Flashcards in Upper GI 2 Deck (20):
30 year old woman presents with pneumonia and is placed in ICU. Ileus requires NG tube drainage. NG tube contains coffee ground type material with occasional blood streaks. Management?
1. Initiation of H2 blockade, sucralfate, Or antacids with each gastric pH monitoring
2. If patient is taking NSAIDs, misoprostol (synthetic prostaglandin E1 analogue)
3. EGD not mandatory
Mechanism of antacids? Mechanism of H2 antagonist? Mechanism of PPI's?
Neutralize gastric acid
Inhibit histamine receptor on parietal cell, decreasing acid secretion
Inhibits ATPase proton pump, blocking acid secretion
Patient undergoes EGD – finds ulcer that's clean, with a white base no active bleeding. Interpretation? Management?
White base means ulcer has not bled recently. Risk of bleeding is low.
Endoscopic therapy is not needed. However necessary to maintain gastric pH at five to reduce risk of bleeding
Patient undergoes EGD – finds duodenal ulcer with fresh clot. interpretation? Management?
Evidence of recent bleeding, has 10-15% chance of rebleeding.
Endoscopic hemostatic therapy is needed. (Injection of epinephrine and sclerosing agents, will contact methods, laser therapy, suturing)
Patient has duodenal ulcer – indications for endoscopic therapy?
1. Active or recent bleeding
2. Large initial blood loss
3. high risk of rebleeding or death with bleed
Patient undergoes EGD – finds duodenal ulcer with fresh clot and visible artery at base. Interpretation? Management?
Highest risk of rebleeding (40%). Usually in the posterior duodenum and involved Gasburg is hungry
Inject area around ulcer to attempt local control. Elective surgical repair in 24-48 hours if significant prior bleed.
Patient undergoes EGD. Duodenal ulcer with fresh bleeding. Patient is hypotensive during endoscopy – management?
Immediate resuscitation with normal saline and packed RBCs. Most likely will need surgery.
Patient with duodenal ulcer has acute renal failure and creatinine of 6 – concern? Management?
Platelet dysfunction caused by uremia increases likelihood of bleeding
Lesson dysfunction with dialysis or ddAVP
Duodenal ulcer in the patient with chronic alcoholic cirrhosis – concern?
1. Elevated prothrombin time due to deficiency of factors (2, 7, 9, 10) – Temporarily correct with FFP
2. Thrombocytopenia due to congestive splenomegaly – partially corrected by platelet transfusion
Gastritis – definition? Associated with? Goal of medical management? When is surgery needed? Type of surgery?
Multiple non-ulcerating erosions in the stomach
Ventilator, trauma, sepsis, burns, renal failure
Keep gastric pH over five
Surgery bleeding does not cease with medical therapy. Subtotal gastrectomy
Patient history of cirrhosis with gastritis and gastric varices – Gastric varices do not respond to which therapies used for esophageal varices? Treatment options?
Banding or sclerotherapy
1. Cyanoacrylate glue
2. If bleeding is uncontrollable, Transjugular intrahepatic portosystemic shunt (TIPS) or splenectomy
Patient with history of chronic pancreatitis presents with gastritis gastric varices – Varices may be the result of? Management bleeding is persistent?
Splenic vein thrombosis resulting in left-sided portal hypertension
Patient with history of cirrhosis presents with esophageal varices – management?
1. Treatment of underlying coagulation abnormalities with FFP and vitamin K
2. Vasopressin or octreotide to lower portal pressure
3. Endoscopic sclerotherapy or variceal banding controls bleeding in 90% of patients
Patient with esophageal varices – choosing between sclerotherapy or band ligation?
Banding is preferred because it causes less injury to the esophagus
Patient with multiple linear erosions in the gastric mucosa at the gastroesophageal junction – suspected diagnosis? Mechanism? Course of bleeding? Management?
Mallory-Weiss syndrome; forceful vomiting causes longitudinal tears in mucosa and submucosa of stomach near the gastroesophageal junction
Bleeding often stops spontaneously
If bleeding continues:
1. Injection or electrocautery
2. If severe, oversewing the laceration via anterior longitudinal gastrostomy
35-year-old man with history of cirrhosis presents with profuse upper G.I. bleeding. EGD reveals esophageal varices. Steps to control the bleeding?
1. Attempt banding varices
2. Correct coagulopathy with FFP and thrombocytopenia with platelet transfusion
3. Octreotide or vasopressin to lower portal pressure
4. If continues to bleed, repeat endoscopy to reassess source and try to control again with banding
5. If still bleeding, portosystemic shunt or balloon tamponade
Pt with esophageal varices– how to decide between octreotide and vasopressin?
Vasopressin can cause coronary constriction so do not give to:
1. Older patients
2. Patients with CAD
3. In conjunction with beta blocker (can cause bradycardia or hypertension)
Balloon tamponade? Main Precaution?
Placing NG tube with attached esophageal gastric balloon to tamponade the bleeding
Only perform if intubated, because high-risk of aspirational pneumonia
Patient with bleeding from esophageal varices. Bleeding is controlled. treatment that may lessen the chance of rebleeding?