Gastroenterology 8

Acute Mesenteric Ischemia

This is an embolus from the heart resulting in an infarction of the bowel.
There is a sudden onset of extremely severe abdominal pain and possible
bleeding as well. Physical examination shows a relatively benign abdomen.
Look for an older patient with a history of valvular heart disease and the very
sudden onset of pain.

Diagnostic Testing
Look for metabolic acidosis (elevated lactic acid) on blood testing and an
elevated amylase level. The most accurate test is angiography.

Treatment
If the bowel is dead, treatment is surgical resection of the bowel. Very ill patients
Abdominal pain out of
should go straight to the operating room for surgical resection. This is a surgi-
proportion to physical
cal emergency. If left undetected and untreated, the patient will die quickly. In exam = Mesenteric
ischemia that is not caused by emboli, treat the underlying low flow state. ischemia

Constipation
The vast majority of cases have no clear etiology. Although Step 3 seldom
asks specifically for the diagnosis, the management of constipation involves
correcting the underlying cause. Therefore, knowing the etiology is the key to
determining the treatment. Following are possible causes of constipation:
· Dehydration: Look for decreased skin turgor in an elderly patient with an
increased BUN-to-creatinine ratio (> 20:1).
· Calcium channel blockers
· Narcotic medication use
· Hypothyroidism
· Diabetes: Loss of sensation in the bowels leads to decreased detection of
stretch in the bowel, which is one of the main stimulants of GI motility.
· Ferrous sulfate iron replacement: The stool is black and can look as though
there is upper GI bleeding. Blood is cathartic and will usually produce rapid
bowel movement. Ferrous sulfate is constipating and is also heme-negative
when one tests for occult blood.
· Anticholinergic medication: This includes tricyclic antidepressants.
Treatment with hydration and increased fiber is always a good option. You
may consider prescribing a bowel regimen with Senokot and docusate.
Dumping Syndrome
Dumping syndrome is a relatively rare disorder related to prior gastric sur-
gery, usually done for ulcer disease. Treatment and eradication of Helicobacter
pylori has made surgery for ulcer disease rare.
The patient presents with shaking, sweating, and weakness.

Basic Science Correlate

Dumping syndrome may involve hypotension. There are 2 causes. One is

the rapid release of the gastric contents into the duodenum, which causes
an osmotic draw into the bowel. The other is a rapid rise in blood glucose
resulting in a reactive hypoglycemia.

Dumping syndrome is managed with frequent small meals.

Necrotic Pancreatitis
Diagnostic Testing
In the past, Ranson’s criteria were the major method of determining the sever-
ity of pancreatitis. Ranson’s criteria are operative criteria to see who needs
pancreatic debridement. The CT scan effectively replaces Ranson’s criteria as
the most precise method of determining severity.

Treatment
When the CT shows > 30 percent necrosis of the pancreas, the patient should
· receive antibiotics such as imipenem; and
· undergo CT-guided biopsy.
If the biopsy shows infected, necrotic pancreatitis, the patient should have
surgical debridement of the pancreas.