GI- Foregut and GI Bleed

Question 1

Define GERD. What causes it?

Answer 1

GERD is stomach acid refluxing into the esophagus.

Inappropriate, intermittent relaxation oath lower esophageal sphincter.
Hiatal hernia = greater incidence.

Question 2

Describe the classic symptoms of GERD.

Answer 2

“Heartburn” often related to lying supine after eating. Abdominal or chest pain.

Question 3

Tx GERD

Answer 3

Initial treatment: elevate the head of the bed & avoid coffee, alcohol, tobacco, spicy food, chocolate, and medications with anticholinergic properties.

Secondary: antiacids (H2 blockers, PPIs)
Lifestyle modifications usually fail. surgery is reserved for severe or resistant cases.
Surgery: Nissen, endocinch, scaring of LES

Question 4

What are the sequelae of GERD?

Answer 4

Esophagitis 
esophageal stricture (mimics cancer)
esophageal ulcer
hemorrhage 
barrett esophagus
esophageal adenocarcinoma

Question 5

How does a PUD present?

Answer 5

Chronic intermittent pain (burning, gnawing, or aching) 
Localized: epigastric
Relieved by antacids or milk
Epigastric tenderness
Occult blood 
N/V

cannot diagnose on clinical presentation

Question 6

Characteristics of Duodenal Ulcers

• main cause
• common
• acid section
• age
• blood type
• pain and food.

Answer 6

Duodenal ulcers

• Cause: H. Pylori
• 75% of cases
• Normal to high acid
• 40s
• Blood O
• pain improves with food and is worse 2-3 hours later

Question 7

Characteristics of Gastric Ulcers

• main cause
• common
• acid section
• age
• blood type
• pain and food.

Answer 7

Gastric Ulcers

• Cause: NSAIDs (including aspirin)
• 25% of cases
• Normal to low acid
• 50s
• Blood A
• Pain unchanged with food.

Question 8

Diagnostic study of choice for a PUD

Answer 8

Most sensitive/ accurate: Endoscopy (golf standard)
Biopsy is mandatory to exclude malignancy for gastric ulcers.

Upper barium- cheaper and less invasive.

Question 9

Most feared complication of a PUD

Answer 9

Perforation.

look for peritoneal signs
free air in abdomen

Tx: Abx (ceftri & metro) and laparotomy with repair

Question 10

Severe PUD that does not respond to treatment

Answer 10

severe, atypical (jejunum) or non healing consider stomach cancer or Zollinger Ellison syndrome.
Check gaskin levels

Question 11

Tx PUD initially

Answer 11

Stop NSAIDs
Stop alcohol and smoking
PPIs
Test and Tx H. Pylori

Question 12

What surgical procedures exist for PUD?

Complications

Answer 12

Antrectomy, vagotomy, Billroth I or II.

Dumping syndrome, post prandial hypoglycemia, afferent loop syndrome, bacteria overgrowth, vitamin deficiencies (b12/ iron), anemia

Question 13

Symptoms of dumping syndrome

Answer 13

Weakness
Dizziness
Sweating
N/V after eating

Question 14

Symptoms of Afferent Loop Syndrome

Answer 14

Bilious vomiting after a meal relieves pain.

Question 15

Most likely diagnosis of epigastric pain with no other symptoms

Answer 15

Functional dyspepsia.
most common cause of epigastric pain,
age <60

Question 16

Most likely diagnosis of epigastric pain with bad taste, cough and hoarseness?

Answer 16

GERD

Question 17

Most likely diagnosis of epigastric pain with diabetes and bloating

Answer 17

gastroparesis

Question 18

Causes of Gastritis

Answer 18

“inflammation or erosion of gastric lining”

• Alcohol
• NSAIDs
• H. Pylori
• Portal Hypertension
• Systemic stress (burns, trauma, sepsis, multi organ failure)

Question 19

presentation of gastritis and diagnosis

Answer 19

GI bleed without pain. (coffee ground/ red blood emesis, black stool).

Cannot diagnose on history alone. EGD shows erosive gastritis. Rule out H. pylori.

Question 20

Most accurate test for H. Pylori

other tests for H.pylori

Answer 20

Most accurate: Endo biospa

other: serology (can identify current vs past), urea breath, stool antigen

Question 21

H. Pylori treatment

Answer 21

Triple therapy: PPI, Clarithromycin, Amoxicillin (metro if penicillin allergy)

If no response: levo, or tetracycline (only use of tetracycline).
Add Bismuth

Question 22

Causes of H.pylori tx failure

Answer 22

Bacterial resistance
nonadherance 
alcohol 
tobacco
NSAID

Question 23

when should you scope for dyspepsia

Answer 23

age >60,
alarm symptoms (dysphagia, weight loss, anemia)
PPIs fail

Question 24

Characteristics of gastronome (ZE) ulcers.

Answer 24

Large >1-2cm
Recurrent after H. pylori eradication
Distal Duodenum
Multiple

Associated with increase somatostatin receptors in abdomen.

Question 25

Gastrinoma (ZE) diagnostic tests

Answer 25

Initial: Endoscopy Most accurate tests: Functional response to secretin (high gastrin) Other: -Somatostatin receptor scintigraphy (nuclear octreotide scan) with endo U/S to exclude metastatic disease

Question 26

Treatment of gastrimnoma (ZE)

Answer 26

Local- surgical removal | metastatic is unresectable. Life long PPI.

Question 27

define and symptoms of diabetic gastroperesis

Answer 27

Autonomic neuropathy leading to dysmotility caused by inability to sense stretch in GI tract. ``` Chronic dyscomfort Bloating Constipation Anorexia N/V Early Satiety ```

Question 28

Best initial test for DM gastroparesis most accurate

Answer 28

BIT: upper endoscopy or abd CT (exclude mass) Most Accurate: Bolus of food tagged with technetium (shows delay in emptying)

Question 29

Tx DM gastroparesis

Answer 29

Initial: Fluids, correct potassium and glucose, blederized foods. Metoclopramide or erythromycin (gastric motility) Gastric electrical stimulation (gastric pacemaker)

Question 30

Define achlorhydria

Answer 30

The absence of hydrochloric acid (HCL) secretion. Most commonly due to pernicious anemia. Associated with other autoimmune. Can also be caused by surgical gastric resection

Question 31

Mechanism of pernicious anemia and achlorhydria

Answer 31

Antiparietal cell antibodies destroy acid-secreting parietal cell causing achorhydria and Vit B12 deficiency.

Question 32

Characteristics of Upper GI Bleed: - Location - Stool - NGT aspirate - Most Common cause - other causes

Answer 32

- proximal to the ligament of Treitz - Tarry, black stool (melena) - NGT positive for blood - MCC: Ulcer - Causes: gastritis, varices, esophagitis, duodenitis, cancer

Question 33

Characteristics of Lower` GI Bleed: - Location - Stool - NGT aspirate - Most Common cause - other causes

Answer 33

- distal to the ligament of Treitz - Bright red blood in stool (hematochezia) - NGT negative for blood - MCC: diverticulosis - Causes: Hemorrhoids, angiodysplasia, polyps, IBD, vascular ectasia, colitis, cancer.

Question 34

Patient with GI bleed and BP 94/62. Best next step in management

Answer 34

Fluid resuscitation prior to identifying etiology of bleed. Assessing BP is the most important initial management for GI bleed. Normal saline or lactated ringers.

Question 35

Tx GI bleed

Answer 35

1. check patient is stable. ABCs & replenish 2. place NG tube and test aspirate 3. Start PPI 4. Perform endoscope (upper or lower depending on symptoms and NGT aspirate). Treat lesions. 5. Run H&H/ coagulation tests (PT, INR). for sever bleed prioritize

Question 36

What radiologic imaging studies can be done to localize a GI bleed?

Answer 36

Radionuclide scenic can detect slow or intermediate bleed. Angiography can defect rapid bleed. Embolization of bleeding can be done. Surgery is reserved for resistant bleed and typically involved resection of bowel (usually colon).

Question 37

Define Ischemic colitis

Answer 37

hypoperfusion of the large bowel, which is mostly transient and self-limiting (nongangrenous form), but can also lead to severe acute ischemia with bowel infarction (gangrenous form)

Question 38

Signs and symptoms of ischemic colitis

Answer 38

LLQ pain mucosal friability on scope clear demarcation between normal and ischemic tissue Self limiting bleeding resolved without specific treatment Hx: DM, HTN, or vascular disease.

Question 39

Additional tx for GI bleeding due to esophageal or gastric varices

Answer 39

- octreotide (decrease portal pressure) - banding - TIPS (transjugular intrahepatic portosystemic shunting) - Propanolol or nadolol (prevention future episodes) - Abx prevents spontaneous bacterial peritonitis (ascites)

Question 40

Bowel contrast with suspected GI perf?

Answer 40

For all GI studies barium is preferred. However is GI perf is suspected, barium can cause chemical peritonitis or mediastinitis. Use water soluble contrast. Caution is aspiration risk as water soluble will cause chemical pneumonitis. when in doubt use water. barium once perf if excluded.

Question 41

Retroperitoneal structures

Answer 41

``` SAD PUCKER: Suprarrenal (adrenal) glands Aorta & inferior vena cava Duodenum Pancreas Ureters Colon (ascending & descending) Kidneys Esophagus Rectum ```