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COMAT: Surgery > Upper GI Bleeding > Flashcards

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, guiac-positive stools

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3
Q

why is it possible to have hematochezia?

A

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

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4
Q

what is the most common cause of significant UGI bleeding?

A

PUD - duodenal and gastric ulcers

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5
Q

what is the common differential diagnosis of UGI bleeding?

A
  • acute gastritis
  • duodenal ulcer
  • esophageal varices
  • gastric ulcer
  • esophageal
  • Mallory-Weiss tear
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6
Q

what is the diagnostic test of choice for UGI bleeding?

A

EGD

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7
Q

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

A

coagulation, injection of epinephrine, injection of sclerosis agents, vatical ligation

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8
Q

why is BUN elevated in UGI bleeding?

A

because of absorption of blood by the GI tract

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9
Q

what are the risk factors for death following UGI bleed?

A

age >60
shock
>5 units of PRBC transfusion
concomitant health problems

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10
Q

what is PUD?

A

gastric and duodenal ulcers

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11
Q

what are the possible consequences of PUD?

A

pain, hemorrhage, perforation, obstruction

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12
Q

which bacteria are associated with PUD?

A

Helicobacter pylori

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13
Q

what is the treatment for H. pylori?

A

treat H. pylori with MOC or ACO 2wk antibiotic regimens

  • MOC: metronidazole, Omeprazole, Clarithromycin
  • ACO: ampicillin, Clarithromycin, Omeprazole
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14
Q

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

A

Valentino’s sign

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15
Q

what is the most common location of a duodenal ulcer?

A

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

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16
Q

what is the classic pain response to food intake with a duodenal ulcer?

A

food classically relieves duodenal ulcer pain

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17
Q

what is the cause of a duodenal ulcer?

A

increased production of gastric acid

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18
Q

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

A

Zollinger-Ellison syndrome

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19
Q

what are the major symptoms of duodenal ulcer?

A

epigastric pain

bleeding

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20
Q

what are the signs of duodenal ulcer?

A

tenderness in epigastric area (possibly), guaiac-positive stool, melon, hematochezia, hematemesis

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21
Q

what is the differential diagnosis of duodenal ulcer?

A

acute abdomen, pancreatitis, cholecystitis, all causes of UGI bleeding, ZES, gastritis, MI, gastric ulcer, reflux

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22
Q

when is surgery indicated for duodenal ulcer?

A

I HOP

  • intractibility
  • hemorrhage
  • obstruction
  • perforation
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23
Q

what artery is involved with bleeding duodenal ulcers?

A

gastroduodenal artery

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24
Q

what are the common surgical options for truncal vagotomy?

A

pyloroplasty

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25
Q

what are the common surgical options for duodenal perforation?

A

graham patch
truncal vagotomy an d pyloroplasty incorporating ulcer
graham patch and highly selective vagotomy
truncal vagotomy and antrectomy

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26
Q

what are the common surgical options for duodenal ulcer intractability?

A

PGV

vagotomy and pyloroplasty

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27
Q

which is more common overall: gastric or duodenal ulcers?

A

duodenal ulcers are more than twice as common as gastric ulcers

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28
Q

what is the classic pain response to food?

A

food classically increases gastric ulcer pain

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29
Q

what is the cause of a gastric ulcer?

A

decreased cytoprotection or gastric protection (decreased bicarbonate/mucous production)

30
Q

is gastric acid production high or low in gastric ulcers?

A

gastric acid production is normal or low

31
Q

what are the associated risk factors for gastric ulcers?

A

smoking, alcohol, burns, trauma, CNS tumor/trauma, NSAIDs, steroids, shock, severe illness, male gender, advanced age

32
Q

what are the symptoms of gastric ulcers?

A

epigastric pain +/- vomiting, anorexia, and nausea

33
Q

how is the diagnosis made for gastric ulcers?

A

history, PE, EGD with multiple biopsoies

34
Q

what is the most common location of a gastric ulcer?

A

lesser curvature

35
Q

when and why should biopsy of a gastric ulcer be performed?

A

with all gastric ulcers to rule out gastric cancer

- if the ulcer does not heal in 6wks after medical treatment, rebiopsy

36
Q

what is the medical treatment for gastric ulcers?

A

similar to that of duodenal ulcer - PPIs or H2 blockers, H.pylori tx

37
Q

what are the indications for surgery for gastric ulcers?

A

I CHOP

  • intractability
  • cancer (rule out)
  • hemorrhage
  • obstruction
  • perforation
38
Q

what is the common operation for hemorrhage, obstruction, and perforation of gastric ulcers

A

distal gastrectomy with excision of the ulcer without vagotomy

39
Q

what are the symptoms of a perforated peptic ulcer?

A

acute onset of upper abdominal pain

40
Q

what is the differential diagnosis for a perforated peptic ulcer?

A

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

41
Q

what type of perforated ulcer may present like acute pancreatitis?

A

posterior perforated duodenal ulcer into the pancreas

- epigastric pain radiating to the back; high serum amylase

42
Q

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

A 
duodenal = decreased pain
gastric = increased pain
43
Q

what is stress gastritis?

A

superficial mucosal erosions in the stressed patient

44
Q

what are the risk factors for stress gastritis?

A

sepsis, intubation, trauma, shock, burn, brain injury

45
Q

what is the prophylactic treatment of stress gastritis?

A

H2 blockers, PPIs, antacids, sucralfate

46
Q

what are the signs/symptoms of stress gastritis?

A

NGT blood, painless

47
Q

what is the treatment of gastritis?

A

lavage out blood clots, give a maximum dose of PPI in a 24hr IV drip

48
Q

what is Mallory-Weiss syndrome?

A

postretching, postemesis longitudinal tear (submucosa and mucosa) of the stomach near the GE junction
- approximately 3/4 are in the stomach

49
Q

what are the causes of a Mallory-Weiss tear?

A

increased gastric pressure, often aggravated by hiatal hernia

50
Q

what are the risk factors for Mallory-Weiss?

A

retching, alcoholism, >50% of patients have hiatal hernia

51
Q

what are the symptoms of Mallory-Weiss?

A

epigastric pain, thoracic substernal pain, emesis, hematemesis

52
Q

what is the ‘classic’ history of Mallory-Weiss?

A

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

53
Q

what is the treatment of Mallory-Weiss?

A

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

54
Q

when is surgery indicated for Mallory-Weiss?

A

when medical/endoscopic treatment fails

55
Q

what is esophageal variceal bleeding?

A

bleeding from formation of esophageal varies from back up of portal pressure via the coronary vein to the submucosal esophageal venous plexuses secondary to portal hypertension from liver cirrhosis

56
Q

what is the ‘rule of 2/3s’ of esophageal variceal hemorrhage?

A

2/3s of the patients with portal hypertension develop esophageal varices
2/3s of patients with esophageal varices bleed

57
Q

what are the signs/symptoms of esophageal variceal bleeding?

A

liver disease, portal hypertension, hematemesis, caput medusa, ascites

58
Q

how is diagnosis of esophageal variceal bleeding made?

A

EGD (very important because only 50% of UGI bleeding in patients with known esophageal varices are bleeding from the varices)

59
Q

what is the acute medical treatment of esophageal variceal bleeding?

A

lower portal pressure with octreotide or vasopressin

60
Q

what are the treatment options of esophageal variceal bleeding?

A

sclerotherapy or band ligation via endoscope, TIPS, liver transplant

61
Q

what is the problem with shunts for esophageal variceal bleeding?

A

decreased portal pressure, but increased encephalopathy

62
Q

what is Boerhaave’s syndrome?

A

post emetic esophageal rupture

63
Q

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

A

no serosa

64
Q

what is the most common location of Boerhaave’s syndrome?

A

posterolateral aspect of the esophagus, 3-5cm above the GE junction

65
Q

what is the cause of rupture in Boerhaave’s syndrome?

A

increased intraluminal pressure, usually caused by violent retching and vomiting

66
Q

what are the associated risk factors for Boerhaave’s syndrome?

A

esophageal reflux disease

67
Q

what are the symptoms of Boerhaave’s syndrome?

A

pain postemesis (may radiate to the back, dysphagia)

68
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 24hrs, neck crepitus, widened mediastinum on cxr

69
Q

what is Mackler’s triad?

A
  • emesis
  • lower chest pain
  • cervical emphysema (subQ air)
70
Q

What is Hamman’s sign?

A

mediastinal crunch or clicking produced by the heart beating against air-filled tissue

71
Q

what is the treatment of Boerhaave’s syndrome?

A

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

72
Q

overall, what is the most common cause of esophageal perforation?

A

iatrogenic

COMAT: Surgery (17 decks)

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