316 Emergency Medicine
It occurs in approximately 7% of patients, and is the second most common
serious complication of PUD. (c)GI penetration is similar to perforation,
except the ulcer erodes into another organ, such as the liver or pancreas.
(d)Gastric outlet obstruction, which occurs in 2% of patients, occurs as a
result of edema and scarring near the gastric outlet. (e)Pernicious anemia
results from an autoimmune disease in which the body develops antibodies
to the acid-secreting cells in the gastric mucosa with ensuing loss of intrinsic
factor, vitamin B12 malabsorption, and the development of anemia. It is not
a complication of PUD.
291.The answer is c.(Tintinalli, p 496.)The complaint of abdominal
pain in the elderly patient should prompt the emergency physician to
lower his or her threshold for considering more serious intra-abdominal
conditions. Patients with a history of arrhythmias (especially atrial fibrillation),
low cardiac output (such as congestive heart failure), or who take particular
medications, such as digoxin, are at high risk for the elusive condition of
mesenteric ischemia.A history of sudden onset abdominal pain with
increasing severity, but with a benign physical examination should prompt
consideration of this entity. Mesenteric ischemia is associated with a high
mortality rate, and initial diagnosis is often incorrect. The diagnostic study
of choice is angiography.
(a)Cholecystitis is the most common surgical emergency in elderly
patients, but patients often localize pain to the RUQ. Ultrasonography is
the initial diagnostic study of choice. (b)Sigmoid volvulus is two to three
times more common than cecal volvulus among the elderly and presents
with gradually increasing abdominal pain, along with nausea and vomiting.
(d)Perforated peptic ulcer often presents with acute onset epigastric pain
followed by peritonitis and GI bleeding, and can be a similarly challenging
condition to diagnose in elderly patients, who may lack dramatic pain or
impressive peritoneal findings. The diagnostic study of choice is CT scan,
although an upright chest or abdominal radiograph, which may show free
air under the diaphragm, should be obtained immediately if the diagnosis
is suspected. (e)Small bowel obstruction may also present with gradually
increasing abdominal pain, nausea, and vomiting. It is not associated with the
comorbid conditions listed, but rather with adhesions following abdominal
surgery, incarcerated groin hernia, polyps, lymphomas, adenocarcinoma,
abdominal abscess, and radiation therapy.