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Upper GI Bleeding Flashcards

1
Q

What is upper GI bleeding?

A

Bleeding into the lumen of the proximal GI tract, proximal to the ligament of Treitz

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2
Q

What are the signs and symptoms of upper GI bleeding?

A

Hematemesis, melena, syncope, shock, fatigue, coffee-ground emesis, hematochezia, epigastric discomfort, epigastric tenderness, signs of hypovolemia, guaiac-positive stools

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3
Q

Why is it possible to have hematochezia with upper GI bleeding?

A

Blood is a cathartic and hematochezia usually indicates a vigorous rate of bleeding from the UGI source

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4
Q

Are stools melenic or melanotic?

A

Melenic

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5
Q

How much blood do you need to have melena?

A

> 50 cc

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6
Q

What are the risk factors for upper GI bleeding?

A

Alcohol, smoking, liver disease, burns, trauma, NSAIDs, vomiting, sepsis, steroids, previous UGI bleed, PUD, esophageal varices, portal hypertension, splenic vein thrombosis, AAA repair

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7
Q

What is the most common cause of significant upper GI bleeding?

A

PUD

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8
Q

What is the common differential diagnosis of upper GI bleeding?

A
  1. Acute gastritis
  2. DU
  3. Esophageal varices
  4. GU
  5. Esophageal
  6. Mallory-Weiss tear
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9
Q

What is the uncommon differential diagnosis of upper GI bleeding?

A

Gastric cancer, hemobilia, duodenal diverticula, gastric volvulus, Boerhaave’s syndrome, aortoenteric fistula, paraesophageal hiatal hernia, epistaxis, NGT irritation, Dieulafoy’s ulcer, angiodysplasia

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10
Q

Which diagnostic tests are useful for upper GI bleeding?

A

History, NGT aspirate, AXR, EGD

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11
Q

What is the diagnostic test of choice with upper GI bleeding?

A

EGD

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12
Q

What are the treatment options with the endoscope during an EGD?

A

Coagulation, injection of epinephrine, injection of sclerosing agents, variceal ligation

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13
Q

Which lab tests should be performed for upper GI bleeding?

A

BMP, bilirubin, LFTs, CBC, T&C, PT/PTT, amylase

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14
Q

Why is BUN elevated with upper GI bleeding?

A

Because of absorption of blood by the GI tract

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15
Q

What is the initial treatment for upper GI bleeding?

A

IVFs, Foley, NGT suction (determine rate), water lavage (remove clots), EGD

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16
Q

Why irrigate in an upper GI bleed?

A

To remove the blood clot so you can see the mucosa

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17
Q

What test may help identify the site of massive upper GI bleeding when EGD fails to diagnose cause and blood continues per NGT?

A

Selective mesenteric angiography

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18
Q

What are the indications for surgical intervention in upper GI bleeding?

A

Refractory or recurrent bleeding and site known; > 3u PRBCs to stabilize or > 6u PRBCs overall

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19
Q

What percentage of patients with upper GI bleeding require surgery?

A

10%

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20
Q

What percentage of patients with upper GI bleeding spontaneously stop bleeding?

A

80-85%

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21
Q

What is the mortality of acute upper GI bleeding?

A

Overall 10%

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22
Q

What are the risk factors for death following an upper GI bleed?

A

Age older than 60; shock; > 5u PRBC transfusion; concomitant health problems

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23
Q

What is PUD?

A

Peptic Ulcer Disease

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24
Q

What is the incidence of PUD in the US?

A

10%

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25
Q

What are the possible consequences of PUD?

A

Pain, hemorrhage, perforation, obstruction

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26
Q

What percentage of patients with PUD develops bleeding from the ulcer?

A

20%

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27
Q

Which bacteria are associated with PUD?

A

H. pylori

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28
Q

What is the treatment for H. pylori infection?

A

2-week regimen of either:
MOC: Metronidazole, Omeprazole, Clarithromycin
ACO: Ampicillin, Clarithromycin, Omeprazole

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29
Q

What is the name of the sign with RLQ pain/peritonitis as a result of succus collecting from a perforated peptic ulcer?

A

Valentino’s sign

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30
Q

In which age group are duodenal ulcers most common?

A

40-65 years

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31
Q

What is the male:female ratio for duodenal ulcers?

A

3:1

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32
Q

What is the most common location for duodenal ulcers?

A

Most are within 2 cm of the pylorus in the duodenal bulb

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33
Q

What is the classic pain response to food intake with duodenal ulcers?

A

Food classically relieves duodenal ulcer pain

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34
Q

What is the cause of duodenal ulcers?

A

Increased production of gastric acid

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35
Q

What syndrome must you always think of with a duodenal ulcer?

A

Zollinger-Ellison syndrome

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36
Q

What are the risk factors for duodenal ulcers?

A

Male, smoking, NSAIDs, uremia, ZES, H. pylori, trauma, burns

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37
Q

What are the symptoms of duodenal ulcers?

A

Epigastric pain (burning, aching, usually several hours postprandial), bleeding, back pain, N/V, anorexia

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38
Q

What are the signs of duodenal ulcers?

A

Tenderness in the epigastric area, guaiac-positive stool, melena, hematochezia, hematemesis

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39
Q

What is the differential diagnosis of duodenal ulcers?

A

Acute abdomen, pancreatitis, cholecystitis, ZES, gastritis, MI, GU, reflux

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40
Q

How is the diagnosis of duodenal ulcer made?

A

H&P, EGD, UGI series

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41
Q

When is surgery indicated with a bleeding duodenal ulcer?

A

> 6 u PRBC overall; > 3 u PRBC to stabilize; significant rebleed

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42
Q

What EGD finding is associated with rebreeding of a duodenal ulcer?

A

Visible vessel in the ulcer crater, recent clot, active oozing

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43
Q

What is the medical treatment of duodenal ulcers?

A

PPIs or H2 receptor antagonists; treat H. pylori

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44
Q

When is surgery indicated for a duodenal ulcer?

A 
I HOP:
Intractability
Hemorrhage
Obstruction
Perforation
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45
Q

How is a bleeding duodenal ulcer surgically corrected?

A

Opening of the duodenum through the pylorus and oversewing of the bleeding vessel

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46
Q

What artery is involved with bleeding duodenal ulcers?

A

Gastroduodenal artery

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47
Q

What are the common surgical options for duodenal perforation?

A

Graham patch;
Truncal vagotomy and pyloroplasty incorporating ulcer;
Graham patch and highly selective vagotomy;
Truncal vagotomy and antrectomy

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48
Q

What are the common surgical options for duodenal obstruction resulting from duodenal ulcer scarring?

A

Truncal vagotomy, antrectomy, and gastroduodenostomy;

Truncal vagotomy and drainage procedure (gastrojejunostomy)

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49
Q

What are the common surgical options for duodenal ulcer intractability?

A

PGV (highly selective vagotomy);
Vagotomy and pyloroplasty
Vagotomy and antrectomy BI or BII

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50
Q

Which ulcer operation has the highest ulcer recurrence rate and the lowest dumping syndrome rate?

A

PGV (proximal gastric vagotomy)

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51
Q

Which ulcer operation has the lowest ulcer recurrence rate and the highest dumping syndrome rate?

A

Vagotomy and antrectomy

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52
Q

Why must you perform a drainage procedure (e.g. pyloroplasty, antrectomy) after a truncal vagotomy?

A

Pylorus will not open after a truncal vagotomy

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53
Q

Which duodenal ulcer operation has the lowest mortality rate?

A

PGV

54
Q

What is a “kissing” ulcer?

A

Two ulcers, each on opposite sides of the lumen

55
Q

Why may a duodenal rupture be initially painless?

A

Fluid can be sterile, with a non-irritating pH of 7.0 initially

56
Q

Why may a perforated duodenal ulcer present as lower quadrant abdominal pain?

A

Fluid from stomach/bile drains down paracolic gutters to lower quadrants and causes local irritation

57
Q

In which age group are gastric ulcers most common?

A

40-70 years

58
Q

Which is more common overall: gastric or duodenal ulcers?

A

Duodenal (> 2 fold)

59
Q

What is the classic pain response to food with gastric ulcers?

A

Food classically increases gastric ulcer pain

60
Q

What is the cause of gastric ulcers?

A

Decreased cytoprotection or gastric protection (i.e. decreased bicarbonate or mucous production)

61
Q

Is gastric acid production high or low with gastric ulcers?

A

Normal or low.

62
Q

Which gastric ulcers are associated with increased gastric acid?

A

Prepyloric and pyloric

63
Q

What are the associated risk factors for gastric ulcers?

A

Smoking, alcohol, burns, trauma, CNS tumor, NSAIDs, steroids, shock, severe illness, male, advanced age

64
Q

What are the symptoms of gastric ulcers?

A

Epigastric pain, +/- N/V, anorexia

65
Q

How is the diagnosis of gastric ulcer made?

A

H&P, EGD with multiple biopsy

66
Q

What is the most common location for gastric ulcers?

A

Lesser curvature

67
Q

When and why should biopsy be performed for a gastric ulcer?

A

To rule out gastric cancer; If ulcer does not heal in 6 weeks after medical treatment, another biopsy must be performed

68
Q

What is the medical treatment for gastric ulcers?

A

PPIs or H2 blockers, treatment of H. pylori

69
Q

When do patients with gastric ulcers need to have an EGD?

A

For diagnosis with biopsies; 6 weeks post-diagnosis to confirm healing and rule out gastric cancer

70
Q

What are the indications for surgery for gastric ulcers?

A 
I CHOP
Intractability
Cancer (rule out)
Hemorrhage
Obstruction
Perforation
71
Q

What is the common operation for hemorrhage, obstruction and perforation secondary to gastric ulcers?

A

Distal gastrectomy with excision of the ulcer without vagotomy unless there is duodenal disease

72
Q

What are the options for concomitant duodenal and gastric ulcers?

A

Resect (BI, BII) and truncal vagotomy

73
Q

What is a common option for surgical treatment of a pyloric gastric ulcer?

A

Truncal vagotomy and antrectomy (BI or BII)

74
Q

What is a common option for a poor operative candidate with a perforated gastric ulcer?

A

Graham patch

75
Q

What must be performed in every operation for gastric ulcers?

A

Biopsy looking for gastric cancer

76
Q

What is Cushing’s ulcer?

A

PUD/gastritis associated with neurologic trauma or tumor

77
Q

What is Curling’s ulcer?

A

PUD/gastritis associated with major burn injury

78
Q

What is a marginal ulcer?

A

Ulcer at the margin of a GI anastamosis

79
Q

What is Dieulafoy’s ulcer?

A

Pinpoint gastric mucosal defect bleeding from an underlying vascular malformation

80
Q

What are the symptoms of a perforated peptic ulcer?

A

Acute onset of upper abdominal pain

81
Q

What causes pain in the lower quadrants with a perforated peptic ulcer?

A

Passage of perforated fluid along colic gutters

82
Q

What are the signs of a perforated peptic ulcer?

A

Decreased bowel sounds, tympanic sound over liver (air), peritoneal signs, tender abdomen

83
Q

What are the signs of posterior duodenal perforation?

A

Bleeding from the gastroduodenal artery (and possibly acute pancreatitis)

84
Q

What sign indicates anterior duodenal perforation?

A

Free air

85
Q

What is the differential diagnosis of perforated peptic ulcer?

A

Acute pancreatitis, acute cholecystitis, perforated acute appendicitis, colonic diverticulitis, MI, any perforated viscus

86
Q

Which diagnostic tests are indicated for a perforated peptic ulcer?

A

XR: free air under diaphragm or in lesser sac in an upright CXR

87
Q

What are the associated lab findings with a perforated peptic ulcer?

A

Leukocytosis, high serum amylase (secondary to absorption into the blood stream from the peritoneum)

88
Q

What is the initial treatment for a perforated peptic ulcer?

A

NPO; NGT; IVF; Foley; antibiotics; PPIs; surgery

89
Q

What is a Graham patch?

A

Piece of omentum incorporated into the suture closure of perforation

90
Q

What are the surgical options for treatment of perforated gastric ulcers?

A

Antrectomy incorporating perforated ulcer;

Graham patch or wedge resection in unstable or poor operative candidates

91
Q

What is the significance of hemorrhage and perforation with duodenal ulcers?

A

May indicate kissing ulcers; posterior is bleeding and anterior is perforated

92
Q

What type of perforated ulcer may present just like acute pancreatitis?

A

Posterior perforated duodenal ulcer into the pancreas

93
Q

What is the classic difference between duodenal and gastric ulcer symptoms as related to food ingestion?

A 
Duodenal = decreased pain
Gastric = increased pain
94
Q

What is a truncal vagotomy?

A

Resection of a 1-2 cm segment of each vagal trunk as it enters the abdomen on the distal esophagus, decreasing gastric acid secretion

95
Q

What other procedure must be performed along with a truncal vagotomy?

A

Drainage procedure (e.g. pyloroplasty, antrectomy, or gastrojejunostomy)

96
Q

What is a vagotomy and antrectomy?

A

Remove antrum and pylorus in addition to vagotomy; reconstruct as a Billroth I or II

97
Q

What is the goal of duodenal ulcer surgery?

A

Decrease gastric acid secretion (and fix IHOP)

98
Q

What is the advantage of proximal gastric vagotomy?

A

No drainage procedure is needed (vagal fibers to the pylorus are preserved)

99
Q

What is a Billroth I?

A

Truncal vagotomy, antrectomy, and gastroduodenostomy

100
Q

What are the contraindications for a Billroth I?

A

Gastric cancer or suspicion of gastric cancer

101
Q

What is a Billroth II?

A

Truncal vagotomy, antrectomy, and gastrojejunostomy

102
Q

What is the Kocher maneuver?

A

Dissect the left lateral peritoneal attachments to the duodenum to allow visualization of posterior duodenum

103
Q

What is stress gastritis?

A

Superficial mucosal erosions in the stressed patient

104
Q

What are the risk factors for stress gastritis?

A

Sepsis, intubation, trauma, shock, burn, brain injury

105
Q

What is the prophylactic treatment for stress gastritis?

A

H2 blockers, PPIs, antacids, sucralfate

106
Q

What are the signs and symptoms of stress gastritis?

A

NGT blood (usually), painless (usually)

107
Q

How is stress gastritis diagnosed?

A

EGD, if bleeding is significant

108
Q

What is the treatment for stress gastritis?

A

Lavage out blood clots, give a maximum dose of PPI in a 24-hour IV drip

109
Q

What is Mallory-Weiss syndrome?

A

Post-retching, post-emesis longitudinal tear (submucosa and mucosa) of the stomach near the GE junction; approximately 75% are in the stomach

110
Q

For what percentage of all upper GI bleeds does Mallory-Weiss syndrome account?

A

10%

111
Q

What are the causes of a Mallory-Weiss tear?

A

Increased gastric pressure, often aggravated by hiatal hernia

112
Q

What are the risk factors for Mallory-Weiss syndrome?

A

Retching, alcoholism, hiatal hernia

113
Q

What are the symptoms of Mallory-Weiss syndrome?

A

Epigastric pain, thoracic substernal pain, emesis, hematemesis

114
Q

What percentage of patients with Mallory-Weiss syndrome will have hematemesis?

A

85%

115
Q

How is the diagnosis of Mallory-Weiss syndrome made?

A

EGD

116
Q

What is the classic history of Mallory-Weiss syndrome?

A

Alcoholic patient after binge drinking: first, vomit food and gastric contents, followed by forceful retching and bloody vomitus

117
Q

What is the treatment for Mallory-Weiss syndrome?

A

Room temperature water lavage, electrocautery, arterial embolization, or surgery for refractory bleeding

118
Q

When is surgery indicated for Mallory-Weiss syndrome?

A

When medical/endoscopic treatment fails

119
Q

Can the Senstaken-Blakemore tamponade balloon be used for treatment of Mallory-Weiss syndrome?

A

No, it makes bleeding worse

120
Q

What is the problem with using shunts to treat portal hypertension?

A

Decreased portal pressure, but increased encephalopathy

121
Q

What is Boerhaave’s syndrome?

A

Post-emetic esophageal rupture

122
Q

Why is the esophagus susceptible to perforation and more likely to break down an anastomosis?

A

No serosa

123
Q

What is the most common location of a Boerhaave tear?

A

Posterolateral aspect of the esophagus (on the left), 3-5 cm above the GE junction

124
Q

What is the cause of Boerhaave’s syndrome?

A

Increased intraluminal pressure, usually caused by violent retching and vomiting

125
Q

What is the associated risk factor for Boerhaave’s syndrome?

A

GERD

126
Q

What are the symptoms of Boerhaave’s syndrome?

A

Pain post-emesis (may radiate to back)

127
Q

What are the signs of Boerhaave’s syndrome?

A

Left pneumothorax, Hamman’s sign, left pleural effusion, subcutaneous/mediastinal emphysema, fever, tachypnea, tachycardia, signs of infection by 24 hours, neck crepitus, widened mediastinum on CXR

128
Q

What is Mackler’s triad?

A
  1. Emesis
  2. Lower chest pain
  3. Cervical emphysema
129
Q

What is Hamman’s sign?

A

Mediastinal crunch or clicking produced by the heart beating against air-filled tissues

130
Q

How is the diagnosis of Boerhaave’s syndrome made?

A

H&P, CXR, esophagram with water-soluble contrast

131
Q

What is the treatment for Boerhaave’s syndrome?

A

Surgery within 24 hours to drain the mediastinum and surgically close the perforation and placement of pleural patch; broad-spectrum antibiotics

132
Q

What is the most common cause of esophageal perforation?

A

Iatrogenic

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