Emergency General Surgery

Question 1

DDX of UGI bleed

Answer 1

Oropharynx –> Ligament of Treitz
MCC: Gastro-duodenal ulcers (25-30%); MW tear/erosive disease; varices; gastropathy; neoplasm; GIST; Dieulafoy/vascular ectasia; hemobilia; iatrogenic following endoscopy

Question 2

What must you consider in someone who has undergone a AAA repair and an UGI bleed?

Answer 2

Aorto-enteric fistula

Question 3

First step in UGI bleed

Answer 3

IV access

Question 4

Important to ask about these medications in an UGI bleed

Answer 4

Anti-coagulation, anti-platelets, NSAIDs

Question 5

Risk factors for UGI bleed

Answer 5

NSAD’s, smoking, MEN I

Question 6

Initial work-up UGI bleed

Answer 6

CBC, BMP, coags, T+S
Upright CXR (pneumoperitoneum)
EGD: 95% –> angiography; tagged RBC scan

Question 7

Forrest classification of peptic ulcers

Answer 7

1a: Actively bleeding/pulsatile: 20% risk 30-day rebleed
1b: Non-pulsitile < 10%
2a: Non-bleeding: visible vessel 15%
2b: Adherent clot; < 5%
2c: Hematin-covered base; 3%
3: Non-bleeding; clean base 3%

Question 8

4 major etiologies of gastric ulcer

Answer 8

H. pylori
NSAIDS
ZES
Neoplasm

Question 9

Options for endoscopic ulcer treatment

Answer 9

Clips, thermal coagulation, vasoconstrictor/sclerosant

Question 10

Should you biospy ulcer?

Answer 10

Yes and antrum for H. pylori

Question 11

If re-bleeds after EGD, next step?

Answer 11

Repeat EGD

Question 12

Where are gastric hypersecretion ulcers located?

Answer 12

Pre-pyloric; duodenal

Question 13

PPI therapy for UGI bleed

Answer 13

80mg bolus and continuous infusion 8mg/hr for 72 hours

Question 14

What is triple therapy for H pylori?

Answer 14

2 ABX active against H pylori and PPI

Question 15

Five types of gastric ulcers

Answer 15

1. Lesser curve; varices
2. 2 ulcers, stomach body/duo; acid hypersecretion
3. Pre-pyloric; acid hypersecretion
4. GE Jx; varices
5. Any location; NSAIDs

Question 16

Surgery for unstable patient with bleeding gastric ulcer

Answer 16

Ex lap; anterior gastrotomy; oversew ulcer; biopsy; repair of gastrotomy

Question 17

Surgery for stable patient with bleeding gastric ulcer; with no history of anti-secretory or H pylori therapy vs. refractory

Answer 17

Refractory: distal gastrectomy with PGV (proximal gastric vagotomy)
Anti-secretory; truncal vagotomy/distal gastrectomy

Question 18

When is a truncal vagotomy indicated in a bleeding gastric ulcer?

Answer 18

Failed previous medical therapy

Question 19

What does a truncal vagotomy do?

Answer 19

Reduced cholinergic stimulation of gastric acid secretion

Question 20

Because vagotomy results in pyloric denervation, what additional procedure is necessary?

Answer 20

Pyloroplasty or antrectomy to ensure gastric drainage