Abdominal Pain and Peptic Ulcer Disease
Abdominal Pain
Definition:
Abdominal pain describes a broad general process with numerous etiologies. Prompt diagnosis and treatment is crucial for abdominal emergencies.
History and exam:
Always ask about onset, location, severity from scale of 1 to 10, character, radiation of pain, and the exacerbating or relieving factors. Ask about accompanying symptoms such as nausea, vomiting, diarrhea, constipation, flatulence, melena, hematemesis, fever, dysuria, hematuria, chest pain, shortness of breath. Clarify the exact sequence of pain and other symptoms.
Physical exam should be thorough and you should examine all four quadrants. All female patients should get a pelvic exam if complaining of lower abdominal pain.
An abdominal xray is a good imaging test to start with for severe abdominal pain or abdominal pain with associated nausea/vomiting. When in doubt, one can order an abdominal xray to help make diagnosis.
Causes of abdominal pain
Right upper quadrant pain
-acute hepatitis, liver abscess, duodenal ulcer, appendicitis (high appendix), gallbladder rupture, acute cholecystitis, pyelonephritis
Right lower quadrant pain
-acute appendicitis, duodenal ulcer, pyelonephritis, kidney stone, acute pancreatitis, inflammatory bowel disease, Yersina enterocolitica infection, biliary peritonitis
Left upper quadrant pain
-acute pancreatitis, perforated gastric ulcer, splenic rupture, splenic infarct, perinephric abscess, pyelonephritis
Left lower quadrant pain
-diverticulitis, inflammatory bowel disease, kidney stone, appendicitis
Mid-lower abdominal pain
- perforated appendix, perforated sigmoid diverticulum, large bowel obstruction, colitis
Epigastric pain
- generalized pain:
o typhoid, TB peritonitis, early appendicitis, small bowel obstruction, gastroenteritis, peptic ulcer disease, pancreatitis, duodenal ulcer
- generalized pain and rigidity (very concerning):
o perforated gastric ulcer, perforated duodenal ulcer, perforated gallbladder, bowel perforation, ruptured ectopic pregnancy
- general pain with circulatory shock (very concerning):
o intrabdominal hemorrhage, ruptured aortic aneurysm, dissecting aortic aneurysm, ruptured ectopic pregnancy, mesenteric ischemia
Other causes of abdominal pain:
****TB peritonitis, typhoid
less common, pneumonia, malaria, sickle cell crisis, uremia, thyroid disease, Pott’s disease, acute porphyria, tabes dorsalis, diabetic ketoacidosis
Women (always consider these with lower abdominal pain):- ovarian torsion, ovarian cyst, ectopic pregnancy, threatened abortion, twisted or inflamed fibroid, dysmenorrhea
Peptic Ulcer Disease
Definition:
Peptic ulcers are common clinical problems characterized by mucosal defects of the GI mucosa of the stomach or duodenum. Men and women are at equal risk.
Pathophysiology:
Gastric acid is an important factor in protein hydrolysis and digestion. Postprandial gastrin expression is controlled by a negative feedback loop where gastrin mediated acid secretion after a meal will in turn stimulate the release of somatostatin. Somatostatin inhibits further release of gastric acid. Increases in gastric acid production is only one factor involved. There are various mechanisms involved in maintaining the protective mucosal barrier. H. pylori has been showed to decrease somatostain production and disrupts the mucosal layer leading to ulcer formation. NSAIDs also disrupt the mucosal layer.
Signs/Symptoms:
Peptic ulcers can present in a variety of ways from asymptomatic iron deficiency anemia to abdominal pain, small bowel obstruction, perforation, and hemorrhage. Includes:
-epigastric abdominal pain: relieved with food (duodenal) or worsened with food (gastric)
-usually dull pain, but may be sharp or burning. Can be associated with nausea/vomiting.
-Gastric outlet obstruction can occur with duodenal ulcers
-can present with upper GI bleed if ulcer is actively bleeding
-NSAID ulcers can present has painless bleeding
Etiology:
-NSAIDs, aspirin use, H.Pylori infection: 90% duodenal ulcers, 70% gastric ulcers, Gastrinoma (Zollinger-Ellison), alcohol, malignancy, Stress related (ICU patients, stroke, ventilator dependence, immunocompromised)
Diagnosis:
History and physical are helpful. Ask about NSAID, asa, alcohol use, history of Hpylori infection and weight loss. Full blood panel will evaluate for iron deficiency anemia. Upper endoscopy is the preferred method for diagnosing peptic ulcer disease, can also get tissue sampling to evaluate for malignancy and Hpylori. Hpylori can also be detected by urea breath testing and serology. Hpylori stool antigen is useful in detecting eradication after antibiotic therapy.
Treatment:
-stop NSAID or asa use for at least 3-4 weeks
-start acid suppression with PPI (proton pump inhibitors) such as omeprazole, intial dose can be 20 mg once a day and can be increased to 40 mg twice day for bleeding ulcers
-acid suppression can also be done with H2 blockers on prn basis with ranitidine
-sulcrafate acts by coating mucosal surface without blocking acid secrtion and can be used with PPI
-Hpylori: can treat with omeprazole, amoxicillin, and metronidzole for 14 days.
-lifestyle changes: stop alcohol and tobacco use
-critically ill patients in ICU should get acid suppression therapy prophylaxis to prevent stress ulcers: usually ranitidine 150 mg BD
PUD complications
-GI bleeding, gastric outlet obstruction, perforation, pancreatitis
Abdominal Pain and PUD Clinical Cases
Case 1
50 yo male with no past medical history presents to hospital complained of abdominal pain. He describes the pain as epigastric in origin and it is constant. The pain is dull and is often worsened by eating. He has had this pain for 1 month. He has had this pain before, last time was over a year ago. His blood pressure is 130/80 and his heart rate is 80.
1. What is the most likely cause of his abdominal pain?
a. Most likely gastric ulcer, given that it is worsened by eating.
2. Where specifically is the lesion located based on his symptoms?
a. As above.
3. What studies do you want to make the diagnosis?
a. EGD, FBP, H. Pylori
He then tells you that he was diagnosed with a bacteria in his stomach the last time he has this type of pain. He was supposed to take antibiotics but he never did.
1. What is the most like etiology for his pain?
a. PUD 2/2 H. Pylori
2. How will to treat him?
a. In addition to sucralfate and an H2 blocker/PPI, should treat with erthyromycin, amoxicillin, and metronidzole for 14 days.
3. What test is used to know if the bacteria has been adequately treated?
a. H. Pylori Stool Antigen.
Case 2
56 yo female with history of HTN is admitted to the ICU when she presented with left sided hemiplegia and found to have a blood pressure of 220/120. She was diagnosed with stroke from hypertensive emergency.
1. Should this patient get GI prophylaxis and why?
a. Yes. All patients in the ICU should get acid suppression to prevent curling’s (stress) ulcers.
2. What kind of prophylaxis should you use?
a. Ranitidine is typically used at BMC. But PPIs are also effective.
