Flashcards in Upper GI Bleeding Deck (132):
What is upper GI bleeding?
Bleeding into the lumen of the proximal GI tract, proximal to the ligament of Treitz
What are the signs and symptoms of upper GI bleeding?
Hematemesis, melena, syncope, shock, fatigue, coffee-ground emesis, hematochezia, epigastric discomfort, epigastric tenderness, signs of hypovolemia, guaiac-positive stools
Why is it possible to have hematochezia with upper GI bleeding?
Blood is a cathartic and hematochezia usually indicates a vigorous rate of bleeding from the UGI source
Are stools melenic or melanotic?
How much blood do you need to have melena?
> 50 cc
What are the risk factors for upper GI bleeding?
Alcohol, smoking, liver disease, burns, trauma, NSAIDs, vomiting, sepsis, steroids, previous UGI bleed, PUD, esophageal varices, portal hypertension, splenic vein thrombosis, AAA repair
What is the most common cause of significant upper GI bleeding?
What is the common differential diagnosis of upper GI bleeding?
1. Acute gastritis
3. Esophageal varices
6. Mallory-Weiss tear
What is the uncommon differential diagnosis of upper GI bleeding?
Gastric cancer, hemobilia, duodenal diverticula, gastric volvulus, Boerhaave's syndrome, aortoenteric fistula, paraesophageal hiatal hernia, epistaxis, NGT irritation, Dieulafoy's ulcer, angiodysplasia
Which diagnostic tests are useful for upper GI bleeding?
History, NGT aspirate, AXR, EGD
What is the diagnostic test of choice with upper GI bleeding?
What are the treatment options with the endoscope during an EGD?
Coagulation, injection of epinephrine, injection of sclerosing agents, variceal ligation
Which lab tests should be performed for upper GI bleeding?
BMP, bilirubin, LFTs, CBC, T&C, PT/PTT, amylase
Why is BUN elevated with upper GI bleeding?
Because of absorption of blood by the GI tract
What is the initial treatment for upper GI bleeding?
IVFs, Foley, NGT suction (determine rate), water lavage (remove clots), EGD
Why irrigate in an upper GI bleed?
To remove the blood clot so you can see the mucosa
What test may help identify the site of massive upper GI bleeding when EGD fails to diagnose cause and blood continues per NGT?
Selective mesenteric angiography
What are the indications for surgical intervention in upper GI bleeding?
Refractory or recurrent bleeding and site known; > 3u PRBCs to stabilize or > 6u PRBCs overall
What percentage of patients with upper GI bleeding require surgery?
What percentage of patients with upper GI bleeding spontaneously stop bleeding?
What is the mortality of acute upper GI bleeding?
What are the risk factors for death following an upper GI bleed?
Age older than 60; shock; > 5u PRBC transfusion; concomitant health problems
What is PUD?
Peptic Ulcer Disease
What is the incidence of PUD in the US?
What are the possible consequences of PUD?
Pain, hemorrhage, perforation, obstruction
What percentage of patients with PUD develops bleeding from the ulcer?
Which bacteria are associated with PUD?
What is the treatment for H. pylori infection?
2-week regimen of either:
MOC: Metronidazole, Omeprazole, Clarithromycin
ACO: Ampicillin, Clarithromycin, Omeprazole
What is the name of the sign with RLQ pain/peritonitis as a result of succus collecting from a perforated peptic ulcer?
In which age group are duodenal ulcers most common?
What is the male:female ratio for duodenal ulcers?
What is the most common location for duodenal ulcers?
Most are within 2 cm of the pylorus in the duodenal bulb
What is the classic pain response to food intake with duodenal ulcers?
Food classically relieves duodenal ulcer pain
What is the cause of duodenal ulcers?
Increased production of gastric acid
What syndrome must you always think of with a duodenal ulcer?
What are the risk factors for duodenal ulcers?
Male, smoking, NSAIDs, uremia, ZES, H. pylori, trauma, burns
What are the symptoms of duodenal ulcers?
Epigastric pain (burning, aching, usually several hours postprandial), bleeding, back pain, N/V, anorexia
What are the signs of duodenal ulcers?
Tenderness in the epigastric area, guaiac-positive stool, melena, hematochezia, hematemesis
What is the differential diagnosis of duodenal ulcers?
Acute abdomen, pancreatitis, cholecystitis, ZES, gastritis, MI, GU, reflux
How is the diagnosis of duodenal ulcer made?
H&P, EGD, UGI series
When is surgery indicated with a bleeding duodenal ulcer?
> 6 u PRBC overall; > 3 u PRBC to stabilize; significant rebleed
What EGD finding is associated with rebreeding of a duodenal ulcer?
Visible vessel in the ulcer crater, recent clot, active oozing
What is the medical treatment of duodenal ulcers?
PPIs or H2 receptor antagonists; treat H. pylori
When is surgery indicated for a duodenal ulcer?
How is a bleeding duodenal ulcer surgically corrected?
Opening of the duodenum through the pylorus and oversewing of the bleeding vessel
What artery is involved with bleeding duodenal ulcers?
What are the common surgical options for duodenal perforation?
Truncal vagotomy and pyloroplasty incorporating ulcer;
Graham patch and highly selective vagotomy;
Truncal vagotomy and antrectomy
What are the common surgical options for duodenal obstruction resulting from duodenal ulcer scarring?
Truncal vagotomy, antrectomy, and gastroduodenostomy;
Truncal vagotomy and drainage procedure (gastrojejunostomy)
What are the common surgical options for duodenal ulcer intractability?
PGV (highly selective vagotomy);
Vagotomy and pyloroplasty
Vagotomy and antrectomy BI or BII
Which ulcer operation has the highest ulcer recurrence rate and the lowest dumping syndrome rate?
PGV (proximal gastric vagotomy)
Which ulcer operation has the lowest ulcer recurrence rate and the highest dumping syndrome rate?
Vagotomy and antrectomy
Why must you perform a drainage procedure (e.g. pyloroplasty, antrectomy) after a truncal vagotomy?
Pylorus will not open after a truncal vagotomy
Which duodenal ulcer operation has the lowest mortality rate?
What is a "kissing" ulcer?
Two ulcers, each on opposite sides of the lumen
Why may a duodenal rupture be initially painless?
Fluid can be sterile, with a non-irritating pH of 7.0 initially
Why may a perforated duodenal ulcer present as lower quadrant abdominal pain?
Fluid from stomach/bile drains down paracolic gutters to lower quadrants and causes local irritation
In which age group are gastric ulcers most common?
Which is more common overall: gastric or duodenal ulcers?
Duodenal (> 2 fold)
What is the classic pain response to food with gastric ulcers?
Food classically increases gastric ulcer pain
What is the cause of gastric ulcers?
Decreased cytoprotection or gastric protection (i.e. decreased bicarbonate or mucous production)
Is gastric acid production high or low with gastric ulcers?
Normal or low.
Which gastric ulcers are associated with increased gastric acid?
Prepyloric and pyloric
What are the associated risk factors for gastric ulcers?
Smoking, alcohol, burns, trauma, CNS tumor, NSAIDs, steroids, shock, severe illness, male, advanced age
What are the symptoms of gastric ulcers?
Epigastric pain, +/- N/V, anorexia
How is the diagnosis of gastric ulcer made?
H&P, EGD with multiple biopsy
What is the most common location for gastric ulcers?
When and why should biopsy be performed for a gastric ulcer?
To rule out gastric cancer; If ulcer does not heal in 6 weeks after medical treatment, another biopsy must be performed
What is the medical treatment for gastric ulcers?
PPIs or H2 blockers, treatment of H. pylori
When do patients with gastric ulcers need to have an EGD?
For diagnosis with biopsies; 6 weeks post-diagnosis to confirm healing and rule out gastric cancer
What are the indications for surgery for gastric ulcers?
Cancer (rule out)
What is the common operation for hemorrhage, obstruction and perforation secondary to gastric ulcers?
Distal gastrectomy with excision of the ulcer without vagotomy unless there is duodenal disease
What are the options for concomitant duodenal and gastric ulcers?
Resect (BI, BII) and truncal vagotomy
What is a common option for surgical treatment of a pyloric gastric ulcer?
Truncal vagotomy and antrectomy (BI or BII)
What is a common option for a poor operative candidate with a perforated gastric ulcer?
What must be performed in every operation for gastric ulcers?
Biopsy looking for gastric cancer
What is Cushing's ulcer?
PUD/gastritis associated with neurologic trauma or tumor
What is Curling's ulcer?
PUD/gastritis associated with major burn injury
What is a marginal ulcer?
Ulcer at the margin of a GI anastamosis
What is Dieulafoy's ulcer?
Pinpoint gastric mucosal defect bleeding from an underlying vascular malformation
What are the symptoms of a perforated peptic ulcer?
Acute onset of upper abdominal pain
What causes pain in the lower quadrants with a perforated peptic ulcer?
Passage of perforated fluid along colic gutters
What are the signs of a perforated peptic ulcer?
Decreased bowel sounds, tympanic sound over liver (air), peritoneal signs, tender abdomen
What are the signs of posterior duodenal perforation?
Bleeding from the gastroduodenal artery (and possibly acute pancreatitis)
What sign indicates anterior duodenal perforation?
What is the differential diagnosis of perforated peptic ulcer?
Acute pancreatitis, acute cholecystitis, perforated acute appendicitis, colonic diverticulitis, MI, any perforated viscus
Which diagnostic tests are indicated for a perforated peptic ulcer?
XR: free air under diaphragm or in lesser sac in an upright CXR
What are the associated lab findings with a perforated peptic ulcer?
Leukocytosis, high serum amylase (secondary to absorption into the blood stream from the peritoneum)
What is the initial treatment for a perforated peptic ulcer?
NPO; NGT; IVF; Foley; antibiotics; PPIs; surgery
What is a Graham patch?
Piece of omentum incorporated into the suture closure of perforation
What are the surgical options for treatment of perforated gastric ulcers?
Antrectomy incorporating perforated ulcer;
Graham patch or wedge resection in unstable or poor operative candidates
What is the significance of hemorrhage and perforation with duodenal ulcers?
May indicate kissing ulcers; posterior is bleeding and anterior is perforated
What type of perforated ulcer may present just like acute pancreatitis?
Posterior perforated duodenal ulcer into the pancreas
What is the classic difference between duodenal and gastric ulcer symptoms as related to food ingestion?
Duodenal = decreased pain
Gastric = increased pain
What is a truncal vagotomy?
Resection of a 1-2 cm segment of each vagal trunk as it enters the abdomen on the distal esophagus, decreasing gastric acid secretion
What other procedure must be performed along with a truncal vagotomy?
Drainage procedure (e.g. pyloroplasty, antrectomy, or gastrojejunostomy)
What is a vagotomy and antrectomy?
Remove antrum and pylorus in addition to vagotomy; reconstruct as a Billroth I or II
What is the goal of duodenal ulcer surgery?
Decrease gastric acid secretion (and fix IHOP)
What is the advantage of proximal gastric vagotomy?
No drainage procedure is needed (vagal fibers to the pylorus are preserved)
What is a Billroth I?
Truncal vagotomy, antrectomy, and gastroduodenostomy
What are the contraindications for a Billroth I?
Gastric cancer or suspicion of gastric cancer
What is a Billroth II?
Truncal vagotomy, antrectomy, and gastrojejunostomy
What is the Kocher maneuver?
Dissect the left lateral peritoneal attachments to the duodenum to allow visualization of posterior duodenum
What is stress gastritis?
Superficial mucosal erosions in the stressed patient
What are the risk factors for stress gastritis?
Sepsis, intubation, trauma, shock, burn, brain injury
What is the prophylactic treatment for stress gastritis?
H2 blockers, PPIs, antacids, sucralfate
What are the signs and symptoms of stress gastritis?
NGT blood (usually), painless (usually)
How is stress gastritis diagnosed?
EGD, if bleeding is significant
What is the treatment for stress gastritis?
Lavage out blood clots, give a maximum dose of PPI in a 24-hour IV drip
What is Mallory-Weiss syndrome?
Post-retching, post-emesis longitudinal tear (submucosa and mucosa) of the stomach near the GE junction; approximately 75% are in the stomach
For what percentage of all upper GI bleeds does Mallory-Weiss syndrome account?
What are the causes of a Mallory-Weiss tear?
Increased gastric pressure, often aggravated by hiatal hernia
What are the risk factors for Mallory-Weiss syndrome?
Retching, alcoholism, hiatal hernia
What are the symptoms of Mallory-Weiss syndrome?
Epigastric pain, thoracic substernal pain, emesis, hematemesis
What percentage of patients with Mallory-Weiss syndrome will have hematemesis?
How is the diagnosis of Mallory-Weiss syndrome made?
What is the classic history of Mallory-Weiss syndrome?
Alcoholic patient after binge drinking: first, vomit food and gastric contents, followed by forceful retching and bloody vomitus
What is the treatment for Mallory-Weiss syndrome?
Room temperature water lavage, electrocautery, arterial embolization, or surgery for refractory bleeding
When is surgery indicated for Mallory-Weiss syndrome?
When medical/endoscopic treatment fails
Can the Senstaken-Blakemore tamponade balloon be used for treatment of Mallory-Weiss syndrome?
No, it makes bleeding worse
What is the problem with using shunts to treat portal hypertension?
Decreased portal pressure, but increased encephalopathy
What is Boerhaave's syndrome?
Post-emetic esophageal rupture
Why is the esophagus susceptible to perforation and more likely to break down an anastomosis?
What is the most common location of a Boerhaave tear?
Posterolateral aspect of the esophagus (on the left), 3-5 cm above the GE junction
What is the cause of Boerhaave's syndrome?
Increased intraluminal pressure, usually caused by violent retching and vomiting
What is the associated risk factor for Boerhaave's syndrome?
What are the symptoms of Boerhaave's syndrome?
Pain post-emesis (may radiate to back)
What are the signs of Boerhaave's syndrome?
Left pneumothorax, Hamman's sign, left pleural effusion, subcutaneous/mediastinal emphysema, fever, tachypnea, tachycardia, signs of infection by 24 hours, neck crepitus, widened mediastinum on CXR
What is Mackler's triad?
2. Lower chest pain
3. Cervical emphysema
What is Hamman's sign?
Mediastinal crunch or clicking produced by the heart beating against air-filled tissues
How is the diagnosis of Boerhaave's syndrome made?
H&P, CXR, esophagram with water-soluble contrast
What is the treatment for Boerhaave's syndrome?
Surgery within 24 hours to drain the mediastinum and surgically close the perforation and placement of pleural patch; broad-spectrum antibiotics