How do I manage a patient with a history of coronary artery bypass grafting (CABG) presenting with a jejunal ulcer?

Management of Jejunal Ulcer in a Patient with History of Coronary Artery Bypass Grafting

For a patient with history of coronary artery bypass grafting presenting with a jejunal ulcer, immediate surgical exploration with laparoscopic primary repair using suturing and omental patch is recommended as the definitive management approach.

Initial Assessment and Stabilization

• Assess hemodynamic stability immediately
• Evaluate for signs of peritonitis (rebound tenderness, guarding, rigidity)
• Check for signs of active bleeding (tachycardia, hypotension, melena, hematemesis)
• Obtain basic labs: CBC, comprehensive metabolic panel, coagulation studies

Diagnostic Approach

1. Endoscopic evaluation is the first-line approach in hemodynamically stable patients 1

   • Allows direct visualization of the ulcer
   • Provides opportunity for therapeutic intervention if bleeding
   • Permits biopsy to rule out malignancy

2. CT scan with IV contrast if endoscopy is inconclusive or unavailable

   • Evaluate for perforation, abscess, or other complications
   • Assess surrounding anatomy

Management Algorithm

For Non-Perforated Jejunal Ulcer:

1. Medical Management:

   • High-dose proton pump inhibitor (PPI) therapy
     • Use opened PPI capsules rather than intact capsules for faster healing 2
     • Opened PPI capsules reduce healing time significantly (91 days vs 342 days) 2
   • Continue PPI therapy for at least 90 days (rather than 30 days) to minimize risk of recurrence 3
   • Consider H. pylori testing and treat if positive

2. Endoscopic Management for bleeding:

   • Injection techniques and mechanical methods preferred over thermal techniques 1
   • Hemostatic powders may be useful for large bleeding areas 1
   • Avoid thermal techniques near anastomotic sites due to risk of ischemia

For Perforated Jejunal Ulcer:

1. Surgical Management:

   • Immediate surgical exploration for unstable patients or those with peritonitis 1
   • Laparoscopic primary repair with omental patch is the preferred approach for stable patients 1
   • Obtain biopsies of the ulceration to exclude malignancy 1

2. Post-Surgical Care:

   • Broad-spectrum antibiotics for 3-4 days 1
   • Early enteral nutrition when feasible
   • PPI therapy for at least 90 days 3

Special Considerations for CABG Patients

• Carefully manage antiplatelet/anticoagulation therapy:

  • Balance risk of bleeding versus thrombotic events
  • Consider cardiology consultation for antiplatelet management
  • Resume anticoagulation as soon as hemostasis is achieved

• Antibiotic prophylaxis:

  • Ensure appropriate endocarditis prophylaxis if indicated
  • Adjust antibiotic dosing based on weight and renal function 1

Pitfalls to Avoid

1. Delayed diagnosis - Jejunal ulcers may be asymptomatic even when severe 4

2. Inadequate PPI administration - Using intact capsules instead of opened capsules results in significantly longer healing times 2

3. Premature discontinuation of PPI therapy - 90-day therapy shows significantly lower ulcer rates than 30-day therapy (6.5% vs 12.4%) 3

4. Overlooking foreign bodies - Check for suture material or staples that may contribute to ulceration 4

5. Missing gastro-gastric fistulas - If present, these require additional surgical management beyond simple repair 1

Follow-up

• Repeat endoscopy every 3 months until complete ulcer healing is confirmed 2
• Continue PPI therapy until healing is documented
• Educate patient on avoiding NSAIDs, smoking, and other ulcerogenic factors
• Monitor for recurrence of symptoms

By following this algorithm, you can effectively manage jejunal ulcers in patients with history of CABG, minimizing complications and optimizing outcomes.