DSA 2: N/V, Dyspepsia, Heartburn, Hematemesis Flashcards
How do you stabilize a pt w/ UGIB
2 large bore (>=18 gauge) IV
unstable pts (signs of shock) –> IVF 0.9% NaCl (aka normal saline) or Lactated Ringer (LR)
ABCs: airway/breathing/circulation
proceed w/ hx, PE, and work up
CBC, PTT/INR, serum creatinine (BUN/Cr ration usually atleast 30:1 in most UGIB), liver enxymes, blood typeing & screen incase transfusion is needed
what are possible etiologies of gastroparesis
endocrine: DM, hypothyroid
infxn: post viral, chagas
postsurgical: vagotomy, partial gastric resection, fundoplication, gastric bypass, whipple)
neurologic: parkinsons, MS, postpolio syndrome, porphorya
rheumatologic syndromes
amyloidosis, medications, eating disorder, paraneoplastic syndrome, or Idiopathic
what is the presentation of gastroparesis & how do you diagnose
intermittent, waxing & waning symptoms
signs of gastric obstruction in the absence of any mechanical lesion (look for obstruction if abd pain present)
chronic/intermittent postprandial fullness (early satiety)
N/V 1-3 hrs after meal
Dx: gastric scintigraphy (gastric emptying study)- use low-fat solid meal; 60% retention after 2 hours or >10% after 4 hrs = abnormal
what can cause perforated viscus
how does it present?
PUD
possible w/ any hollow organ that perforates
NPO, IV ABx, pre-op labs, surgery consult
emergency surgery
=free air under diaphragm (pneumoperitoneum) or air in mediastinum(pneumomediastium) - see in x-ray or CT
What is the pathophys and RFs for DU
anterior wall of proximal duodenum (90-95% caued by H. pylori)
= gastric acid hypersecretion bc inflam cells release cytokines that stimulate antral G cells & diminised production of somatostatin by D cells
gastrin stimulation –> increased parietal cell mass –> exaggerated acid response
mucosal defense compromised bc H. pylori effects on pathches of gastric metaplasia (result from acid hypersecretion or rapid gastic emptying)
RF: glucocorticoids, NSAIDS, zollinger-ellison syndrome, severe medical/surgical stress
what is the DDx for dyspepsia/heartburn/indigestion
- GERD
- Gastritis
- PUD & severe medical/surgical stress ulcers
- cholecystitis
- pancreatitis
what is the prevalence of H. pylori and how is it transmitted
immigrants from developing countries, poverty/ low SES, overcrowding, rural, limited education, increases w/ age
person-person (fecal oral) -infancy/childhood
What is type A chronic gastritis associated with
Achlorhydia- loss of acid inhibition of gastic G cells –> hypergastrinemia –> hyperplasia of gastric enterochromaggin like cells –> 5% become carcinoid tumors
pernicious anemia (gastritis) - decreased IF –> Vit B12 malabs –> megaloblastic anemia (F>M) –> 3x increase risk of gastric adenocarcinoma
DM, thryoiditis, grave’s (autoimmune disorders)
how do you treat zollinger ellison syndrome
PPI
exploratory laparotomy - resect primary tumor & soliary metastases when possible
in pt w/ MEN 1 - cant resect & usually multifocal - so 1st treat hyperparathyroid (may help with hypergastrinemia) ; for unresectable tumor - parietal vagotomy
chemo for metastatic tumor
What is the etiology and presentation of type A gastritis
=FUNDIC-type –> affect fundic glands/mucosa) –> loss of rugal folds
elderly
Autoimmune mechanism: Auto-Ab to parietal cells or anti-intrinsic factor Ab
= usually aysmp - sxs if carcinoid or vit B12 def
what are the characterisitics of acute gastritis
- etiology:
- erosive (superfical, deep, hemorrhagic) or non-erosive (H. pylori; acute –> chronic)
- alc, meds, cocaine, ischemia, viral, bacterial H. pylori, stress/shock, radiation, allergy
Sxs: abd pain, N/V, anorexia, belching, bloating
Dx: EGD w/ Bx (test for H.pylori)
Tx: treat/avoid/stop underlying cause, endoscopic intervention for bleeding , PPI, sucralfate, H2 blocker, treat & eradicate H. pylori
When is eradication of H. pylori recommended
PUD
MALToma
(otherwise not routinely recommended)
What is the presentation and PE of Hemorrhagic (erosive) gastropathy/gastritis
MCC in erosive gastritis is: UGIB
- hematemesis, “coffee ground” emesis, or bloody aspirate in nasogastric suction, or melena.
- may be asymp
- epigastric discomfort
- nausea, hematemesis, or melena
- hyperactive bowel sounds
bc its superficial –> hemodynamically significant bleeding = rare
PE depend on underlying cause: vitals normal, liver dz stigmata, acutely distressed/severely ill, etc.
What is the definition, etiology and diagnostic method for esophageal varices?
=dilated submucosal veins in the esophagus
Etiology: MC 2ndary to portal HTN (cirrhosis)
Dx upper EGD (diagnostic & therapeutic)
What are the 3 types of Stress related mucosal dz (SRMD) - aka stress ulcers
curling ulcers: peptic ulcer (duodenum) in pt w/ extensive burns
cushing’s ulcer: peptic ulcer from severe brain injury or w/ other lesions of the CNS
severe medical/surgical illness (ICU)
What may cause sxs that mimic UGIB
med w/ iron or bismuth –> mimic melena
liquids w/ red dye (kool-aid) & certain foods (beets) –> mimin hematochezia
How do you treat GI bleeds
UGIB/LGIB: identify & stabilize, CBC, chem profile, INR/PT/PTT, type & screen or cross, 2 large bore IVs, fluid bolus if signs of shock, blood transfusion if indicated
UGIB:
PPI (PUD bleed)
octerotide: pt w/ varices
Abx if variceal bleeding
how do you treat gastroparesis
no specific tx
acute exacerbation - nasogastric suction & IV fluids
advice to eat small, freq meals w/ low fiber, milk and gas-forming foods and fat
AVOID agents that decrease GI motility in DM pts - MAINTAIN glucose levels <200 mg/dl bc hyperglycemia can slow gastric emptying in absence of dabetic neuropathy
meds:
metoclopramide (risk of tardive dyskinesia) - involuntary unintentional movement, lip smaking, twitching
erythromycin
gastric electrical stimulation w/ internally implanted neuro stimulator
how do you diagnose and treat type A chronic gastritis
Dx: CBC, B12, folic acid, methylmalonic acid and homocysteine assay, IF Abs, parital cell Abs; endoscopy w/ Bx
Tx: paraentral (IM) B12 supplements if extensive atrophy & metaplasia in antrum and body
dysplasia & small carcinoids require endoscopic surveillance
what is the etiology and complications of type B gastritis
= ANTRAL** type = **H. pylori gastritis
H. pylori –> early in life or setting of malnutrition (malabs –> B12 deficiency) or low gastric acid output
complications- b12 def,** low gastric acid output_, increased risk of gastric adenocarcinoma_, atrophic gastrtis, **gastric B cell lymphoma
What are the clinical features associated w/ DU
maybe asymp
dyspepsia, burning (gnawing) epigastric pain - 1-3 hours AFTER meals
nocturnal (periods of fasting)
relieved by food or antacid & have recurrence 2-4 hrs later
what is the etiology, presentation and Tx for Menetrier dz
idiopathic; characterized by giant thick gastric folds involving predom the body of the stomach & chronic protein loss -severe hypoprotienemia & anasarca (general body swelling)
nausea, epigastic pain, wt. loss, diarrhea (GIB NOT common)
use EGD w/ Bx to Dx
Tx: severe cases = gastric resection;
increased risk for gastic adenocarinoma (monitor)
What is the etiology, presentation and diagnostic test for Mallory Weiss Tear
etiology: superficial/non-transmural tear - GE jxn; precipitated by vomiting, retching or vigourous cough (will be in Hx)
= common cause of UGIB
may be asym
nausea/hematemesis & vital sign/PE = normal!
Dx: Hx & upper EGD
what are PE findings of UGIB
signs of hypovolemia: Vital signs!
- mild-mod (<15% blood volume loss) : resting tachycardia
- volume loss of atleast 15% - orthostatic hypotension (decrease sBP by >20 &/or increase HR of 20 beat/min after moving from recumbency to standing)
- volume loss of atleast 40%: supine hypotension
Stool color- clue of location of bleed
acute abd: severe pain, (+) rebound, (+) involuntary guarding ==> concern for perforation - rule out BEFORE endoscopy
why is HCT not a relaible indicator for severe acute bleeding
bc takes 24-72 hrs to equilibrate
how do you diagnose and treat acute SBO
Dx: plain abd radiography (KUB/Abd series x-ray) or CT scan
-see dilated loops of small bowel, air fluid levels
Tx: NGT to suction, supportive, surgery if NGT isnt helpful
what is important Hx/presentation for UGIB
severe bleeding: anemia, hypovolemia, orthostatic dizziness, confusion, angina, tachycardia, angina syncope, weak, SOB, severe palpitations & cold/clammy extremeties
hematemesis, melena, hemotochezia?
- co-morbid conditions: aortic stenosis, renal dz : AVM, telangiectasia, angiodysplasia
- smoking- PUD, malignancy
- liver dz: portal HTN cause varices
- Alc abuse: varicies, erosive, esophagitis/gastritis, PUD
- H. pylori, NSAIDs: PUD
Meds: BE THOROUGH! aspirin (salicylates), glucocorticoids, NSAIDs, anti-coags
what are the clinical features of GU
maybe asymp
dyspepsia, Burning epigastric pain- worsen w/ food w/i 30 mins of eating
Nausea/anorexia/bloating
food aversion
*perfrom endoscopy w/ Bx to rule out malignancy*
what should you consider if pt comes in w/ dyspepsia/ heartburn/ indigestion w/ severe epigastric pain
complicated PUD - perforation or penetration
other causes: MI/infarction, esophageal rupture, gastic volvulus, gastric/intestinal ischemia, ruptured aoritc aneurysm
what is the etiology, presentation and diagnostic test for Boerhaave syndrome (spontaneous esophageal perforation)
etiology: spontaneous - Hx of forceful retching/vomiting & alc use
transmural rupture at GE jxn
can be life-threatening!
pt in distress, has pleurtic/retrosternal chest pain, hematemesis
may have pneumomediastinum or subQ emphysema
Dx: clinical suspicion, CXR for pneumomediastinum/subQ emphysema & CT w/ contrast
what are RFs for gastric adenocarcinoma (including malignant gastric ulcers)
Diet: smoked fish/meat, pickled vegtables, reduced intake of fruit/veggies
meds: nitrosamines, benzpyrene
other: h. pylori, chronic gastritis, smoking, blood type A, Menetrier’s Dz
what should your initial evaluation be if pt presents w/ acute UGIB
are they stable or not?
volume status (severity of bleed) *HCT is a POOR early indicator*
do they have increased risk of re-bleed & death? - >60 yo, comorbid illnesses, sBP <90, pulse > 90, bright red blood in nasogastric aspirate or rectal exam
assess hemodynamic status
admit to ICU!
What diagnostic tests are used to diagnose various causes of N/V
plain radiograph- abd (intestinal obstruction); chest (pseudomediastinum, aspiration pneumonitis)
EGD
Gastric emptying scan (gastroparesis)
CT of brain
many labs
pregnancy test (beta-Hcg)
what is the pathophys and presentation of acute paralytic ileus
pathophy: neurogenic failure or loss of peristalsis in the intestine in the absence of mechanical obstruction
N/V, obstipation, distention
minimal abd tenderness, decreased/absent bowel sounds
(seen in hospitalized pt due to surgery, peritonitis, electrolyte imbalance, meds, severe medical illness
how do you detect H. pylori
- fecal Ag test: sensitive, specific, $
- Ab in serum: $, preferred if endoscope not required
- urea breath test: confirm eradication of H. pylori
- upper endoscopy w/ gastric Bx: histology & rapid urease testing of antrum- clofazimine
- Warthin-starry silver stain & immunohistochem stain
How do you treat hemorrhagic (erosive) gastropathy/gastritis
remove offending agent: aspirin/NSAID/Alc
maintenance of O2 &blood volume
portal HTN gastropathy- Beta-blocker (propranolol or nadolol)
prevent of stress ulcers in critically ill pts- H2 Blocker or PPI reduce incidence (hourly PO liquid antacids, sucralfate,or IV PPI)
enteral nutrition reduces risk of stress-related bleeding
what is the purpose of an upper endocsopy in an acute UGIB
all pt w/ UGIB should undergo endoscopy w/i 24 hrs of arrive in ED
=diagnostic && therapeutic
benefits:
- identify bleed
- determine risk of rebleed & guide triage
- render endoscopic therapy
how do you diagnose and treat acute paralytic ileus
how do you prevent it
plain abd radiograph or CT scan - gas & fluid distention in small/large bowel
Tx precipitating condition
if severe/prolonged –> nasogastric suction & paraentral fluids & electrolytes
post-op ileus reduced by using pt controlled or epidural analgesia and avoidance of intravenous opiods as wel as early ambulation, gum chewing, initiation of clear liquid diet
OMM if no contraindication
restrict oral intake w/ gradual liberalization of diet as bowel fxn returns
How do you raise Hbg in adults by 1 g/dL
1 unit packed RBC (PRBCs) raise Hbg in adults by 1g/dL
What are sxs that present w/ esophageal varices
do not cause sxs of dyspepsia, dysphagia, or retching, per se
Acute gastrointestinal hemorrhage- melena, hematochezia, hematemesis
After retching
1/3 pts with varices –> UGIB
Can be serious/life-threatening - usually severe bleed –> hypovolemia manifested by postural vital signs/shock
what levels should be obtained in zollinger ellison syndrome pts to exclude MEN-1
- serum parathyroid hormone (PTH)- iPTH (intact PTH)
- prolactin
- LH-FSH
- GH
What are complications of H. pylori infxns
chronic gastritis –> atrophic gastritis & gastric CA
Adenocarcinoma
MALToma (tx by treating H.pylori infxn)
*reason why you should confirm eradication after treatment! - urea breath test, fecal-Ag test, endoscopy w/ Bx*
how does Dieulafoy lesion present & how do you Dx?
fatigue, hematemesis, obscure GI bleed, Occult GI bleed –> iron def anemia (life threatening)
Dx: awareness/clinical suspicion & careful upper EGD
14 yo F presents w/ abd pain and N/V, whats your plan?
Pregnancy test!!!
blood or urine
RMR child-bearing age = broad spectrum!!!
but if pt has hysterectomy, dont need test
How do you diagnose UGIB
CBC
EGD- diagnosis & Tx intervention of active bleeding
nasogastric lavage - if doubt the origin is from upper gi
What are PE/Dx findings for gastric adenocarcinoma
virchows nodes
Krukenberg tumors: metastasis to ovaries
signet-ring cells
linitis plastica (leather bottle stomach)
What is the pathophys and RFs for GU
in lesser curve of antrum of stomach (75% H. pylori w/ increased risk if smoker)
normal/reduced gastric acid secretory rates –> gastritis bc reflus of duodenal content (including bile)
RF: glucocorticoids, chronic renal failure, renal transplant, cirrhosis, chronic lung dz, severe medical/surgical stress; chronic NSAID/Salicylate use (increased risk of bleeding/perforation)
What are the microbiological characterisitics of H.pylori
spiral (curved)
gram (-)
micoaeruphilic
urease producing rod (baccili) w/ flagella
Cag-A (+) toxin - increased risk of ulcer and gastric cancer
what is the etiology of hemorrhagic (erosive) gastropathy/gastritis
how do you Dx
- aspirin and NSAIDs
- alcoholic (Portal HTN gastropathy)
- severe stress/critically ill
Dx: upper EGD w/ Bx - no significant inflam on histology; CBC, chemistry (liver/kidney fxn), INR/PT/PTT
how do you diagnose and treat GAVE syndrome
upper EGD: watermelon stripes - red tortuous ectatic vessel columns along longitudinal fold of antrum) *dont confuse w/ portal HTN gastropathy has changes in fundus*
Tx: transfusion if needed, endoluminal therapies
what are complications of N/V
- rupture esophagus- Boerhaave syndrome
- hematemesis from mucosal tear (mallory-weiss tear)
- dehydration, malnutrtion, dental caries and eriosins
- metablic alkalosis & hypokalemia
- aspiration pneumonitis
what are important Hx components when pt presents w/ N/V
timing - morning? - pregnancy, uremia, alc gastritis ; during or after meal?
character- feculent = distal intestinal obstruction or gastrocolic fistula; or projectile = maybe increased intracranial pressure
medication
Associated sxs: vertigo/tinnitus -Meniere’s dz; relief of abd pain after vomiting = peptic ulcer ; early satiety = gastroparesis
what is the DDx for UGIB
- PUD/Stress ulcer
- esophageal varcies (pt w/ portal hypertension/cirrhosis)
- hemorrhagic gastropathy/gastritis (alc, aspirin, NSAIDs, critically-ill, Zollinger ellison syndrome)
- mallory-weiss tear/borhaave syndrome
- dieulafoy lesion - submucosal vessels
- GAVE syndrome- watermelon stomach
What is the etiology of Zolinger ellison syndrome
Primary Gastrinoma = non-beta islet cell –> gastrin secreting tumor
- Pancreas (25%)
- Proximal duodenum (45%)
- Lymph nodes (5-15%)
2/3 = malignant &(1/3 metastasized to liver at presentation)
=Slow growing
25% associated w/ auto. dom. familial syndrome MEN 1 (multiple endocrine neoplasia type 1) = pancreatic gastrinoma (insulinoma), hyperparathyroidism (increased Ca2+), pituitary neoplasm (gigantism)
Compare and Contrast chronic gastritis caused by H.pylori vs. autoimmune cause
what are classic sxs of UGIB
hematemesis (bright red/coffee grou)
melena (after 50-100 mL blood loss)
hematochezia (bright red blood per rectum - in massive bleed)
*rmr upper GI = proximal to L. of Treitz*
what is the etiology of Dieulafoy lesion
- elderly, male
- Already hospitalized/ taking NSAIDs, aspirin, warfarin/ no Hx of GI pathology
- MC: proximal stomach –> recurrent, intermittent bleeding
= rare, aberrant large- caliber submucosal A
=obscure GI bleeding that may result in treacherous & life-threatening GI hemorrhage
Obscure Gl bleeding = overt/occult bleeding –> difficult to locate bc pathology is anatomically inaccessible, small, or subtle
=histologically normal vessel w/ abnormally large diameter (1–3 mm); tortuous course w/i submucosa & typically, the lesion protrudes thru a small mucosal defect (2–5 mm) -> fibrinoid necrosis at base
What is the etiology and presentation of GAVE syndrome
= rare, multiple superficial telangiectasia in gastric antrum “watermelon stomach”
seen in diffuse scleroderma & cirrhosis
MC: elderly (70s)
= fatigue, nondescript abd pain, occult GI bleed –> iron def anemia
when should you consider Zollinger ellison syndrome to your DDx
PUD that wont respond to tx or is severe, atypical, recurrent
if ulcer is severe, refractory to therapy, associated w/ ulcer in atypical location, associated w/ diarrhea (NGT suction suposed to stop diarrhea), steatorrhea, wt. loss,
Primary gastrinoma ==> duodenum (45%) –> then pancreatic (25%); 5-15% LN; or in submucosal or in multiple
what are risk factors for esophageal varices
how can you prevent rebleeding
RF
- size (> 5 mm)
- EGD show red wale markings (longitudinal dilated venules on the varix surface)
- severity of liver disease (assessed by Child scoring C >B >A)
- active alcohol abuse—pts w/ cirrhosis who continue to drink have an extremely risk of bleed
Prevent rebleed: Nonselective beta-adrenergic blockers (propranolol, nadolol) reduce the risk (SE = fatigue & hypotension)
Long-term treatment with band ligation reduces the incidence of rebleeding to 30%
How do you diagnose Zolinger Ellison syndrome
EGD: large mucosal folds (hypertrophic gastric mucosa)
Serum (fasting) gastrin: draw when fasting & no acid suppression meds –> >1000 ng/L (or >150pg/mL) = confirm!
(+) secretin stimulation test: if (-) think other reasons for hypergastrinemia (chronic fundic (type A ) gastritis
Endoscopic ultrasonography (EUS), CT and MRI scans: large hepatic metastases & primary lesions (low sensitivity for small lesions)
What is the etiology and presentation of acute small bowel obstruction (SBO)
commonly bc adhesions - multiple abd surgery, diverticulits, crohns dz
N/V (maybe feculent), obstipation (no BM or flatus), abd pain & distention, minimal abd tenderness, deceased/absent bowel sounds & high pitch tinkling bowel sounds (rain on tin roof)
