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Flashcards in Upper GI Bleeding Deck (132):
1

What is upper GI bleeding?

Bleeding into the lumen of the proximal GI tract, proximal to the ligament of Treitz

2

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

3

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

4

Are stools melenic or melanotic?

Melenic

5

How much blood do you need to have melena?

> 50 cc

6

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

7

What is the most common cause of significant upper GI bleeding?

PUD

8

What is the common differential diagnosis of upper GI bleeding?

1. Acute gastritis
2. DU
3. Esophageal varices
4. GU
5. Esophageal
6. Mallory-Weiss tear

9

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

10

Which diagnostic tests are useful for upper GI bleeding?

History, NGT aspirate, AXR, EGD

11

What is the diagnostic test of choice with upper GI bleeding?

EGD

12

What are the treatment options with the endoscope during an EGD?

Coagulation, injection of epinephrine, injection of sclerosing agents, variceal ligation

13

Which lab tests should be performed for upper GI bleeding?

BMP, bilirubin, LFTs, CBC, T&C, PT/PTT, amylase

14

Why is BUN elevated with upper GI bleeding?

Because of absorption of blood by the GI tract

15

What is the initial treatment for upper GI bleeding?

IVFs, Foley, NGT suction (determine rate), water lavage (remove clots), EGD

16

Why irrigate in an upper GI bleed?

To remove the blood clot so you can see the mucosa

17

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

18

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

19

What percentage of patients with upper GI bleeding require surgery?

10%

20

What percentage of patients with upper GI bleeding spontaneously stop bleeding?

80-85%

21

What is the mortality of acute upper GI bleeding?

Overall 10%

22

What are the risk factors for death following an upper GI bleed?

Age older than 60; shock; > 5u PRBC transfusion; concomitant health problems

23

What is PUD?

Peptic Ulcer Disease

24

What is the incidence of PUD in the US?

10%

25

What are the possible consequences of PUD?

Pain, hemorrhage, perforation, obstruction

26

What percentage of patients with PUD develops bleeding from the ulcer?

20%

27

Which bacteria are associated with PUD?

H. pylori

28

What is the treatment for H. pylori infection?

2-week regimen of either:
MOC: Metronidazole, Omeprazole, Clarithromycin
ACO: Ampicillin, Clarithromycin, Omeprazole

29

What is the name of the sign with RLQ pain/peritonitis as a result of succus collecting from a perforated peptic ulcer?

Valentino's sign

30

In which age group are duodenal ulcers most common?

40-65 years

31

What is the male:female ratio for duodenal ulcers?

3:1

32

What is the most common location for duodenal ulcers?

Most are within 2 cm of the pylorus in the duodenal bulb

33

What is the classic pain response to food intake with duodenal ulcers?

Food classically relieves duodenal ulcer pain

34

What is the cause of duodenal ulcers?

Increased production of gastric acid

35

What syndrome must you always think of with a duodenal ulcer?

Zollinger-Ellison syndrome

36

What are the risk factors for duodenal ulcers?

Male, smoking, NSAIDs, uremia, ZES, H. pylori, trauma, burns

37

What are the symptoms of duodenal ulcers?

Epigastric pain (burning, aching, usually several hours postprandial), bleeding, back pain, N/V, anorexia

38

What are the signs of duodenal ulcers?

Tenderness in the epigastric area, guaiac-positive stool, melena, hematochezia, hematemesis

39

What is the differential diagnosis of duodenal ulcers?

Acute abdomen, pancreatitis, cholecystitis, ZES, gastritis, MI, GU, reflux

40

How is the diagnosis of duodenal ulcer made?

H&P, EGD, UGI series

41

When is surgery indicated with a bleeding duodenal ulcer?

> 6 u PRBC overall; > 3 u PRBC to stabilize; significant rebleed

42

What EGD finding is associated with rebreeding of a duodenal ulcer?

Visible vessel in the ulcer crater, recent clot, active oozing

43

What is the medical treatment of duodenal ulcers?

PPIs or H2 receptor antagonists; treat H. pylori

44

When is surgery indicated for a duodenal ulcer?

I HOP:
Intractability
Hemorrhage
Obstruction
Perforation

45

How is a bleeding duodenal ulcer surgically corrected?

Opening of the duodenum through the pylorus and oversewing of the bleeding vessel

46

What artery is involved with bleeding duodenal ulcers?

Gastroduodenal artery

47

What are the common surgical options for duodenal perforation?

Graham patch;
Truncal vagotomy and pyloroplasty incorporating ulcer;
Graham patch and highly selective vagotomy;
Truncal vagotomy and antrectomy

48

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)

49

What are the common surgical options for duodenal ulcer intractability?

PGV (highly selective vagotomy);
Vagotomy and pyloroplasty
Vagotomy and antrectomy BI or BII

50

Which ulcer operation has the highest ulcer recurrence rate and the lowest dumping syndrome rate?

PGV (proximal gastric vagotomy)

51

Which ulcer operation has the lowest ulcer recurrence rate and the highest dumping syndrome rate?

Vagotomy and antrectomy

52

Why must you perform a drainage procedure (e.g. pyloroplasty, antrectomy) after a truncal vagotomy?

Pylorus will not open after a truncal vagotomy

53

Which duodenal ulcer operation has the lowest mortality rate?

PGV

54

What is a "kissing" ulcer?

Two ulcers, each on opposite sides of the lumen

55

Why may a duodenal rupture be initially painless?

Fluid can be sterile, with a non-irritating pH of 7.0 initially

56

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

57

In which age group are gastric ulcers most common?

40-70 years

58

Which is more common overall: gastric or duodenal ulcers?

Duodenal (> 2 fold)

59

What is the classic pain response to food with gastric ulcers?

Food classically increases gastric ulcer pain

60

What is the cause of gastric ulcers?

Decreased cytoprotection or gastric protection (i.e. decreased bicarbonate or mucous production)

61

Is gastric acid production high or low with gastric ulcers?

Normal or low.

62

Which gastric ulcers are associated with increased gastric acid?

Prepyloric and pyloric

63

What are the associated risk factors for gastric ulcers?

Smoking, alcohol, burns, trauma, CNS tumor, NSAIDs, steroids, shock, severe illness, male, advanced age

64

What are the symptoms of gastric ulcers?

Epigastric pain, +/- N/V, anorexia

65

How is the diagnosis of gastric ulcer made?

H&P, EGD with multiple biopsy

66

What is the most common location for gastric ulcers?

Lesser curvature

67

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

68

What is the medical treatment for gastric ulcers?

PPIs or H2 blockers, treatment of H. pylori

69

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

70

What are the indications for surgery for gastric ulcers?

I CHOP
Intractability
Cancer (rule out)
Hemorrhage
Obstruction
Perforation

71

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

72

What are the options for concomitant duodenal and gastric ulcers?

Resect (BI, BII) and truncal vagotomy

73

What is a common option for surgical treatment of a pyloric gastric ulcer?

Truncal vagotomy and antrectomy (BI or BII)

74

What is a common option for a poor operative candidate with a perforated gastric ulcer?

Graham patch

75

What must be performed in every operation for gastric ulcers?

Biopsy looking for gastric cancer

76

What is Cushing's ulcer?

PUD/gastritis associated with neurologic trauma or tumor

77

What is Curling's ulcer?

PUD/gastritis associated with major burn injury

78

What is a marginal ulcer?

Ulcer at the margin of a GI anastamosis

79

What is Dieulafoy's ulcer?

Pinpoint gastric mucosal defect bleeding from an underlying vascular malformation

80

What are the symptoms of a perforated peptic ulcer?

Acute onset of upper abdominal pain

81

What causes pain in the lower quadrants with a perforated peptic ulcer?

Passage of perforated fluid along colic gutters

82

What are the signs of a perforated peptic ulcer?

Decreased bowel sounds, tympanic sound over liver (air), peritoneal signs, tender abdomen

83

What are the signs of posterior duodenal perforation?

Bleeding from the gastroduodenal artery (and possibly acute pancreatitis)

84

What sign indicates anterior duodenal perforation?

Free air

85

What is the differential diagnosis of perforated peptic ulcer?

Acute pancreatitis, acute cholecystitis, perforated acute appendicitis, colonic diverticulitis, MI, any perforated viscus

86

Which diagnostic tests are indicated for a perforated peptic ulcer?

XR: free air under diaphragm or in lesser sac in an upright CXR

87

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)

88

What is the initial treatment for a perforated peptic ulcer?

NPO; NGT; IVF; Foley; antibiotics; PPIs; surgery

89

What is a Graham patch?

Piece of omentum incorporated into the suture closure of perforation

90

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

91

What is the significance of hemorrhage and perforation with duodenal ulcers?

May indicate kissing ulcers; posterior is bleeding and anterior is perforated

92

What type of perforated ulcer may present just like acute pancreatitis?

Posterior perforated duodenal ulcer into the pancreas

93

What is the classic difference between duodenal and gastric ulcer symptoms as related to food ingestion?

Duodenal = decreased pain
Gastric = increased pain

94

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

95

What other procedure must be performed along with a truncal vagotomy?

Drainage procedure (e.g. pyloroplasty, antrectomy, or gastrojejunostomy)

96

What is a vagotomy and antrectomy?

Remove antrum and pylorus in addition to vagotomy; reconstruct as a Billroth I or II

97

What is the goal of duodenal ulcer surgery?

Decrease gastric acid secretion (and fix IHOP)

98

What is the advantage of proximal gastric vagotomy?

No drainage procedure is needed (vagal fibers to the pylorus are preserved)

99

What is a Billroth I?

Truncal vagotomy, antrectomy, and gastroduodenostomy

100

What are the contraindications for a Billroth I?

Gastric cancer or suspicion of gastric cancer

101

What is a Billroth II?

Truncal vagotomy, antrectomy, and gastrojejunostomy

102

What is the Kocher maneuver?

Dissect the left lateral peritoneal attachments to the duodenum to allow visualization of posterior duodenum

103

What is stress gastritis?

Superficial mucosal erosions in the stressed patient

104

What are the risk factors for stress gastritis?

Sepsis, intubation, trauma, shock, burn, brain injury

105

What is the prophylactic treatment for stress gastritis?

H2 blockers, PPIs, antacids, sucralfate

106

What are the signs and symptoms of stress gastritis?

NGT blood (usually), painless (usually)

107

How is stress gastritis diagnosed?

EGD, if bleeding is significant

108

What is the treatment for stress gastritis?

Lavage out blood clots, give a maximum dose of PPI in a 24-hour IV drip

109

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

110

For what percentage of all upper GI bleeds does Mallory-Weiss syndrome account?

10%

111

What are the causes of a Mallory-Weiss tear?

Increased gastric pressure, often aggravated by hiatal hernia

112

What are the risk factors for Mallory-Weiss syndrome?

Retching, alcoholism, hiatal hernia

113

What are the symptoms of Mallory-Weiss syndrome?

Epigastric pain, thoracic substernal pain, emesis, hematemesis

114

What percentage of patients with Mallory-Weiss syndrome will have hematemesis?

85%

115

How is the diagnosis of Mallory-Weiss syndrome made?

EGD

116

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

117

What is the treatment for Mallory-Weiss syndrome?

Room temperature water lavage, electrocautery, arterial embolization, or surgery for refractory bleeding

118

When is surgery indicated for Mallory-Weiss syndrome?

When medical/endoscopic treatment fails

119

Can the Senstaken-Blakemore tamponade balloon be used for treatment of Mallory-Weiss syndrome?

No, it makes bleeding worse

120

What is the problem with using shunts to treat portal hypertension?

Decreased portal pressure, but increased encephalopathy

121

What is Boerhaave's syndrome?

Post-emetic esophageal rupture

122

Why is the esophagus susceptible to perforation and more likely to break down an anastomosis?

No serosa

123

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

124

What is the cause of Boerhaave's syndrome?

Increased intraluminal pressure, usually caused by violent retching and vomiting

125

What is the associated risk factor for Boerhaave's syndrome?

GERD

126

What are the symptoms of Boerhaave's syndrome?

Pain post-emesis (may radiate to back)

127

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

128

What is Mackler's triad?

1. Emesis
2. Lower chest pain
3. Cervical emphysema

129

What is Hamman's sign?

Mediastinal crunch or clicking produced by the heart beating against air-filled tissues

130

How is the diagnosis of Boerhaave's syndrome made?

H&P, CXR, esophagram with water-soluble contrast

131

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

132

What is the most common cause of esophageal perforation?

Iatrogenic