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G14 Gastroenterology
Small and Large Bowel
Toronto Notes 2019
If at high risk for development of ulcers, prophylaxis with PPI indicated
Risk Factors for NSAID-induced Peptic Ulcer
• previouspepticulcers/UGIB
• age(≥65yr)
• highdoseofNSAID/multipleNSAIDsbeingtaken
• concomitantcorticosteroiduse
• concomitantcardiovasculardisease/othersignificantdiseases
Treatment
• prophylacticcytoprotectivetherapywithaPPIisrecommendedifanyoftheaboveriskfactorsexist concomitantly with ASA/NSAID use
• lowerNSAIDdoseorstopalltogetherandreplacewithacetaminophen
• combine NSAID with PPI or misoprostol (less effective) in one tablet
• entericcoatingofAspirin®(ECASA)providesminorbenefitsincethisdecreasesincidenceoferosion,
not incidence of ulceration
Stress-Induced Ulceration
Definition
• ulcerationorerosionintheupperGItractofillpatients,usuallyinICU(stressisphysiological,not psychiatric)
• lesionsmostcommonlyinfundusofstomach
Pathophysiology
• unclear:likelyinvolvesischemia;maybecausedbyCNSdisease,acidhypersecretion,Cushingulcers • mechanicalventilationisthemostimportantriskfactor
Risk Factors
• mechanicalventilation • anti-coagulation
• multi-organ failure
• septicemia
• severesurgery/trauma
• CNSinjury(“Cushing’sulcers”)
• burns involving more than 35% of body surface
Clinical Features
• UGIB(seeUpperGastrointestinalBleeding,G25) • painless
Treatment
• prophylaxiswithgastricacidsuppressantsdecreasesriskofUGIB;PPImostpotentbutmayincrease risk of pneumonia; H2 blockers less potent but less likely to cause pneumonia
• treatmentsameasforbleedingpepticulcerbutoftenlesssuccessful
Gastric Carcinoma
• seeGeneralSurgery,GS19
Small and Large Bowel
Classification of Diarrhea
Definition
• clinically:diarrheadefinedasstoolsthatarelooserand/ormorefrequentthannormal(i.e.≥3xperday); physiologically: 24 h stool weight >200 g (less useful clinically)
Classification
• acutevs.chronic
• smallvolume(tablespoonsofstool;typicalofcolonicdiseases)vs.largevolume(>1/2cupstool;typical
of small bowel diseases)
• watery: secretory (diarrhea persists with fasting) vs. osmotic (diarrhea stops with fasting)
• steatorrhea
• inflammatory
• functional
Curling’s and Cushing’s Ulcers
• Curling’s ulcer: acute peptic ulcer of the
duodenum resulting as a complication from severe burns when reduced plasma volume leads to ischemia and cell necrosis (sloughing) of the gastric mucosa (think BURN from a CURLing iron)
• Cushing’s ulcer: peptic ulcer produced by elevated intracranial pressure (may be due to stimulation of vagal nuclei secondary
to elevated ICP which leads to increased secretion of gastric acid)
Curling’s and Cushing’s Ulcers
• Curling’s ulcer: acute peptic ulcer of the
duodenum resulting as a complication from severe burns when reduced plasma volume leads to ischemia and cell necrosis (sloughing) of the gastric mucosa (think BURN from a CURLing iron)
• Cushing’s ulcer: peptic ulcer produced by elevated intracranial pressure (may be due to stimulation of vagal nuclei secondary
to elevated ICP which leads to increased secretion of gastric acid)