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Surgical Recall > General Surgery - Upper GI Bleeding > Flashcards

General Surgery - Upper GI Bleeding Flashcards

1
Q

What is upper GI bleeding?

A

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

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2
Q

What are the signs/symptoms?

A

Hematemesis, melena, syncope,
shock, fatigue, coffee-ground emesis,
hematochezia, epigastric discomfort,
epigastric tenderness, signs of
hypovolemia, guaiac-positive stools

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3
Q

Why is it possible to have hematochezia?

A

Blood is a cathartic and hematochezia
usually indicates a vigorous rate of
bleeding from the UGI source

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4
Q

Are stools melenic or
melanotic?

A

Melenic (melanotic is incorrect)

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5
Q

How much blood do you
need to have melena?

A

>50 cc of blood

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6
Q

What are the risk factors?

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

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7
Q

What is the most common
cause of significant UGI
bleeding?

A

PUD—duodenal and gastric ulcers (50%)

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8
Q

What is the common differential diagnosis of UGI bleeding?

A
  • *1. Acute gastritis
    2. Duodenal ulcer**
    3. Esophageal varices
    4. Gastric ulcer
    5. Esophageal
    6. Mallory-Weiss tear
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9
Q

What is the uncommon differential diagnosis of UGI bleeding?

A

Gastric cancer, hemobilia, duodenal
diverticula, gastric volvulus, Boerhaave’s
syndrome, aortoenteric fistula,
paraesophageal hiatal hernia, epistaxis,
NGT irritation, Dieulafoy’s ulcer,
angiodysplasia

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10
Q

Which diagnostic tests are
useful?

A

History, NGT aspirate, abdominal x-ray, endoscopy (EGD)

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11
Q

What is the diagnostic test of
choice with UGI bleeding?

A

EGD (>95% diagnosis rate)

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12
Q

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

A

Coagulation, injection of epinephrine
(for vasoconstriction), injection of
sclerosing agents (varices), variceal ligation
(banding)

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13
Q

Which lab tests should be
performed?

A

Chem-7, bilirubin, LFTs, CBC, type & cross, PT/PTT, amylase

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14
Q

Why is BUN elevated?

A

Because of absorption of blood by the GI
tract

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15
Q

What is the initial treatment?

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 H2O—will
    remove clots)
  4. EGD: endoscopy (determine etiology/
    location of bleeding and possible
    treatment—coagulate bleeders)
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16
Q

Why irrigate in an upper GI bleed?

A

To remove the blood clot so you can see
the mucosa

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17
Q

What test may help identify
the site of MASSIVE UGI
bleeding when EGD fails to
diagnose cause and blood
continues per NGT?

A

Selective mesenteric angiography

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18
Q

What are the indications for surgical intervention in UGI bleeding?

A

Refractory or recurrent bleeding and site
known, >3 u PRBCS to stabilize or
>6 u PRBCs overall

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19
Q

What percentage of patients
require surgery?

A

~10%

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20
Q

What percentage of patients
spontaneously stop bleeding?

A

~80% to 85%

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21
Q

What is the mortality of acute UGI bleeding?

A

Overall 10%, 60–80 years of age 15%,
older than 80 years of age 25%

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22
Q

What are the risk factors for death following UGI bleed?

A

Age older than 60 years
Shock
>5 units of PRBC transfusion
Concomitant health problems

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23
Q

What is Peptic Ulcer Disease (PUD)?

A

Gastric and duodenal ulcers

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24
Q

What is the incidence in the United States?

A

~10% of the population will suffer from
PUD during their lifetime!

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25
Q

What are the possible
consequences of PUD?

A

Pain, hemorrhage, perforation, obstruction

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26
Q

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

A

~20%

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27
Q

Which bacteria are
associated with PUD?

A

Helicobacter pylori

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28
Q

What is the treatment?

A

Treat H. pylori with MOC or ACO
2-week antibiotic regimens:
MOC: Metronidazole, Omeprazole,
Clarithromycin (Think: MOCk)
or
ACO: Ampicillin, Clarithromycin,
Omeprazole

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29
Q

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

A

Valentino’s sign

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30
Q

In which age group are duodenal ulcers most common?

A

40–65 years of age (younger than
patients with gastric ulcer)

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31
Q

What is the ratio of male to
female patients?

A

Men > women (3:1)

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32
Q

What is the most common location?

A

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

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33
Q

What is the classic pain response to food intake?

A

Food classically relieves duodenal ulcer
pain (Think: Duodenum = Decreased
with food)

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34
Q

What is the cause?

A

Increased production of gastric acid

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35
Q

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

A

Zollinger-Ellison syndrome

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36
Q

What are the associated risk factors?

A

Male gender, smoking, aspirin and other
NSAIDs, uremia, Z-E syndrome,
H. pylori, trauma, burn injury

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37
Q

What are the symptoms?

A

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

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38
Q

What are the signs?

A

Tenderness in epigastric area (possibly),
guaiac-positive stool, melena,
hematochezia, hematemesis

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39
Q

What is the differential diagnosis?

A

Acute abdomen, pancreatitis, cholecystitis,
all causes of UGI bleeding, Z-E
syndrome, gastritis, MI, gastric ulcer,
reflux

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40
Q

How is the diagnosis made?

A

History, PE, EGD, UGI series
(if patient is not actively bleeding)

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41
Q

When is surgery indicated with a bleeding duodenal ulcer?

A

Most surgeons use: >6 u PRBC
transfusions, >3 u PRBCs needed to
stabilize, or significant rebleed

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42
Q

What EGD finding is associated with rebleeding?

A

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

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43
Q

What is the medical treatment?

A

PPIs (proton pump inhibitors) or H2
receptor antagonists—heal ulcers in
4 to 6 weeks in most cases
Treatment for H. pylori

44
Q

When is surgery indicated?

A

The acronym “I HOP”:
Intractability
Hemorrhage (massive or relentless)
Obstruction (gastric outlet obstruction)
Perforation

45
Q

How is a bleeding duodenal ulcer surgically corrected ?

A

Opening of the duodenum through the
pylorus
Oversewing of the bleeding vessel

46
Q

What artery is involved with
bleeding duodenal ulcers?

A

Gastroduodenal artery

47
Q

What are the common
surgical options for the
following conditions:

Duodenal perforation?

A

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)

48
Q

Duodenal obstruction resulting from ulcer scarring (gastric outlet obstruction)?

A 
Truncal vagotomy, antrectomy, and
duodenal gastroduodenostomy (BI or BII)
Truncal vagotomy and drainage procedure
(gastrojejunostomy)
49
Q

Duodenal ulcer intractability?

A

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

50
Q

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

A

PGV (proximal gastric vagotomy)

51
Q

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

A

Vagotomy and antrectomy

52
Q

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

A

Pylorus will not open after a truncal vagotomy

53
Q

Which duodenal ulcer operation has the lowest mortality rate?

A

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

54
Q

What is a “kissing” ulcer?

A

Two ulcers, each on opposite sides of the
lumen so that they can “kiss”

55
Q

Why may a duodenal rupture be initially painless?

A

Fluid can be sterile, with a nonirritating
pH of 7.0 initially

56
Q

Why may a perforated
duodenal ulcer present as
lower quadrant abdominal
pain?

A

Fluid from stomach/bile drains down paracolic gutters to lower quadrants and causes localized irritation

57
Q

In which age group are gastric ulcers most common?

A

40–70 years old (older than the duodenal
ulcer population)
Rare in patients younger than 40 years

58
Q

How does the incidence in
men compare with that of
women?

A

Men > women

59
Q

Which is more common overall: gastric or duodenal ulcers?

A

Duodenal ulcers are more than twice as
common as gastric ulcers (Think:
Duodenal = Double rate)

60
Q

What is the classic pain
response to food?

A

Food classically increases gastric ulcer pain

61
Q

What is the cause?

A

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

62
Q

Is gastric acid production
high or low?

A

Gastric acid production is normal or low!

63
Q

Which gastric ulcers are
associated with increased
gastric acid?

A

Prepyloric

Pyloric

Coexist with duodenal ulcers

64
Q

What are the associated risk factors?

A

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

65
Q

What are the symptoms?

A

Epigastric pain
+/- Vomiting, anorexia, and nausea

66
Q

How is the diagnosis made?

A

History, PE, EGD with multiple biopsy

(looking for gastric cancer)

67
Q

What is the most common
location?

A

~70% are on the lesser curvature; 5% are on the greater curvature

68
Q

When and why should biopsy be performed?

A

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

69
Q

What is the medical treatment?

A

Similar to that of duodenal ulcer—PPIs or
H2 blockers, Helicobacter pylori treatment

70
Q

When do patients with gastric ulcers need to have an EGD?

A
  1. For diagnosis with biopsies
  2. 6 weeks postdiagnosis to confirm
    healing and rule out gastric cancer!
71
Q

What are the indications for
surgery?

A

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)

72
Q

What is the common operation for hemorrhage, obstruction, and perforation?

A 
Distal gastrectomy with excision of the
ulcer **without** vagotomy unless there is
duodenal disease (i.e., BI or BII)
73
Q

What are the options for
concomitant duodenal and
gastric ulcers?

A

Resect (BI, BII) and truncal vagotomy

74
Q

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

A

Truncal vagotomy and antrectomy (i.e., BI or BII)

75
Q

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

A

Graham patch

76
Q

What must be performed in
every operation for gastric
ulcers?

A

Biopsy looking for gastric cancer

77
Q 
# Define the following terms:
Cushing’s ulcer
A

PUD/gastritis associated with neurologic
trauma or tumor (Think: Dr. Cushing =
NeuroSurgeon = CNS)

78
Q

Curling’s ulcer

A

PUD/gastritis associated with major burn
injury (Think: curling iron burn)

79
Q

Marginal ulcer

A

Ulcer at the margin of a GI anastomosis

80
Q

Dieulafoy’s ulcer

A

Pinpoint gastric mucosal defect bleeding
from an underlying vascular malformation

81
Q

What are the symptoms of a perforated peptic ulcer?

A
82
Q

What causes pain in the
lower quadrants?

A

Passage of perforated fluid along colic gutters

83
Q

What are the signs of a perforated peptic ulcer?

A

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

84
Q

What are the signs of
posterior duodenal erosion/
perforation?

A

Bleeding from gastroduodenal artery (and possibly acute pancreatitis)

85
Q

What sign indicates anterior
duodenal perforation?

A

Free air (anterior perforation is more common than posterior)

86
Q

What is the differential diagnosis?

A

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

87
Q

Which diagnostic tests are indicated?

A

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)

88
Q

What are the associated lab findings?

A

Leukocytosis, high amylase serum
(secondary to absorption into the blood
stream from the peritoneum)

89
Q

What is the initial treatment?

A

NPO: NGT (↓ contamination of the
peritoneal cavity)
IVF/Foley catheter
Antibiotics/PPIs
Surgery

90
Q

What is a Graham patch?

A

Piece of omentum incorporated into the
suture closure of perforation

91
Q

What are the surgical options for treatment of a duodenal perforation?

A 
Graham patch (open or laparoscopic)
Truncal vagotomy and pyloroplasty
incorporating ulcer
Graham patch and highly selective
vagotomy
92
Q

What are the surgical options for perforated gastric ulcer?

A

Antrectomy incorporating perforated
ulcer, Graham patch or wedge resection
in unstable/poor operative candidates

93
Q

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

A

May indicate two ulcers (kissing);
posterior is bleeding and anterior is
perforated with free air

94
Q

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

A

Posterior perforated duodenal ulcer
into the pancreas (i.e., epigastric pain
radiating to the back; high serum
amylase)

95
Q

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

A

Duodenal = decreased pain

Gastric = increased pain

(Think: Duodenal = Decreased pain)

96
Q 
# Define the following terms:
Graham patch
A

For treatment of duodenal perforation in
poor operative candidates/unstable
patients
Place viable omentum over perforation
and tack into place with sutures

97
Q

Truncal vagotomy

A

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

98
Q

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

A

“Drainage procedure” (pyloroplasty, antrectomy, or gastrojejunostomy),
because vagal fibers provide relaxation of
the pylorus, and, if you cut them, the
pylorus will not open

99
Q 
# Define the following terms:
Vagotomy and pyloroplasty
A

Pyloroplasty performed with vagotomy to
compensate for decreased gastric emptying

100
Q

Vagotomy and antrectomy

A

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

101
Q

What is the goal of duodenal
ulcer surgery?

A

Decrease gastric acid secretion (and fix IHOP)

102
Q

What is the advantage of
proximal gastric vagotomy
(highly selective
vagotomy)?

A

No drainage procedure is needed; vagal fibers to the pylorus are preserved; rate of dumping syndrome is low

103
Q

What is a Billroth I (BI)?

A

Truncal vagotomy, antrectomy, and
gastroduodenostomy (Think: BI ONE
limb off of the stomach remnant)

104
Q

What are the contraindications for a Billroth I?

A

Gastric cancer or suspicion of gastric cancer

105
Q
A

Surgical Recall (15 decks)

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