Perforated Peptic Ulcer

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Define perforated peptic ulcer
Perforation of the tum tum or proximal duodenum secondary to ulcer formation.

Recurrent ulceration is a complication of PUD
What 2 things cause most peptic ulcers
H pylori
NSAIDs
Acute or chronic inflammation of the gastric mucosa
Gastritis
Continuous or recurrent upper abdominal pain or discomfort. Potentially includes nausea, bloating, and caused by numerous things.....
Dyspepsia
PUD more common in young or old?
Old, it increases with age
Over 1/2 of GI bleeds are due to...
PUD
Large initial bleed, continued or recurrent bleed, old age, and comorbidities all increase what?
Likelihood of death from GI bleed as a result of PUD
What types of secretions protect gastric mucosa?
Bicarb and mucus
What enhances the flow of bicarb and mucus?
Prostaglandins
What malignancy does having H. pylori predispose you to?
MALT lymphoma
and
Adenocarcinoma of the stomach
What bacteria is found in up to 95% of ulcers?
H. pylori
How do NSAIDs cause ulcers?
They inhibit PGE synthesis, which prevents production of mucus and bicarb
What type of tumors can cause ulcers?
Gastrin secreting tumors raise acid and pepsin levels, but rarely cause ulcers by themselves
What is the main approach for ulcer treatment?
Acid reduction
Ulcers are NOT related to these 2 things
Diet
Booze
Predisposing factors for ulcers:
*Fam hx
Smoking*
Renal failure, transplant
Cirrhosis
Stress
COPD & PUD are bffs
What is the most classic symptom of perforated ulcer?
Burning epigastric pain
What relieves the pain of ulcers?
Food
Antacids
Milk (also a food, amirite?)
When does the pain recur the most?
Upon gastric emptying
Is this PUD? Post-prandial pain, food intolerance, nausea, retrosternal pain, belching.
Nope
What may be the only PE sign during physical exam for a perforated ulcer?
Epigastric tenderness, usually sudden onset
What happens when gut contents spill into the peritoneal cavity?
Chemical or bacterial peritonitis
Again, who may present with no S/S?
Old farts
What might have occurred if your patient presents with abrupt, severe back pain?
Posterior perforation onto the pancreas, potentially leading to pancreatitis
S/S of bleeding ulcers
Hematemesis
Melena
Hematochezia
What should you establish upon suspicion of perforated ulcer?
ABC
Look for S/S of hypovolemia
Start on O2
What might epigastric pain mimic?
Inferior MI! Cuidado!
Abdominal S/S on exam
Maybe rigid, surgical abdomen
Exquisite epigastric pain
Systemic S/S on exam
Pale, diaphoretic from shocky
T/F: Like diarrhea, PUD can be clinically diagnosed.
F
What labs should you get when you suspect perforated ulcer?
CBC
BMP
Coags
Type and cross
Belly labs-amylase, lipase, LFTs
Cardiac markers
H. pylori testing
How likely is a PUD patient to need an EKG?
Unlikely
What might you see on standing CXR with a perforation?
Farts
What type of GI contrast study should you do with suspected perforation?
Gastrografin, not barium
How awesome is CT scan for diagnosing PUD?
It's not
Why would you put in an NG tube?
To aspirate clots, blood, and coffee
Put it on low, intermittent suction
Should you lavage the gut with the NG tube?
Nope. It doesn't really do much, other than clear blood for the scope (that we aren't doing)
Generalized care for perforated ulcers includes these 4 things
Fluids
Blood
ABX
Pain control
What meds heal ulcers faster than H2 blockers?
PPIs
What type of therapy is indicated for H. pylori?
Triple!
What is the most commonly prescribed H2 blocker in the ED?
Famotidine (Pepcid)
Examples of PPIs
Esomeprazole
Lansoprazole
Omeprazole
Pantoprazole
Rabeprazole
This cheap and easy medication covers the ulcer site and protects it from acid. It also stimulates PGE release. It's not quite as good as H2 blockers or PPIs, and it used mainly to prevent stress-related bleeding

-From pharm 2
Sucralfate (Carafate)
What is the gold standard for PUD diagnosis?

Why?
Endoscopy

It allows visualization and biopsy
Patients with suspected PUD should be treated for H. pylori if appropriate, then referred to....

(spoken)
PCM

OR

Gastroenterology for endoscopy
What are the "alarming features" that require endoscopy?

These people need F/U and are at risk for tumor, CA, or perforation.
Age >55
Weight loss
Early satiety
Persistent barfing
Dysphagia
Anemia + bleeding
Gut mass
Persistent anorexia
Jaundice
What is the leading cause of UGI bleed?
PUD hemorrhage
How could PUD cause obstruction?
Scarring of the gastric outlet from chronic PUD, or edema from ulcers
Perforated peptic ulcer dispo
General surgery. Scope if no air in peritoneal space or send to OR if air in abdomen
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