Case 2

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

2. 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.”

3. Vital Signs • Blood pressure • 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

4. Physical Exam • Abdomen • Auscultation reveals hypoactive bowel sounds • Guarding of anterolateral abdominal wall, but no rebound tenderness • Epigastricand 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 acromioclavicularand sternoclavicular joints all normal and do not produce change in left shoulder pain

5. 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

6. 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

7. 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

8. 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?

9. Questions • What are the boundaries of the lesser 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

10. 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

11. 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.

12. 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.

13. 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

14. Peptic Ulcer Disease • Complications • Perforation • 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.

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

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

17. 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

18. 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?

19. 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