Upper GI Bleeding, C40 P254-270 Flashcards
(148 cards)
1
Q
What is it?
P254
A
Bleeding into the lumen of the proximal
GI tract, proximal to the ligament of
Treitz
2
Q
What are the signs/symptoms?
P254
A
Hematemesis, melena, syncope, shock, fatigue, coffee-ground emesis, hematochezia, epigastric discomfort, epigastric tenderness, signs of hypovolemia, guaiac-positive stools
3
Q
Why is it possible to have
hematochezia?
P254
A
Blood is a cathartic and hematochezia
usually indicates a vigorous rate of
bleeding from the UGI source
4
Q
Are stools melenic or melanotic?
P254
A
Melenic (melanotic is incorrect)
5
Q
How much blood do you
need to have melena?
P254
A
>50 cc of blood
6
Q
What are the risk factors?
P254
A
Alcohol, cigarettes, liver disease, burn/ trauma, aspirin/NSAIDs, vomiting, sepsis, steroids, previous UGI bleeding, history of peptic ulcer disease (PUD), esophageal varices, portal hypertension, splenic vein thrombosis, abdominal aortic aneurysm repair (aortoenteric fistula), burn injury, trauma
7
Q
What is the most common
cause of significant UGI
bleeding?
P255
A
PUD—duodenal and gastric ulcers (50%)
8
Q
What is the common
differential diagnosis of
UGI bleeding?
P255
A
- Acute gastritis
- Duodenal ulcer
- Esophageal varices
- Gastric ulcer
- Esophageal
- Mallory-Weiss tear
9
Q
What is the uncommon
differential diagnosis of
UGI bleeding?
P255
A
Gastric cancer, hemobilia, duodenal diverticula, gastric volvulus, Boerhaave’s syndrome, aortoenteric fistula, paraesophageal hiatal hernia, epistaxis, NGT irritation, Dieulafoy’s ulcer, angiodysplasia
10
Q
Which diagnostic tests are useful?
P255
A
History, NGT aspirate, abdominal x-ray,
endoscopy (EGD)
11
Q
What is the diagnostic test of
choice with UGI bleeding?
P255
A
EGD ( >95% diagnosis rate)
12
Q
What are the treatment
options with the endoscope
during an EGD?
P255
A
Coagulation, injection of epinephrine
(for vasoconstriction), injection of
sclerosing agents (varices), variceal ligation
(banding)
13
Q
Which lab tests should be performed?
P255
A
Chem-7, bilirubin, LFTs, CBC,
type & cross, PT/PTT, amylase
14
Q
Why is BUN elevated?
P255
A
Because of absorption of blood by the GI
tract
15
Q
What is the initial treatment?
P255
A
1. IVFs (16 G or larger peripheral
IVS x 2), Foley catheter (monitor
fluid status)
2. NGT suction (determine rate and
amount of blood)
3. Water lavage (use warm H(2)O—will
remove clots)
4. EGD: endoscopy (determine etiology/
location of bleeding and possible
treatment—coagulate bleeders)
16
Q
Why irrigate in an upper GI bleed?
P256
A
To remove the blood clot so you can see
the mucosa
17
Q
What test may help identify the site of MASSIVE UGI bleeding when EGD fails to diagnose cause and blood continues per NGT? P256
A
Selective mesenteric angiography
18
Q
What are the indications for
surgical intervention in UGI
bleeding?
P256
A
Refractory or recurrent bleeding and site
known, >3 u PRBCS to stabilize or
>6 u PRBCs overall
19
Q
What percentage of patients
require surgery?
P256
A
≈10%
20
Q
What percentage of patients
spontaneously stop bleeding?
P256
A
≈80% to 85%
21
Q
What is the mortality of acute
UGI bleeding?
P256
A
Overall 10%, 60–80 years of age 15%,
older than 80 years of age 25%
22
Q
What are the risk factors for
death following UGI bleed?
P256
A
Age older than 60 years
Shock
>5 units of PRBC transfusion
Concomitant health problems
23
Q
PEPTIC ULCER DISEASE (PUD)
What is it?
P256
A
Gastric and duodenal ulcers
24
Q
PEPTIC ULCER DISEASE (PUD)
What is the incidence in the
United States?
P256
A
≈10% of the population will suffer from
PUD during their lifetime!
25
PEPTIC ULCER DISEASE (PUD)
What are the possible
consequences of PUD?
P256
Pain, hemorrhage, perforation, obstruction
26
```
PEPTIC ULCER DISEASE (PUD)
What percentage of patients
with PUD develops bleeding
from the ulcer?
P256
```
≈20%
27
PEPTIC ULCER DISEASE (PUD)
Which bacteria are associated with PUD?
P256
Helicobacter pylori
28
PEPTIC ULCER DISEASE (PUD)
What is the treatment?
P257
```
Treat H. pylori with MOC or ACO
2-week antibiotic regimens:
MOC: Metronidazole, Omeprazole,
Clarithromycin (Think: MOCk)
or
ACO: Ampicillin, Clarithromycin,
Omeprazole
```
29
```
PEPTIC ULCER DISEASE (PUD)
What is the name of the sign
with RLQ pain/peritonitis as
a result of succus collecting
from a perforated peptic ulcer?
P257
```
Valentino’s sign
30
DUODENAL ULCERS
In which age group are
these ulcers most common?
P257
40–65 years of age (younger than
| patients with gastric ulcer)
31
DUODENAL ULCERS
What is the ratio of male to
female patients?
P257
Men > women (3:1)
32
DUODENAL ULCERS
What is the most common location?
P257
Most are within 2 cm of the pylorus in
| the duodenal bulb
33
DUODENAL ULCERS
What is the classic pain
response to food intake?
P257
Food classically relieves duodenal ulcer pain (Think: Duodenum = Decreased with food)
34
DUODENAL ULCERS
What is the cause?
P257
Increased production of gastric acid
35
```
DUODENAL ULCERS
What syndrome must you
always think of with a
duodenal ulcer?
P257
```
Zollinger-Ellison syndrome
36
DUODENAL ULCERS
What are the associated risk factors?
P257
Male gender, smoking, aspirin and other
NSAIDs, uremia, Z-E syndrome,
H. pylori, trauma, burn injury
37
DUODENAL ULCERS
What are the symptoms?
P257
Epigastric pain—burning or aching, usually
several hours after a meal (food, milk,
or antacids initially relieve pain)
Bleeding
Back pain
Nausea, vomiting, and anorexia
↓ appetite
38
DUODENAL ULCERS
What are the signs?
P258
Tenderness in epigastric area (possibly),
guaiac-positive stool, melena,
hematochezia, hematemesis
39
DUODENAL ULCERS
What is the differential diagnosis?
P258
Acute abdomen, pancreatitis, cholecystitis,
all causes of UGI bleeding, Z-E
syndrome, gastritis, MI, gastric ulcer,
reflux
40
DUODENAL ULCERS
How is the diagnosis made?
P258
History, PE, EGD, UGI series
| if patient is not actively bleeding
41
DUODENAL ULCERS
When is surgery indicated
with a bleeding duodenal ulcer?
P258
Most surgeons use: >6 u PRBC
transfusions, >3 u PRBCs needed to
stabilize, or significant rebleed
42
DUODENAL ULCERS
What EGD finding is
associated with rebleeding?
P258
Visible vessel in the ulcer crater, recent
| clot, active oozing
43
DUODENAL ULCERS
What is the medical treatment?
P258
PPIs (proton pump inhibitors) or H(2)
receptor antagonists—heal ulcers in
4 to 6 weeks in most cases
Treatment for H. pylori
44
DUODENAL ULCERS
When is surgery indicated?
P258
```
The acronym “I HOP”:
Intractability
Hemorrhage (massive or relentless)
Obstruction (gastric outlet obstruction)
Perforation
```
45
DUODENAL ULCERS
How is a bleeding duodenal
ulcer surgically corrected?
P258
Opening of the duodenum through the
pylorus
Oversewing of the bleeding vessel
46
DUODENAL ULCERS
What artery is involved with
bleeding duodenal ulcers?
P258
Gastroduodenal artery
47
```
DUODENAL ULCERS
What are the common surgical options for the
following conditions:
Truncal vagotomy?
P258
```
Pyloroplasty
48
```
DUODENAL ULCERS
What are the common surgical options for the
following conditions:
Duodenal perforation?
P259
```
```
Graham patch (poor candidates, shock,
prolonged perforation)
Truncal vagotomy and pyloroplasty
incorporating ulcer
Graham patch and highly selective
vagotomy
Truncal vagotomy and antrectomy
(higher mortality rate, but lowest
recurrence rate)
```
49
DUODENAL ULCERS
What are the common surgical options for the
following conditions:
Duodenal obstruction resulting from duodenal
ulcer scarring (gastric outlet obstruction)?
P259
Truncal vagotomy, antrectomy, and
gastroduodenostomy (BI or BII)
Truncal vagotomy and drainage procedure
(gastrojejunostomy)
50
```
DUODENAL ULCERS
What are the common surgical options for the
following conditions:
Duodenal ulcer intractability?
P259
```
```
PGV (highly selective vagotomy)
Vagotomy and pyloroplasty
Vagotomy and antrectomy BI or BII
(especially if there is a coexistent
pyloric/prepyloric ulcer) but
associated with a higher mortality
```
51
```
DUODENAL ULCERS
Which ulcer operation has
the highest ulcer recurrence
rate and the lowest dumping
syndrome rate?
P259
```
PGV (proximal gastric vagotomy)
52
```
DUODENAL ULCERS
Which ulcer operation has
the lowest ulcer recurrence
rate and the highest
dumping syndrome rate?
P259
```
Vagotomy and antrectomy
53
```
DUODENAL ULCERS
Why must you perform a
drainage procedure
(pyloroplasty, antrectomy)
after a truncal vagotomy?
P259
```
Pylorus will not open after a truncal
| vagotomy
54
```
DUODENAL ULCERS
Which duodenal ulcer
operation has the lowest
mortality rate?
P259
```
```
PGV (1/200 mortality), truncal vagotomy
and pyloroplasty (1–2/200), vagotomy
and antrectomy (1%–2% mortality)
Thus, PGV is the operation of choice
for intractable duodenal ulcers with
the cost of increased risk of ulcer
recurrence
```
55
DUODENAL ULCERS
What is a “kissing” ulcer?
P260
Two ulcers, each on opposite sides of the
| lumen so that they can “kiss”
56
DUODENAL ULCERS
Why may a duodenal rupture
be initially painless?
P260
Fluid can be sterile, with a nonirritating
| pH of 7.0 initially
57
DUODENAL ULCERS
Why may a perforated duodenal ulcer present as lower quadrant abdominal pain?
P260
Fluid from stomach/bile drains down
paracolic gutters to lower quadrants and
causes localized irritation
58
GASTRIC ULCERS
In which age group are these
ulcers most common?
P260
40–70 years old (older than the duodenal
ulcer population)
Rare in patients younger than 40 years
59
GASTRIC ULCERS
How does the incidence in
men compare with that of women?
P260
Men > women
60
GASTRIC ULCERS
Which is more common
overall: gastric or duodenal ulcers?
P260
Duodenal ulcers are more than twice as
common as gastric ulcers
(Think: Duodenal = Double rate)
61
GASTRIC ULCERS
What is the classic pain
response to food?
P260
Food classically increases gastric ulcer
| pain
62
GASTRIC ULCERS
What is the cause?
P260
Decreased cytoprotection or gastric
protection (i.e., decreased bicarbonate/
mucous production)
63
GASTRIC ULCERS
Is gastric acid production
high or low?
P260
Gastric acid production is normal or low!
64
```
GASTRIC ULCERS
Which gastric ulcers are
associated with increased
gastric acid?
P260
```
Prepyloric
Pyloric
Coexist with duodenal ulcers
65
GASTRIC ULCERS
What are the associated risk factors?
P260
Smoking, alcohol, burns, trauma, CNS
tumor/trauma, NSAIDs, steroids, shock,
severe illness, male gender, advanced age
66
GASTRIC ULCERS
What are the symptoms?
P260
Epigastric pain
| +/- Vomiting, anorexia, and nausea
67
GASTRIC ULCERS
How is the diagnosis made?
P261
History, PE, EGD with multiple biopsy
| looking for gastric cancer
68
GASTRIC ULCERS
What is the most common location?
P261
≈70% are on the lesser curvature; 5% are
| on the greater curvature
69
GASTRIC ULCERS
When and why should biopsy
be performed?
P261
With all gastric ulcers, to rule out gastric
cancer
If the ulcer does not heal in 6 weeks after
medical treatment, rebiopsy (always
biopsy in O.R. also) must be performed
70
GASTRIC ULCERS
What is the medical treatment?
P261
Similar to that of duodenal ulcer—PPIs or
| H(2) blockers, Helicobacter pylori treatment
71
```
GASTRIC ULCERS
When do patients with
gastric ulcers need to have
an EGD?
P261
```
1. For diagnosis with biopsies
2. 6 weeks postdiagnosis to confirm
healing and rule out gastric cancer!
72
GASTRIC ULCERS
What are the indications for surgery?
P261
The acronym “I CHOP”:
Intractability
```
Cancer (rule out)
Hemorrhage (massive or relentless)
Obstruction (gastric outlet obstruction)
Perforation
(Note: Surgery is indicated if gastric
cancer cannot be ruled out)
```
73
```
GASTRIC ULCERS
What is the common
operation for hemorrhage,
obstruction, and perforation?
P261
```
```
Distal gastrectomy with excision of the
ulcer without vagotomy unless there is
duodenal disease (i.e., BI or BII)
```
74
```
GASTRIC ULCERS
What are the options for
concomitant duodenal and
gastric ulcers?
P261
```
Resect (BI, BII) and truncal vagotomy
75
```
GASTRIC ULCERS
What is a common option
for surgical treatment of a
pyloric gastric ulcer?
P261
```
Truncal vagotomy and antrectomy
| i.e., BI or BII
76
```
c
What is a common option for
a poor operative candidate
with a perforated gastric ulcer?
P261
```
Graham patch
77
GASTRIC ULCERS
What must be performed in
every operation for gastric ulcers?
P262
Biopsy looking for gastric cancer
78
GASTRIC ULCERS
Define the following terms:
Cushing’s ulcer
P262
PUD/gastritis associated with neurologic
trauma or tumor
(Think: Dr. Cushing = NeuroSurgeon = CNS)
79
GASTRIC ULCERS
Define the following terms:
Curling’s ulcer
P262
PUD/gastritis associated with major burn
| injury (Think: curling iron burn)
80
GASTRIC ULCERS
Define the following terms:
Marginal ulcer
P262
Ulcer at the margin of a GI anastomosis
81
GASTRIC ULCERS
Define the following terms:
P262
Dieulafoy’s ulcer
82
PERFORATED PEPTIC ULCER
What are the symptoms?
P262
Acute onset of upper abdominal pain
83
PERFORATED PEPTIC ULCER
What causes pain in the
lower quadrants?
P262
Passage of perforated fluid along colic
| gutters
84
PERFORATED PEPTIC ULCER
What are the signs?
P262
Decreased bowel sounds, tympanic
sound over the liver (air), peritoneal
signs, tender abdomen
85
PERFORATED PEPTIC ULCER
What are the signs of posterior duodenal erosion/perforation?
P262
Bleeding from gastroduodenal artery
| and possibly acute pancreatitis
86
PERFORATED PEPTIC ULCER
What sign indicates anterior
duodenal perforation?
P262
```
Free air (anterior perforation is more
common than posterior)
```
87
PERFORATED PEPTIC ULCER
What is the differential diagnosis?
P262
Acute pancreatitis, acute cholecystitis,
perforated acute appendicitis, colonic
diverticulitis, MI, any perforated viscus
88
PERFORATED PEPTIC ULCER
Which diagnostic tests are indicated?
P262
```
X-ray: free air under diaphragm or in
lesser sac in an upright CXR (if upright
CXR is not possible, then left lateral
decubitus can be performed because air
can be seen over the liver and not
confused with the gastric bubble)
```
89
PERFORATED PEPTIC ULCER
What are the associated lab findings?
P263
Leukocytosis, high amylase serum
(secondary to absorption into the blood
stream from the peritoneum)
90
PERFORATED PEPTIC ULCER
What is the initial treatment?
P263
```
NPO: NGT (↓ contamination of the
peritoneal cavity)
IVF/Foley catheter
Antibiotics/PPIs
Surgery
```
91
PERFORATED PEPTIC ULCER
What is a Graham patch?
P263
Piece of omentum incorporated into the
| suture closure of perforation
92
```
PERFORATED PEPTIC ULCER
What are the surgical
options for treatment of a
duodenal perforation?
P263
```
```
Graham patch (open or laparoscopic)
Truncal vagotomy and pyloroplasty
incorporating ulcer
Graham patch and highly selective
vagotomy
```
93
PERFORATED PEPTIC ULCER
What are the surgical options
for perforated gastric ulcer?
P263
Antrectomy incorporating perforated
ulcer, Graham patch or wedge resection
in unstable/poor operative candidates
94
```
PERFORATED PEPTIC ULCER
What is the significance of
hemorrhage and perforation
with duodenal ulcer?
P263
```
May indicate two ulcers (kissing);
posterior is bleeding and anterior is
perforated with free air
95
```
PERFORATED PEPTIC ULCER
What type of perforated
ulcer may present just like
acute pancreatitis?
P263
```
Posterior perforated duodenal ulcer
into the pancreas (i.e., epigastric pain
radiating to the back; high serum
amylase)
96
```
PERFORATED PEPTIC ULCER
What is the classic difference
between duodenal and
gastric ulcer symptoms as
related to food ingestion?
P263
```
Duodenal = decreased pain
Gastric = increased pain
(Think: Duodenal = Decreased pain)
97
TYPES OF SURGERIES
Define the following terms:
Graham patch
P264
```
For treatment of duodenal perforation in
poor operative candidates/unstable
patients
Place viable omentum over perforation
and tack into place with sutures
```
98
TYPES OF SURGERIES
Define the following terms:
Truncal vagotomy
P264
Resection of a 1- to 2-cm segment of
each vagal trunk as it enters the
abdomen on the distal esophagus,
decreasing gastric acid secretion
99
```
TYPES OF SURGERIES
What other procedure must
be performed along with a
truncal vagotomy?
P264
```
```
“Drainage procedure” (pyloroplasty,
antrectomy, or gastrojejunostomy),
because vagal fibers provide relaxation of
the pylorus, and, if you cut them, the
pylorus will not open
```
100
TYPES OF SURGERIES
Define the following terms:
Vagotomy and pyloroplasty
P264 (picture)
Pyloroplasty performed with vagotomy to
| compensate for decreased gastric emptying
101
TYPES OF SURGERIES
Define the following terms:
Vagotomy and antrectomy
P265
Remove antrum and pylorus in addition
to vagotomy; reconstruct as a Billroth
I or II
102
TYPES OF SURGERIES
What is the goal of duodenal
ulcer surgery?
P265
Decrease gastric acid secretion (and fix
| IHOP)
103
```
TYPES OF SURGERIES
What is the advantage of
proximal gastric vagotomy
(highly selective vagotomy)?
P265 (picture)
```
No drainage procedure is needed; vagal
fibers to the pylorus are preserved; rate
of dumping syndrome is low
104
TYPES OF SURGERIES
What is a Billroth I (BI)?
P265 (picture)
Truncal vagotomy, antrectomy, and
gastroduodenostomy (Think: BI = ONE
limb off of the stomach remnant)
105
TYPES OF SURGERIES
What are the contraindica-tions for a Billroth I?
P265
Gastric cancer or suspicion of gastric
| cancer
106
TYPES OF SURGERIES
What is a Billroth II (BII)?
P266 (picture)
Truncal vagotomy, antrectomy, and
gastrojejunostomy (Think: BII = TWO
limbs off of the stomach remnant)
107
TYPES OF SURGERIES
What is the Kocher maneuver?
P266
Dissect the left lateral peritoneal
attachments to the duodenum to allow
visualization of posterior duodenum
108
STRESS GASTRITIS
What is it?
P266
Superficial mucosal erosions in the
| stressed patient
109
STRESS GASTRITIS
What are the risk factors?
P266
Sepsis, intubation, trauma, shock, burn,
| brain injury
110
STRESS GASTRITIS
What is the prophylactic treatment?
P266
H(2) blockers, PPIs, antacids, sucralfate
111
STRESS GASTRITIS
What are the signs/symptoms?
P266
NGT blood (usually), painless (usually)
112
STRESS GASTRITIS
How is it diagnosed?
P266
EGD, if bleeding is significant
113
STRESS GASTRITIS
What is the treatment for gastritis?
P266
LAVAGE out blood clots, give a maximum
| dose of PPI in a 24-hour IV drip
114
MALLORY-WEISS SYNDROME
What is it?
P266
Post-retching, postemesis longitudinal
tear (submucosa and mucosa) of the
stomach near the GE junction; approximately
three fourths are in the stomach
115
```
MALLORY-WEISS SYNDROME
For what percentage of all
upper GI bleeds does this
syndrome account?
P267
```
≈10%
116
MALLORY-WEISS SYNDROME
What are the causes of a tear?
P267
Increased gastric pressure, often
| aggravated by hiatal hernia
117
MALLORY-WEISS SYNDROME
What are the risk factors?
P267
Retching, alcoholism (50%), >50% of
| patients have hiatal hernia
118
MALLORY-WEISS SYNDROME
What are the symptoms?
P267
Epigastric pain, thoracic substernal pain,
| emesis, hematemesis
119
MALLORY-WEISS SYNDROME
What percentage of patients
will have hematemesis?
P267
85%
120
MALLORY-WEISS SYNDROME
How is the diagnosis made?
P267
EGD
121
MALLORY-WEISS SYNDROME
What is the “classic” history?
P267
Alcoholic patient after binge drinking—
first, vomit food and gastric contents,
followed by forceful retching and bloody
vomitus
122
MALLORY-WEISS SYNDROME
What is the treatment?
P267
Room temperature water lavage (90% of
patients stop bleeding), electrocautery,
arterial embolization, or surgery for
refractory bleeding
123
MALLORY-WEISS SYNDROME
When is surgery indicated?
P267
When medical/endoscopic treatment fails
| >6 u PRBCs infused
124
```
MALLORY-WEISS SYNDROME
Can the Sengstaken-
Blakemore tamponade
balloon be used for
treatment of Mallory-Weiss
tear bleeding?
P267
```
No, it makes bleeding worse
Use the balloon only for bleeding
from esophageal varices
125
ESOPHAGEAL VARICEAL BLEEDING
What is it?
P267
```
Bleeding from formation of esophageal
varices from back up of portal pressure
via the coronary vein to the submucosal
esophageal venous plexuses secondary to
portal hypertension from liver cirrhosis
```
126
```
ESOPHAGEAL VARICEAL BLEEDING
What is the “rule of two
thirds” of esophageal
variceal hemorrhage?
P268
```
```
Two thirds of patients with portal
hypertension develop esophageal
varices
Two thirds of patients with esophageal
varices bleed
```
127
ESOPHAGEAL VARICEAL BLEEDING
What are the signs/symptoms?
P268
Liver disease, portal hypertension,
| hematemesis, caput medusa, ascites
128
ESOPHAGEAL VARICEAL BLEEDING
How is the diagnosis made?
P268
```
EGD (very important because only 50%
of UGI bleeding in patients with known
esophageal varices are bleeding from the
varices; the other 50% have bleeding
from ulcers, etc.)
```
129
ESOPHAGEAL VARICEAL BLEEDING
What is the acute medical treatment?
P268
Lower portal pressure with somatostatin
| and vasopressin
130
```
ESOPHAGEAL VARICEAL BLEEDING
In the patient with CAD,
what must you give in
addition to the vasopressin?
P268
```
Nitroglycerin—to prevent coronary
artery vasoconstriction that may result
in an MI
131
ESOPHAGEAL VARICEAL BLEEDING
What are the treatment options?
P268
Sclerotherapy or band ligation via
| endoscope, TIPS, liver transplant
132
ESOPHAGEAL VARICEAL BLEEDING
What is the Sengstaken-
Blakemore balloon?
P268
Tamponades with an esophageal balloon
| and a gastric balloon
133
ESOPHAGEAL VARICEAL BLEEDING
What is the problem with shunts?
P269
Decreased portal pressure, but increased
| encephalopathy
134
BOERHAAVE’S SYNDROME
What is it?
P269
Postemetic esophageal rupture
135
BOERHAAVE’S SYNDROME
Who was Dr. Boerhaave?
P269
Dutch physician who first described the
syndrome in the Dutch Grand Admiral
Van Wassenaer in 1724
136
```
BOERHAAVE’S SYNDROME
Why is the esophagus
susceptible to perforation
and more likely to break
down an anastomosis?
P269
```
No serosa
137
BOERHAAVE’S SYNDROME
What is the most common location?
P269
Posterolateral aspect of the esophagus (on
| the left), 3 to 5 cm above the GE junction
138
BOERHAAVE’S SYNDROME
What is the cause of rupture?
P269
Increased intraluminal pressure, usually
| caused by violent retching and vomiting
139
BOERHAAVE’S SYNDROME
What is the associated risk factor?
P269
Esophageal reflux disease (50%)
140
BOERHAAVE’S SYNDROME
What are the symptoms?
P269
```
Pain postemesis (may radiate to the back,
dysphagia)
```
141
BOERHAAVE’S SYNDROME
What are the signs?
P269
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
142
BOERHAAVE’S SYNDROME
What is Mackler’s triad?
P269
1. Emesis
2. Lower chest pain
3. Cervical emphysema (subQ air)
143
BOERHAAVE’S SYNDROME
What is Hamman’s sign?
P269
“Mediastinal crunch or clicking”
produced by the heart beating against
air-filled tissues
144
BOERHAAVE’S SYNDROME
How is the diagnosis made?
P269
History, physical examination, CXR,
| esophagram with water-soluble contrast
145
BOERHAAVE’S SYNDROME
What is the treatment?
P270
Surgery within 24 hours to drain the
mediastinum and surgically close the
perforation and placement of pleural
patch; broad-spectrum antibiotics
146
```
BOERHAAVE’S SYNDROME
What is the mortality rate
if less than 24 hours until
surgery for perforated
esophagus?
P270
```
≈15%
147
```
BOERHAAVE’S SYNDROME
What is the mortality rate
if more than 24 hours until
surgery for perforated
esophagus?
P270
```
≈33%
148
```
BOERHAAVE’S SYNDROME
Overall, what is the
most common cause of
esophageal perforation?
P270
```
Iatrogenic (most commonly cervical
| esophagus)
