Table 24 Laura Butz, Natalie King Chris Minning, Fred Roepcke Case 2 Table 24 Laura Butz, Natalie King Chris Minning, Fred Roepcke

62 year-old white male in ER – appears apprehensive and uncomfortable, body bent forward History Sitting after lunch, sharp (“stabbing”) pain in abdomen Began RU quadrant, spread over LU quadrant and around to back Pain was intense for a few hours, now ache that has spread all along left side of abdomen Motion makes pain worse Pain in left shoulder No history of previous abdominal pain, heart or lung disease Not taking medication, drinks a beer 2 to 3 nights/week He has felt nauseous all day and vomited right after the pain struck – “It looked like I vomited coffee grounds.”

Vital Signs Blood pressure Pulse: 95bpm Rhythm: Regular Lying supine: 135/80 left arm and 135/75 right arm Standing: 130/75 left arm and 130/70 right arm Pulse: 95bpm Rhythm: Regular Temperature: 100.5oF Respiratory rate: 22 breaths/min Height: 5’10” Weight: 210 lbs. BMI 30.1

Physical Exam Abdomen Musculoskeletal – left shoulder Auscultation reveals hypoactive bowel sounds Guarding of anterolateral abdominal wall, but no rebound tenderness Epigastric and left hypochondriac regions are tender to deep palpation Musculoskeletal – left shoulder Active and passive movements of left arm and isometric tests of left arm movements involving shoulder acromioclavicular and sternoclavicular joints all normal and do not produce change in left shoulder pain

Questions What is guarding of the anterior abdominal wall? Tensing of the abdominal wall muscles to guard inflamed organs within the abdomen from the pain of pressure upon them. The tensing is detected when the abdomen wall is pressed. What is rebound tenderness A sensation of pain felt when pressure is suddenly removed Represents aggravation of the parietal layer of peritoneum

Questions What is the significance of “coffee grounds” in the vomitus? Hematemesis: vomiting of blood Vomiting of red blood or coffee ground material indicates upper GI bleed Vomiting of coffee-ground material results from upper GI bleed that has slowed or stopped – conversion of red Hb to brown hematin by gastric acid

Questions What organs are considered part of the upper GI tract? Esophagus, stomach, duodenum What could cause these organs to bleed? Esophageal varices, peptic ulcer disease/perforation, tumors of the esophagus and stomach, gastritis, gastroenteritis, esophagitis

Questions Which structures are located in the RUQ? Liver, gall bladder, hepatic flexure of large intestine, pylorus of stomach, duodenum Which structures are located in the LUQ? Spleen, pancreas, stomach, esophagus and sphincter, splenic flexure of large intestine If one of these organs were infected or perforated, where would the infection or fluids go?

Questions What are the boundaries of the lesser sac? Greater sac? Ligaments: hepatoduodenal, hepatogastric Posterior to these ligaments, posterior to stomach, anterior to posterior wall and pancreas, inferior to diaphragm Inferior recess within gastrocolic ligament of greater omentum Greater sac? Posterior to anterior abdominal wall, anterior to stomach and greater omentum, inferior to diaphragm

Questions Explain the source and distribution of the patient’s pain. Infection from organ or contents of organ (gastric juice, pancreatic enzymes, etc.) have entered lesser sac causing the transition from acute to diffuse pain in the epigastric and left hypochondriac regions

Questions What is significant about the pain in his shoulder? The superior boundary of the lesser sac is the diaphragm. The phrenic nerves are carrying the sensory information via C3, C4, and C5. The neurons at spinal cord levels C3 and C4 also receive sensation from the shoulder via supraclavicular nerves. Thus pain arising from the diaphragm often may be referred to the shoulder.

Peptic Ulcer Disease Peptic ulcer disease (PUD) is one of the most common diseases affecting the GI tract. A diagnosis can be difficult because it has a wide spectrum of clinical presentations, ranging from asymptomatic to vague epigastric pain, nausea, and iron-deficiency anemia to acute life-threatening hemorrhage.

Peptic Ulcer Disease A major causative factor (60% of gastric and 90% of duodenal ulcers) is chronic inflammation due to Helicobachter pylori. The bacterium can cause a chronic active gastritis, resulting in increased gastrin secretion. Gastrin, in turn, stimulates the production of gastric acid by parietal cells. The acid erodes the mucosa and causes the ulcer. An estimated 60% of Americans older than 60 years harbor H pylori

Peptic Ulcer Disease Complications Perforation Penetration Bleeding gastric and duodenal content leaks into the peritoneum Penetration An ulcer can go through the muscular wall of the stomach or duodenum and continue into an adjacent organ, such as the liver or pancreas Bleeding Vomiting bright red blood or reddish brown clumps of partially digested blood that look like coffee grounds and passing black or obviously bloody stools can be symptoms of a bleeding ulcer.

Peptic Ulcer Disease Pain with radiation to the back is suggestive of a posterior penetrating gastric ulcer complicated by pancreatitis.

Pancreas Produces digestive juices and hormones, including insulin Bile duct joins main pancreatic duct before emptying into duodenum

Pancreatitis Digestive enzymes become active within the gland and attack the pancreas Sudden, constant pain in upper abdomen – tenderness with guarding Pain often relieved by bending forward Nausea, vomiting, fever, tachycardia, tachypnea, hypotension, Internal bleeding can occur in severe cases Mild jaundice Diminished or absent bowel sounds Severe cases may have a Grey Turner sign or Cullen sign, bluish discoloration caused by retroperitoneal leak of blood from pancreas in hemorrhagic pancreatitis

Peritonitis Inflammation of the peritoneum Symptoms: Abdominal guarding Movement makes pain worse Rebound tenderness Would rebound tenderness be present in peritonitis of the lesser sac?

Treatment For Peptic Ulcer Disease Because infection with H. pylori bacteria is a major cause of ulcers, antibiotics are often used. Sometimes bismuth subsalicylate is used in combination with antibiotics. Neutralizing or reducing stomach acid by taking drugs that directly inhibit the stomach's production of acid promotes healing regardless of cause. Perforation requires immediate laproscopic surgery to repair the hole