Upper GI Flashcards
1
Q
What are key items in the differential for upper GI bleed?
A
Gastritis Gastric ulcer Duodenal ulcer Erosive esophagitis Mallory-Weiss tear Esophageal varices Gastric cancer Angiodysplasia Isolated gastric varies Aortoenteric fistula
2
Q
What are key lifestyle factors that must be asked about in upper GI bleed?
A
Alcohol use
NSAID use
3
Q
What does bright-red bloody emesis tell you about location of the bleed?
A
UGI
4
Q
What does coffee ground emesis tell you about location of the bleed?
A
UGI
5
Q
What does black, tarry, foul-smelling stool (melon) tell you about location of the bleed?
A
UGI usually, LGI possible
6
Q
What does bright red bloody stool tell you about the location of the bleed?
A
LGI probably, may be UGI
7
Q
What does maroon colored stool tell you about the location of the bleed?
A
UGI (probably)
LGI (maybe)
8
Q
What causes esophageal varies?
A
Cirrhosis: portal vein has more difficulty draining its blood into the scarred liver duh that blood flows retrograde under high pressure back into esophagus
9
Q
What is acute vs. chronic gastritis?
A
Acute: erosive, superficial inflammation in stomach lining due to dysfunction of mucosal defenses
Chronic: Non erosive inflammation of gastric mucosa: due to inflammation
10
Q
What is a Dieulafoy’s lesion?
A
rare cause upper GI bleed: vascular malformation: large tortuous artery in the submucosa is eroded by gastric acid
11
Q
What causes acute gastritis?
A
NSAID abuse
Alcohol
Steroids
Uremia
12
Q
What causes chronic gastritis?
A
Pernicious anemia, H. pylori
13
Q
What artery can be behind a gastric ulcer in the posterior wall of stomach?
A
Splenic
14
Q
What artery can be behind a gastric ulcer in the lesser curvature of the stomach?
A
Left gastric artery
15
Q
What artery can be behind a duodenal ulcer in the posterior wall of 1st portion of duodenum?
A
Gastroduodenal artery
16
Q
Where is UGI bleeding coming from?
A
Proximal to ligament of Treitz
17
Q
Why can Hb or hematocrit be normal in spite of major GI bleed?
A
Because of loss of all portions of blood at same rate: do not see drop until 12-24 hours later once kidney begins to conserve Na and water
18
Q
What happens to BUN/Cr during UGI bleed?
A
Increases to >36 signifies UGI bleed
19
Q
How can bloody emesis and bright red blood per rectum present together?
A
UGI bleed: very fast transit through GI tract - no time for digestion
20
Q
What is difference between obscure and occult GI bleeding?
A
Occult: not known to patient
Obscure: obvious bleeding to patient, but hard to identify source on endoscopy (usually due to bleeding in small bowel)
21
Q
What are first steps in management of UGI bleed?
A
2 large bore IVs IVF resuscitation NGT Blood: type and cross Admit
22
Q
Why place NGT in UGI bleed?
A
Differentiate between UGI and LGI bleed
23
Q
What is difference between “type & screen” vs. “type & cross”?
A
Type and screen: no likely blood transfusion.
Type and cross: likelihood of needing blood is high
24
Q
What does blood typing determine?
A
ABO and Rh status
25
What does blood screening determine?
Presence of alloantibodies in recipient's blood that may react with donor blood
26
What does blood crossmatching determine?
Recipient blood tested against donor packed cells to determine if there is clinically sig response to antigens on donor cells
27
After admission for UGI bleed, what is the next step to determine source of bleeding? In what window?
Endoscopy w/in 12 hours
28
After admission for UGI bleed, if endoscopy is negative, what do we do?
Look in small bowel: capsule endoscopy, push enteroscopy, angiography, look in LGI
29
When do we give blood transfusion ?
Only when Hb < 7
30
Where in the hospital do we manage UGI bleed?
ICU
31
How do we position bed in patient who is vomiting blood?
Head of bed to 30 degrees unless ongoing hypotension
32
After resuscitation for UGI bleed, what is next step?
- Correct coagulopathy w/ blood/platelets/FFP if needed
- Reverse anticoagulants
- Start PPI
33
What are endoscopic therapeutic options for UGI bleed?
Inject epi
Bipolar electrocoagulation
Endoscopic clips
Plasma coagulator
34
When do we take UGI bleed patients to surgery?
- Failure of endoscopic therapy (>twice)
- Persistent hemodynamic instability despite aggressive resuscitation
- CV dz w poor predictive response to hypotension
- Hemorrhagic shock
35
What are surgical options for bleeding ulcer that fails medical management?
Duodenal: open duodenum, 3-point ligation of ulcer
Gastric: excise and close for acute vs. distal gastrectomy for chronic history of ulcer dz
36
If ulcer or gastritis is found on endoscopy, what else do we test for?
H. pylori - Tx with PPI, clarithromycin, amoxicillin
37
How do we test for H. pylori?
Urea breath test: test for ammonia labeled with c isotope in breath that the patient eats
38
How do we manage UGI bleed for esophageal varies?
- Short term AB prophylaxis
- Esophageal band ligation is best option
- Repeat endoscopy to band any remaining vessels
39
What is the best way to prevent recurrent UGI bleed from esophageal varies?
beta blockers (propranolol)
40
How do we manage UGI bleed from Mallory-Weiss tear?
Self limited - very rarely need sclerosis therapy or electrocautery
41
In alcoholic patient, what is important to calculate before surgery?
MELD: Model for End Stage Liver Disease which can influence surgical decision making
42
What do we think of with isolated gastric varies along the greater curve of stomach?
Splenic vein thrombosis from prior pancreatitis: splenectomy is curative
43
For patients with chronic NSAID therapy, what can we use to prevent ulcers?
PPIs
44
What does free air under the diaphragm indicate?
Perforated viscus
45
What are most common causes of free air under diaphragm?
Perforated ulcers
| Perforated diverticulitis
46
What are most common symptoms in a patient with PUD?
Burning in epigastric region, non radiating
47
How do patients with perforated peptic ulcers present?
- Acute onset sharp abdominal pain in epigastrium that rapidly becomes diffuse
- Shoulder pain
- Peritonitis: exquisite tenderness to palpation, abdominal guarding and rigidity
- SIRS
48
What are most common cause of peptic ulcers?
H. pylori
49
How do NSAIDs lead to peptic ulcers?
Inhibit production of prostaglandins that regulate inflammation in gastric mucosa and reduce acid production
50
What factors can lead to peptic ulcers?
NSAID use
Smoking
Alcohol
High stress environments
51
What are type I peptic ulcers?
Lesser curvature, no acid hypersecretion (disruption in mucosal defense)
52
What are type II peptic ulcers?
Lesser curvature/duodenum with acid hypersecretion
53
What are type III peptic ulcers?
Prepyloric with acid hypersecretion
54
What are type IV peptic ulcers?
Gastric cardia without acid hypersecretion (disruption in mucosal defense)
55
What are type V peptic ulcers?
Any location in stomach: associated with NSAID use so no acid hypersecretion (disruption in mucosal defense)
56
How id diagnosis of perforated PUD established?
Clinical exam: guarding with palpation and muscle rigidity
| Confirmed by radiology findings
57
What labs do we send in suspected perforated PUD?
```
CBC
Blood chemistry
- Look for elevated WBC, CRP, decreased albumin, elevated BUN/Cr
- Amylase/Lipase to r/o pancreatitis
- LFTs: cholecystitis or cholelithiasis
```
58
What imaging do we order for suspected perforated PUD?
Acute abdominal series or upright CXR
59
What is the classic finding on abdominal or chest XR in perforated PUD?
Pneumoperitoneum: hyperlucent area under one or both hemidiaphragms
- Also look retroperitoneal for posterior gastric!
60
What studies are contraindicated in suspected perforated PUD?
- Barium UGI series (causes barium peritonitis)
| - Upper endoscopy (can exacerbate with air)
61
What is the role of CT scan in workup of perforated peritonitis?
CT scan with gastrografin: Diagnose pneumoperitoneum and confirm diagnosis
- Also can tell if spontaneously sealed itself
62
What is morbidity and mortality of perforated peptic ulcer?
> 25%
63
What is definitive management of perforated peptic ulcer?
- ICU admission
- Volume resuscitation
- NGT placement
- Antibiotics for sepsis
- Triple therapy if H pylori positive
64
How do we treat duodenal ulcer perforation?
Primary closure with omental patch
65
How do we treat gastric ulcer perforation?
Primary closure, biopsy omental patch vs. wedge resection
66
What is important to rule out in patient with any gastric ulcer?
Malignancy
67
What are two possible causes of ulcers?
Acid hypersecretion
| Mucosal defense hyposecretion
68
What are the key findings in perforated ulcer? PE, labs, imaging
PE: acute abdomen with diffuse peritonitis
Labs: Elevated WBC
Imaging: free air under diaphragm (XR) and CT
69
What are key features of Boerhaave's syndrome?
- CP after forceful vomiting
- Crepitus with palpation around the sternum
- L sided pleural effusion
- SIRS
70
What are the risk factors for Boerhaave's syndrome?
- Alcoholics
| - Overeating --> aggressive vomiting
71
Why is Boerhaave's syndrome so often unrecognized?
CP has such a large differential
72
What is Mackler's triad? what's it for?
Vomiting
Thoracic pain
SubQ emphysema
- Suggests Boerhaave's
73
What are clinical signs most often observed in Boerhaave's?
Vomiting > thoracic pain > dyspnea ? epigastric pain ? dysphagia
74
What is most specific sign of an esophageal rupture?
SubQ emphysema = pathognomonic
75
How does Boerhaave's present differently than Mallory Weiss?
Boerhaave's: thoracic pain radiating to back, L pleural effusion, sepsis
M-w: Upper GI bleed
76
What are most common causes of esophageal perforation?
- Iatrogenic injury during upper endoscopy: most common
- Blunt or penetrating trauma
- Foreign body ingestion
- Perforating malignancy
- Only 10-20% Boerhaave's
77
How does Boerhaave's most commonly present?
Thoracic pain radiating to the lower back and aggravated by swallowing
78
What is the pathophysiology of Boerhaave's?
Transmural esophageal perforation 2/2 increased intragastric pressure induced by vomiting
79
Why do patients with Boerhaave's become so septic?
- Gross contamination of mediastinum
- Often leads to rupture of pleura as well: 2/2 gastric and bilious contents eroding through the lining
- Once pleura disrupted, gross contamination of pleural cavity also occurs
- Mediastinitis / pleuritis eventually lead to sepsis
80
What is first step in workup of suspected Boerhaave's?
CXR: should see L pleural effusion and atelectasis, but can be normal if it has not been > 1 hour
81
If CXR is questionable in suspected Boerhaave's, what is the next diagnostic step?
CT with oral contrast:
- Identify extent of perforation
- Assists in decision on surgical approach
- If not Boerhaave's, helps id another differential
82
Is there a role for endoscopy in Boerhaave's?
No: more air into esophagus can enlarge the opening/hole
83
What are the initial steps in management of a Boerhaave's patient?
- IVF resuscitation
- NPO
- Antibiotics to over oral bacteria + fungal
- PPI to reduce secretions
- Place arterial line if hemodynamically unstable
84
What is the key timeframe for detection and treatment in Boerhaave's?
Within 24 hours!
85
Who gets conservative management with Boerhaave's? What is conservative?
Contained leak w/in mediastinum:
- NPO
- NGT
- IV antibiotics / fluids
- Parenteral nutrition
86
What is the goal for surgery for Boerhaave's?
Within 24 hours
87
What is standard treatment(surgery) for Boerhaave's?
- Debride necrotic tissue around perforation
- Primary suture closure
- Cover with pedicle flap
88
What causes death in Boerhaave's?
Contamination of mediastinum and pleura: leads to sepsis, shock and multi organ failure
89
In which patients is conservative management considered for Boerhaave's?
Minimal comorbidites
No signs of sepsis / shock
Perforation < 24 h
Leak that is small/contained or has self-sealed
90
What is the mortality of Boerhaave's?
50%
91
What is the differential for vague abdominal pain, weight loss, difficulty eating and melena?
```
PUD
GERD
Panreatitis
Cholelithiasis
Hiatal hernia
Gastric outlet obstruction
SBO
Gastric cancer
```
92
What to think: weight loss and positive FOBT?
Malignancy until proven otherwise
93
What is triple therapy for H. pylori?
Amoxicillin
Clarithromycin
Omeprazole
94
Why don't we screen for gastric cancer?
Not cost effective due to low rate in US
95
Why is mortality rate so high for gastric cancer?
- No screening
- By the time sx appear, already stage III to IV
- Sx of gastric cancer are vague
96
What are most common symptoms for a patient with gastric cancer?
1 Weight loss
2 Abdominal pain
Perhaps dyphagia, nausea, early satiety, rarely a palpable mass
97
Are there specific findings on physical exam for gastric cancer?
Usually non specific, often absent
If present:
- Palpable L supraclavicular nodes (Virchow's nodes)
- Periumbilical lymphadenopathy (SMJ nodes)
- Left axillary node (Irish's node)
98
What are the 2 types of gastric adenocarcinoma?
1 Intestinal type
| 2 Diffuse type
99
What are hallmark features of intestinal type gastric adenocarcinoma?
- Arises from gastric mucosa usually in distal stomach
- Sporadic: high exposure to tobacco, alcohol, poor diet
- Largely decreased due to H. pylori eradication
100
What are hallmark features of diffuse type gastric adenocarcinoma?
- Arises from lamina propria and grows in infiltrative, submucosal pattern
- Leads to gastric thickening without discrete mass often in proximal stomach
101
What is linitis plastica?
Diffuse type gastric cancer: if it infiltrates the entire gastric wall / esophagus / duodenum = linitis plastica.
- High mortality rate!
102
What is the vascular supply to the stomach and where do those arteries branch from?
```
L/R gastrics: lesser curve
L/R gastroepiploics: greater curve
L gastric: celiac
R gastric: common hepatic
L gastroepiploic: splenic
R gastroepiploic: R gastric / common hepatic
```
103
Why do patients with gastric cancer get iron deficiency anemia?
slow intermittent bleeding of the tumor
104
What is the best way to diagnose a patient with suspected gastric cancer?
Upper endoscopy: visualize and biopsy lesion
105
Once diagnosis of gastric cancer is established, what further workup is recommended?
1 Endoscopic ultrasound: assess tumor size, depth and lymph node involvement for TNM staging
2 CT abdomen to see if surgical candidate, r/o liver mets
3 PET scan: look for mets and nodes
106
Why is staging of gastric tumor important?
To determine intervention: surgery vs. chemo vs. radiation
107
When do we use chemotherapy in locally advanced gastric cancer?
Before surgery!
108
What stages of gastric cancer get preoperative chemotherapy?
Stage 1B or higher
109
What is the benefit of postoperative chemo and radiation in gastric cancer?
Improved overall survival
110
What is the surgical approach for gastric cancer in the distal stomach?
Subtotal gastrectomy
111
What is the surgical approach for gastric cancer in the proximal stomach?
Proximal or total gastrectomy
112
What are the margins of gastric cancer stage R0 resection?
5cm
113
How many lymph nodes should be taken in gastric cancer surgery? Why?
> 15 to properly stage
114
How do we treat MALT lymphoma in the stomach?
1. Low grade: H. pylori eradication
| 2. High grade: chemo
115
Why does the 5 year mortality remain high for gastric cancer?
Advanced disease present at diagnosis
116
What gene mutation has been shown to often be present in gastric cancers?
HER2 - do genetic testing before induction chemotherapy
117
What other types of gastric cancers are there, besides adeno?
GIST: mesenchymal tumors
Gastric carcinoids
Gastric lymphoma
118
Why do patients get dumping syndrome after gastric resection?
Absence of regulatory effect of the pyloric sphincter: hyperosmolar state in the small intestine leads to increased water secretion into the lumen, leading to diarrhea and hypotension
119
What are common complications after a gastric resection?
```
Diarrhea
Darly satiety
Dumping syndrome
Anastomotic leak
SBO
Internal hernia
```
120
How are anastomotic leaks identified?
- Presentation: peritonitis, fevers, tachycardia, leukocytosis, sepsis
- Confirm with upper GI with gastrografin: will see contrast extravasation
121
How do we treat anastomotic leak?
1. Source control: reoperate to repair suture line and abdominal washout/drainage
2. Post op: NPO with TPN, NGT to reduce gastric contents
122
What do we NOT do as first treatment for anastomotic leak?
Resection and revision of anastomosis: control it to try and salvage initial operation!
123
What are GIST tumors?
Smooth, submucosal tumors that express C-KIT and CD117
