Do you ppx varices w/ sclerotherapy?
NO!
Only do after 1st episode bleeding
How do we know an NG tube is in correct place to eval for UGI bleed?
Need to get bile back
Know is sampling stomach and duodenum
How long after acid ingestion does fibrosis result?
6-13 weeks
Commonly pyloric stricture
How long do you have diabetes to get diabetic gastroparesis?
> 10 years
Dx esophageal perforation
Contrast (usually H2O soluble) esophogram
- Gastrografin-contrast esophography
Need broad spectrum abx, TPN, and surgical repair
Causes pill esophagitis
Can cause esophageal perforation!
Tetracyclines Aspirin NSAIDs Alendronate KCl Quinidine Iron
Young pt, no smoking w/ Chronic fixed, fleshy growth on hard palate
Torus palatinus
- benign bony growth on midline suture of hard palate
- congenital, usually in younger pts, women, and Asians
- usually < 2 cm in size and can inc in size during life
Acute bacterial parotitis
Dehydrated post op pts and elderly most prone to develop infection
Can avoid w/ fluid hydration + oral hygiene
Usually staph aureus infection
Dx esophageal perforation
water soluble contrast
Tx esophageal perforation
Surgery - closure of esophagus
Drain mediastinum
Need to do in 6 hrs to prevent development of mediastinitis
Best 1st diagnostic tool for GI Bleed?
NGT lavage
UGIB more common than lower GIB
Secretion contents of
- bile
- SI
- saliva
- gastric juice
- colon
- pancreatic
Bile + SI
- like LR
Saliva, gastric, colon
- high K
- low Na
Pancreatic
- high bicarb
Esophagitis
Assoc w/ reflex or infection or lye ingestion
HSV 1 = punched out ulcers
CMV = linear ulcers
Candida = pseudomembrane
Plummer Vinson syndrome
Due to Fe deficiency
Dysphagia
Glossitis
Iron deficiency anemia
Increases risk of SCC of esophagus
Barrett’s esophagus
Glandular metaplasia
Nonkeratinzed stratified squamous –> columnar epithelium
Due to chronic acid reflux
Assoc w/ esophagitis, esophageal ulcers, increased risk of esophageal cancer
Menetrier’s disease
Gastric hypertrophy w/ protein loss, parietal cell atrophy, and increase mucous cells
Precancerous
SUPER hypertrophy of rugae of stomach
Gastric vs duodenal ulcer
Gastric
- GREATER pain w/ meals
- H. pylori is majority
- due to decreased mucosal protection against acid
- increased risk of cancer
Duodenal ulcer
- DECREASED pain w/ meals
- 100% have H. pylori
- Hypertorphy of Brunner’s glands
- Never malignant
Tx peptic ulcers
3x therapy
PPI
Clarithromycin
Amoxicillin (metronidazole if PXN allergy)
Most common serious complication of peptic ulcer disease
Hemorrhage
Tx:
- fluid + blood resuscitation
- med tx
- endoscopic intervention
Usually will stop bleeding spontaneously
When do surgery for GERD?
Nissen fundoplication for:
Long standing symptomatic disease cannot be controlled by medical means
Intolerant to PPIs
Don’t want to take long term meds
Complications - ulceration, stenosis
Resection for: Severe Dysplasia (if only on sub-medical therapy; try optimal med therapy if not on it first)
Dx esophageal dysmotility
Manometry is definitive
Barium 1st
Esophageal cancer
- signs
- types
- dx
Signs:
- dysphagia for solids –> softs –> liquids
- wt loss
SCC in smokers
Adenocarcinoma in GERD
High incidence in those w/ corrosive esophagitis
ALWAYS do barium before endoscopy to avoid perforation
Have to do endoscopy and bx for diagnosis
Tx
- Mallory Weiss tear
- Boerhaave syndrome
MW tear
- endoscopy + photocoagulation
Boerhaave
- dx w/ gastrografin 1st, then barium if it is negative
- emergency surgery repair
Tx MALToma of stomch
Tx h pylori and can reverse it if it is low grade!
Esophageal atresia
- sx
- work up
- tx
Sx:
- excess salivation after birth
- choking spells after 1st feeding
- NGT coils in chest
Most common type is upper esophagus is blind, fistula between lower esophagus and trachea
Workup:
- R/o VACTER
Tx:
- primary surgical repair
- if delayed, put in gastrostomy to protect lungs from acid reflux
Green vomiting in newborn + double bubble sign
What could it be?
Duodenal atresia
Annular pancreas
Malrotation of intestine (most dangerous and at risk for ischemia)
Green vomiting in newborn + multiple air fluid levels on xray - what is it?
Intestinal atresia
Usually vascular event in utero
Indications for bariatric surgery
BMI > 40
or
BMI > 35 + comorbidities
N/v and dilated bowel loops s/p bariatric surgery
what is the dx?
these symptoms and signs along with X Rays represent bowel obstruction.
In a patient with gastric bypass, this is often due to an internal hernia.
Retrocolic position of the Roux limb predisposes patients to developing an internal hernia through the transverse mesocolon.
Vit deficiency to watch out for s/p gastric bypass
Vit B12 - b/c no stomach to make intrinsic factor to bind
The inability to tolerate a diet that has progressed from solids to liquids in an otherwise stable patient s/p gastric bypass is very suggestive of……
a stenosis of the gastrojejunostomy.
dx w/ UGI series w/ contrast.
Endoscopy can also visualize the stenosis and can also be used to treat the stenosis using balloon dilators.
Inability to tolerate a diet after a laparoscopic band suggests
either the band is too tight or has slipped.
An UGI series or even plain X Rays can diagnose a slipped band but, if the band is too tight then an UGI series will be needed.
Emergent treatment is to decompress the band by removing fluid from the port (band adjustment).
Billroth I
Remove pylorus (distal stomach)
Proximal stomach - duodenum connectino
Billroth II
Connect lower stomach (greater curvature) to jejunum directly side-to-side
Resect lower antrum stomach
For refractory peptic ulcer disease
Alcoholic person +
UGI bleed +
evidence of cirrohosis
S/p resusscuitation w/ fluids, what do you do next?
Endoscopy!
Sclerotherapy can contorl hemorrhage in most cases
Angiography will r/o arterial hemorrhage but will not show bleeding varices
When do you do surgery on sliding esophageal hernia?
Symptomatic + objectively documented esophagitis or stenosis
Refulx is not an indication unless progresses to the 2 above
Size of hernia is not important
Massive hematemesis in children - what is this due to?
Variceal bleeding (almost always)
Results from extrahepatic portal V obstruction 2/2 bacterial infection from patent umbilical v during infancy
Tx electively for recurrent bleeding episodes. Bleeding usually stops and is self limited
Tx Zolinger ellison syndrome
Most will die of mets than primiary
Highly selective vagotomy + tumor resection
Dx:
Gastrin levels
If gastrin levels not diagnostic, secretin stim test (usually will decrease gastrin) will confirm ZES
Most common presentation of idiopathic retroperitoneal fibrosis
Ureteral obstruction
Most reliable objective indicator of GERD
24 hr pH monitoring
Assoc sx of esophageal perforation
Chest pain (ASAP)
SubQ emphysema (1 hr)
Pleural effusion usually on L (immediate or > 6h later)
Fever, leukocytosis 2/2 sepsis from mediastinis (>4 hr)
Death
Dx esophageal perforation
Water-soluble contrast esophogram - Gastrographin
Barium is more sensitive but it can be assoc w/ mediastinitis adn peritonitis if there is a tear
1 cause esophageal perforation
Iatrogenic (endoscopy)
Person w/ duodenal ulcers
Failed med therapy (ppi+ amoxicillin + clarithromycin) and ulcer is getting larger
What do you do?
How about gastric ulcer?
Surgery
Highly selective vagotomy (chice procedure)
- fundus and body denervated + antrum and pylorus innveration intact so gastric emptying and mixing can stll happen
Truntal vagotomy
Pyloroplasty
Vagotomy + antrectomy
Billroth I partial gastrectomy (no vagotomy)
When do you resect gastric ulcers?
If treated medically for 18 weeks and no healing
No vagotomy performed
What should be done for all gastric ulcers?
biopsied to r/o malignancy
Types of gastric ulcers & treatments
I & 2 - low acid output
3& 4 - high acid output
1 - lesser curvature of body of stomach possibly 2/2 to NSAIDs or steroids
- tx: antrectomy +/- vagotomy if intractable
2- gastric and duodenal
- tx: vagotomy + pylorplasty w/ oversewing of ulcer in duodenal ulcer
- tx: vagotomy + gastrojejunostomy if gastric outlet obstruction
3 - pyloric and prepyloric
- tx: antrectomy + vagotomy
4 - At GE junction,
- tx: partial gastrectomy but NO vagotomy
For perforated ulcers, you close most of them but when do you do a vagotomy?
When the person has had the ulcer for a while and managed on meds but the meds have not worked.
gastric pH needed to reduce risk of rebleeding
5
Where is an actively bleeding ulcer usually?
In posterior duodenum involving gastroduodenal A
Tx difference for gastric vs. duodenal ulcers
Need to bx gastric ulcers b/c may have underlying gastric cancer
Will excise gastric ulcers rather than oversew
Only oversew duodenal ulcers that are new - recurrent ones, will resect and do a vagotomy
Tx actively bleeding esophagea varices
Band bleeding esophageal varices w /EGD
correct coagulopathy w/ FFP + Plt transfusion
Tx w/ IV octreotide to lower portal pressure. Can also use IV vasopressin
Continue to bleed…
- repeat endoscopy
Final steps if still bleeding…
portosystemic shunt
balloon tamponade
Beta blockers may lessen chance of rebleeding
Gastric lymphoma tx
Get rid of H pylori!
Surgery only if H. pylori eradication doesn’t shrink tumor an tumor is stage 1 or 2
Dieulafoy’s lesion
Often in proximal stomach
Abnormally large submucosal A protruding through small solitary mucosal defect
1 ongenital diaphragmatic hernia in infants
Foramen of Bochdalek
Also most likely to cause ARDS in infants
Tx mallory weiss tear
Usually stops bleeding by itself
If not..
Balloon tamponade or
endoscopic control of bleeding or
Gastrotomy and suture ligation
Dumping syndrome tx
1) Dietary modification
2) Octreotide in resistant cases
3) Reconstructive surgery for intractable cases
