DSA 2: N/V, Dyspepsia, Heartburn, Hematemesis

Question 1

How do you stabilize a pt w/ UGIB

Answer 1

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

Question 2

what are possible etiologies of gastroparesis

Answer 2

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

Question 3

what is the presentation of gastroparesis & how do you diagnose

Answer 3

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

Question 4

what can cause perforated viscus

how does it present?

Answer 4

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

Question 5

What is the pathophys and RFs for DU

Answer 5

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

Question 6

what is the DDx for dyspepsia/heartburn/indigestion

Answer 6

1. GERD
2. Gastritis
3. PUD & severe medical/surgical stress ulcers
4. cholecystitis
5. pancreatitis

Question 7

what is the prevalence of H. pylori and how is it transmitted

Answer 7

immigrants from developing countries, poverty/ low SES, overcrowding, rural, limited education, increases w/ age

person-person (fecal oral) -infancy/childhood

Question 8

What is type A chronic gastritis associated with

Answer 8

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)

Question 9

how do you treat zollinger ellison syndrome

Answer 9

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

Question 10

What is the etiology and presentation of type A gastritis

Answer 10

=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

Question 11

what are the characterisitics of acute gastritis

Answer 11

• 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

Question 12

When is eradication of H. pylori recommended

Answer 12

PUD

MALToma

(otherwise not routinely recommended)

Question 13

What is the presentation and PE of Hemorrhagic (erosive) gastropathy/gastritis

Answer 13

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.

Question 14

What is the definition, etiology and diagnostic method for esophageal varices?

Answer 14

=dilated submucosal veins in the esophagus

Etiology: MC 2ndary to portal HTN (cirrhosis)

Dx upper EGD (diagnostic & therapeutic)

Question 15

What are the 3 types of Stress related mucosal dz (SRMD) - aka stress ulcers

Answer 15

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)

Question 16

What may cause sxs that mimic UGIB

Answer 16

med w/ iron or bismuth –> mimic melena

liquids w/ red dye (kool-aid) & certain foods (beets) –> mimin hematochezia

Question 17

How do you treat GI bleeds

Answer 17

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

Question 18

how do you treat gastroparesis

Answer 18

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

Question 19

how do you diagnose and treat type A chronic gastritis

Answer 19

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

Question 20

what is the etiology and complications of type B gastritis

Answer 20

= 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

Question 21

What are the clinical features associated w/ DU

Answer 21

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

Question 22

what is the etiology, presentation and Tx for Menetrier dz

Answer 22

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)

Question 23

What is the etiology, presentation and diagnostic test for Mallory Weiss Tear

Answer 23

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

Question 24

what are PE findings of UGIB

Answer 24

signs of hypovolemia: Vital signs!

1. mild-mod (<15% blood volume loss) : resting tachycardia
2. volume loss of atleast 15% - orthostatic hypotension (decrease sBP by >20 &/or increase HR of 20 beat/min after moving from recumbency to standing)
3. 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

Question 25

why is HCT not a relaible indicator for severe acute bleeding

Answer 25

bc takes 24-72 hrs to equilibrate

Question 26

how do you diagnose and treat acute SBO

Answer 26

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

Question 27

what is important Hx/presentation for UGIB

Answer 27

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

Question 28

what are the clinical features of GU

Answer 28

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\*

Question 29

what should you consider if pt comes in w/ dyspepsia/ heartburn/ indigestion w/ severe epigastric pain

Answer 29

complicated PUD - perforation or penetration _other causes: **MI/infarction**_, esophageal rupture, gastic volvulus, gastric/intestinal ischemia, ruptured aoritc aneurysm

Question 30

what is the etiology, presentation and diagnostic test for Boerhaave syndrome (spontaneous esophageal perforation)

Answer 30

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**

Question 31

what are RFs for gastric adenocarcinoma (including malignant gastric ulcers)

Answer 31

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

Question 32

what should your initial evaluation be if pt presents w/ acute UGIB

Answer 32

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!**

Question 33

What diagnostic tests are used to diagnose various causes of N/V

Answer 33

plain radiograph- abd (intestinal obstruction); chest (pseudomediastinum, aspiration pneumonitis) EGD Gastric emptying scan (gastroparesis) CT of brain many labs **pregnancy test (beta-Hcg)**

Question 34

what is the pathophys and presentation of acute paralytic ileus

Answer 34

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_

Question 35

how do you detect H. pylori

Answer 35

1. _fecal Ag test_: sensitive, specific, $ 2. _Ab in serum_: $, preferred if endoscope not required 3. _urea breath test_: **confirm eradication of H. pylori** 4. _upper endoscopy w/ gastric Bx:_ histology & rapid urease testing of antrum- clofazimine 5. _Warthin-starry silver stain & immunohistochem stain_

Question 36

How do you treat hemorrhagic (erosive) gastropathy/gastritis

Answer 36

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

Question 37

what is the purpose of an upper endocsopy in an acute UGIB

Answer 37

**all pt w/ UGIB should undergo endoscopy w/i 24 hrs of arrive in ED** **=diagnostic && therapeutic** benefits: 1. identify bleed 2. determine risk of rebleed & guide triage 3. render endoscopic therapy

Question 38

how do you diagnose and treat acute paralytic ileus how do you prevent it

Answer 38

**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

Question 39

How do you raise Hbg in adults by 1 g/dL

Answer 39

**1 unit packed RBC (PRBCs) raise Hbg in adults by 1g/dL**

Question 40

What are sxs that present w/ esophageal varices

Answer 40

_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**

Question 41

what levels should be obtained in zollinger ellison syndrome pts to exclude MEN-1

Answer 41

* serum parathyroid hormone (PTH)- iPTH (intact PTH) * prolactin * LH-FSH * GH

Question 42

What are complications of H. pylori infxns

Answer 42

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\***

Question 43

how does Dieulafoy lesion present & how do you Dx?

Answer 43

fatigue, **hematemesis, obscure GI bleed, Occult GI bleed --\> iron def anemia (life threatening)** Dx: _awareness/clinical suspicion & **careful upper EGD**_

Question 44

14 yo F presents w/ abd pain and N/V, whats your plan?

Answer 44

**_Pregnancy test!!!_** blood or urine RMR child-bearing age = broad spectrum!!! but if pt has hysterectomy, dont need test

Question 45

How do you diagnose UGIB

Answer 45

CBC **EGD- diagnosis & Tx intervention of active bleeding** nasogastric lavage - if doubt the origin is from upper gi

Question 46

What are PE/Dx findings for gastric adenocarcinoma

Answer 46

virchows nodes Krukenberg tumors: metastasis to ovaries signet-ring cells linitis plastica (leather bottle stomach)

Question 47

What is the pathophys and RFs for GU

Answer 47

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)

Question 48

What are the microbiological characterisitics of H.pylori

Answer 48

_spiral (curved)_ _gram (-)_ _micoaeruphilic_ _urease producing rod (baccili) w/ flagella_ **Cag-A (+) toxin -** increased risk of ulcer and gastric cancer

Question 49

what is the etiology of hemorrhagic (erosive) gastropathy/gastritis how do you Dx

Answer 49

1. aspirin and NSAIDs 2. alcoholic (**Portal HTN gastropathy**) 3. severe stress/critically ill Dx: **upper EGD w/ Bx** - _no significant inflam on histology_; CBC, chemistry (liver/kidney fxn), INR/PT/PTT

Question 50

how do you diagnose and treat GAVE syndrome

Answer 50

**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_

Question 51

what are complications of N/V

Answer 51

1. rupture esophagus- Boerhaave syndrome 2. hematemesis from mucosal tear (mallory-weiss tear) 3. dehydration, malnutrtion, dental caries and eriosins 4. metablic alkalosis & hypokalemia 5. aspiration pneumonitis

Question 52

what are important Hx components when pt presents w/ N/V

Answer 52

**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

Question 53

what is the DDx for UGIB

Answer 53

1. _PUD/Stress ulcer_ 2. _esophageal varcies_ (**pt w/ portal hypertension/cirrhosis**) 3. _hemorrhagic gastropathy/gastritis_ (alc, aspirin, NSAIDs, critically-ill, _Zollinger ellison syndrome)_ 4. _mallory-weiss tear/borhaave syndrome_ 5. _dieulafoy lesion_ - submucosal vessels 6. _GAVE syndrome_- watermelon stomach

Question 54

What is the etiology of Zolinger ellison syndrome

Answer 54

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)**

Question 55

Compare and Contrast chronic gastritis caused by H.pylori vs. autoimmune cause

Answer 55

Question 56

what are classic sxs of UGIB

Answer 56

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\*

Question 57

what is the etiology of Dieulafoy lesion

Answer 57

* 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

Question 58

What is the etiology and presentation of GAVE syndrome

Answer 58

= 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**

Question 59

when should you consider Zollinger ellison syndrome to your DDx

Answer 59

**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

Question 60

what are risk factors for esophageal varices how can you prevent rebleeding

Answer 60

RF 1. **size** (\> 5 mm) 2. EGD show **red wale markings** (longitudinal dilated venules on the varix surface) 3. **severity of liver disease** (assessed by Child scoring C \>B \>A) 4. **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%

Question 61

How do you diagnose Zolinger Ellison syndrome

Answer 61

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)

Question 62

What is the etiology and presentation of acute small bowel obstruction (SBO)

Answer 62

**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)_**