Rosen & Barkin's 5-Minute Emergency Medicine Consult (522 page)

959.13 Fracture of corpus cavernosum penis

BASICS

• Produced by breakdown in gastric or duodenal mucosal defenses
  
• Imbalance exists between production of acid and ability of mucosa to prevent damage.
  

• Helicobacter pylori
  :
  
  • Gram-negative spiral bacteria that live in mucous layer
    
  • Responsible for 90–95% of duodenal ulcers and 80% of gastric ulcers
    
  • Increases antral gastrin production and decreases mucosal integrity
    
• NSAIDs:
  
  • Interfere with prostaglandin synthesis
    
  • Lead to break in mucosa
    
• Aspirin
  
• Cigarette smoking
  
• Alcohol
  
• Severe physiologic stress
  
• Hypersecretory states (uncommon)
  
• Genetics (>20% have family history)
  

DIAGNOSIS

• Epigastric pain or tenderness (80–90%):
  
  • Burning, gnawing, aching pain
    
  • Location: midline, xiphoid, or umbilicus
    
• Duodenal ulcers:
  
  • Pain occurs 90 min -- 3 hr after meals
    
  • Usually awakens patient at night
    
  • Food and antacids relieve pain
    
• Gastric ulcers:
  
  • Pain worsens after meals
    
  • Nausea and anorexia
    
• Difficult to differentiate clinically between gastric and duodenal ulcers
  
• Relief of pain with antacids
  
• Heme-positive stools
  
• Complications of peptic ulcer disease (PUD):
  
  • Acute perforation:
    
    • Rigid, boardlike abdomen
      
    • Generalized rebound tenderness
      
    • Pain radiation to back or shoulder
      
  • Obstruction:
    
    • Pain with vomiting
      
    • Succussion splash from retained gastric contents and abdominal distention
      
  • Hemorrhage:
    
    • Hematemesis
      
    • Melena
      
    • Hypotension
      
    • Tachycardia
      
    • Skin pallor
      
    • Orthostatic changes
      

• NSAID, Aspirin
  
• Smoking
  
• Previous history of PUD
  
• Family history of stomach cancer
  
• Abdominal pain
  
• Diarrhea
  
• Weakness
  

• Abdominal pain
  
• Signs of anemia
  
• Guaiac-positive stool
  

• Careful physical exam including Hemoccult testing and vital signs with orthostatics
  
• For stable patients, oral GI cocktail typically relieves pain:
  
  • Antacid: 30 mL
    
  • Viscous lidocaine: 10 mL
    

• Normal lab values in uncomplicated ulcer disease
  
• CBC:
  
  • Low hematocrit with bleeding
    
  • Leukocytosis with perforation/penetration
    
• Amylase/lipase:
  
  • Elevated with perforation/penetration
    
  • Pancreatitis in differential diagnosis
    
• Electrolytes, BUN/creatinine, glucose for critically ill
  
• Type and cross-match for significant blood loss
  
• H. pylori
  testing (urea breath test,
  H. pylori
  antibodies, IgG)
  

• Chest radiograph/abdominal series:
  
  • Evaluate for perforations/obstructions
    

• ECG:
  
  • For elderly patients
    
  • Myocardial ischemia in differential diagnosis
    
• Endoscopy:
  
  • Procedure of choice
    
  • Outpatient unless significant hemorrhage
    
  • Allows for biopsies of gastric/duodenal ulcers for presence of
    H. pylori
    
  • Detects malignant gastric ulcers
    
• Upper GI series:
  
  • Single contrast barium diagnoses 70–80%
    
  • Double contrast diagnoses 90%
    
• Gastrin level is elevated in Zollinger–Ellison syndrome
  

• Gastroesophageal reflux
  
• Biliary colic
  
• Cholecystitis
  
• Pancreatitis
  
• Gastritis
  
• Abdominal aortic aneurysm
  
• Aortic dissection
  
• Myocardial infarction
  
• Subset with symptoms and no ulcer on endoscopy called
  nonulcer dyspepsia
  

TREATMENT

• ABCs
  
• IV fluid resuscitation for hypotensive/shock patients
  

• ABCs
  
• Identify ulcer complications (hemorrhage, perforation, obstruction)
  
• Treat hypotension with lactated Ringer/normal saline fluid bolus via 2 large-bore IVs
  
• Type and cross early
  
• Nasogastric tube (NGT) for gastric decompression/check for hemorrhage
  

• Pain control with antacids (GI cocktail) or IV H
  ₂
  antagonists
  
• Avoid narcotics—may mask serious illness.
  
• Promotion of ulcer healing:
  
  • Antacids
    
  • H
    ₂
    antagonists (cimetidine, famotidine, ranitidine, nizatidine):
    
    • May continue for 2–5 yr for ulcer suppression therapy
      
  • Proton-pump inhibitors (PPIs; omeprazole, lansoprazole, or pantoprazole):
    
    • If H
      ₂
      antagonists have failed
      
  • Sucralfate
    
  • Prostaglandin congeners (misoprostol)
    
  • Sucralfate, H
    ₂
    -receptor antagonists, and PPIs should not be combined because of lack of documented benefit
    
• Gastric outlet obstruction:
  
  • Decompress stomach with NGT
    
  • IV hydration
    
• Gastric hemorrhage:
  
  • IV fluid resuscitation
    
  • Blood transfusion depending on loss/hematocrit
    
  • Foley catheter to monitor volume status
    
  • GI consultation
    
• Perforation:
  
  • IV hydration
    
  • Foley catheter to monitor hydration status
    
  • Preoperative antibiotics
    
  • Emergency surgical consultation
    
• Treatment of
  H. pylori
  infection:
  
  • Invasive or noninvasive testing to confirm infection
    
  • Oral eradication antibiotic therapy options:
    
    • PPI (omeprazole 20 mg BID or lansoprazole 30 mg PO BID) and 2 antibiotics (clarithromycin 500 mg BID + metronidazole 500 mg BID) for 14 days
      
    • H
      ₂
      blocker, bismuth subsalicylate (Pepto-Bismol) + either amoxicillin 1,000 mg BID or tetracycline 500 mg QID in combination with either metronidazole 250 mg QID or clarithromycin 500 mg BID for 14 days
      
    • Most common regimen: Omeprazole 20 mg or lansoprazole 30 mg + clarithromycin 500 mg and amoxicillin 1 g, all taken twice a day for 2 wk
      
• Stop NSAIDs
  
• Surgical therapy:
  
  • Refractory ulcer
    
  • Complications:
    
    • Bleeding
      
    • Perforation
      
    • Pyloric stenosis
      

• Bismuth subsalicylate: 2 525 mg tabs PO
  
• Maalox Plus: 2–4 tabs PO QID
  
• Misoprostol: 100–200 mg PO QID
  
• Mylanta II: 2–4 tabs PO QID
  
• Sucralfate: 1 g PO QID for 6–8 wk
  
• Famotidine (H
  ₂
  blocker): 40 mg PO nightly at bedtime (peds: 0.5–0.6 mg/kg q12h) for 6–8 wk
  
• Nizatidine (H
  ₂
  blocker): 300 mg PO nightly at bedtime for 6–8 wk; 20 mg PO BID (peds: 0.6–0.7 mg/kg q12–24h) for 2 wk
  
• Ranitidine (H
  ₂
  blocker): 300 mg PO nightly at bedtime (peds: 5–10 mg/kg/24h given q12h) for 6–8 wk
  
• Cimetidine (H
  ₂
  blocker): 400 mg PO BID for 6–8 wk
  
• Lansoprazole (PPI): 30 mg PO BID for 2 wk
  
• Pantoprazole (PPI): 40 mg PO daily for 2 wk
  
• Omeprazole (PPI): 20 mg PO BID for 2 wk
  
• Rabeprazole (PPI): 20 mg PO daily for 6 wk
  
• Esomeprazole (PPI): 40 mg daily for 4 wk
  
• H. pylori
  therapy:
  
  • PPI (omeprazole 20 mg or lansoprazole 30 mg), clarithromycin 500 mg BID for 2 wk, amoxicillin 1 g BID for 2 wk
    
  • For penicillin-allergic patients: PPI + clarithromycin 500 mg BID + metronidazole 500 mg BID for 14 days
    
  • 4-drug therapy: H
    ₂
    blocker, bismuth subsalicylate (Pepto-Bismol) + either amoxicillin 1,000 mg BID or tetracycline 500 mg QID in combination with either metronidazole 250 mg QID or clarithromycin 500 mg BID for 14 days
    

H. pylori
eradication regimes:

• PPI (omeprazole 20 mg or lansoprazole 30 mg), clarithromycin 500 mg BID for 2 wk, amoxicillin 1 g BID for 2 wk
  
• For penicillin-allergic patients: PPI + clarithromycin 500 mg BID + metronidazole 500 mg BID for 14 days
  
• Sequential 10 day therapy in high prevalence areas:
  
  • Double therapy for 5 days
    
    • PPI
      
    • Amoxicillin
      
  • Followed by triple therapy for 5 days
    
    • PPI
      
    • Clarithromycin
      
    • Metronidazole
      
• 4-drug therapy: H
  ₂
  blocker, bismuth subsalicylate (Pepto-Bismol) + either amoxicillin 1,000 mg BID or tetracycline 500 mg QID in combination with either metronidazole 250 mg QID or clarithromycin 500 mg BID for 14 days