice – may show air-fluid levels
    • If plain film not conclusive – CT abdomen/Pelvis
    • Order CBC – leukocytosis may be present, order CMP- elevated BUN may be present due to dehydration
  • Treatment:
    • Patient placed on NPO, nasogastric suctioning tube, and IV fluids
    • If not responsive or worsening – exploratory laparotomy

Fecal Impaction:

  • Fecal impaction usually occurs when a large, dry piece of stool gets stuck in the colon – usually in the rectum
    • an impaction that is more proximal is more consistent with a neoplasm – usually symptoms of constipation are new in onset, associated with anorexia and weight loss
    • you should ask the patient about their use of laxatives as sudden cessation can cause constipation and lead to impaction
    • ask about use of opiates – cause constipation
  • Symptoms/Signs: 
    • patient usually complains of abdominal pain, nausea, vomiting, straining and inability to have a BM
    • complaints of leakage of liquid stool – happens when colon gets distended and stool above impaction travels around and leaks out of rectum
    • complaints of leakage of urine – pressure from impaction on the bladder
    • confirm with digital rectal exam where you feel a hard stool in the rectal vault, may also feel abdominal mass
  • Treatment:
    • manual disimpaction
    • saline enema if digital disimpaction unsuccessful
    • discuss dietary and lifstyle changes: increase fluids, increase fiber (metamucil, benefiber), exercise
  • Complications:
    • Perforation, ulceration

 

Well, that is it for today’s study session, 4 topics reviewed and many more to go, hope you enjoyed studying with me, if you have any questions….just ask! :)

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