GI- Foregut and GI Bleed Flashcards
Define GERD. What causes it?
GERD is stomach acid refluxing into the esophagus.
Inappropriate, intermittent relaxation oath lower esophageal sphincter.
Hiatal hernia = greater incidence.
Describe the classic symptoms of GERD.
“Heartburn” often related to lying supine after eating. Abdominal or chest pain.
Tx GERD
Initial treatment: elevate the head of the bed & avoid coffee, alcohol, tobacco, spicy food, chocolate, and medications with anticholinergic properties.
Secondary: antiacids (H2 blockers, PPIs)
Lifestyle modifications usually fail. surgery is reserved for severe or resistant cases.
Surgery: Nissen, endocinch, scaring of LES
What are the sequelae of GERD?
Esophagitis esophageal stricture (mimics cancer) esophageal ulcer hemorrhage barrett esophagus esophageal adenocarcinoma
How does a PUD present?
Chronic intermittent pain (burning, gnawing, or aching) Localized: epigastric Relieved by antacids or milk Epigastric tenderness Occult blood N/V
cannot diagnose on clinical presentation
Characteristics of Duodenal Ulcers
- main cause
- common
- acid section
- age
- blood type
- pain and food.
Duodenal ulcers
- Cause: H. Pylori
- 75% of cases
- Normal to high acid
- 40s
- Blood O
- pain improves with food and is worse 2-3 hours later
Characteristics of Gastric Ulcers
- main cause
- common
- acid section
- age
- blood type
- pain and food.
Gastric Ulcers
- Cause: NSAIDs (including aspirin)
- 25% of cases
- Normal to low acid
- 50s
- Blood A
- Pain unchanged with food.
Diagnostic study of choice for a PUD
Most sensitive/ accurate: Endoscopy (golf standard)
Biopsy is mandatory to exclude malignancy for gastric ulcers.
Upper barium- cheaper and less invasive.
Most feared complication of a PUD
Perforation.
look for peritoneal signs
free air in abdomen
Tx: Abx (ceftri & metro) and laparotomy with repair
Severe PUD that does not respond to treatment
severe, atypical (jejunum) or non healing consider stomach cancer or Zollinger Ellison syndrome.
Check gaskin levels
Tx PUD initially
Stop NSAIDs
Stop alcohol and smoking
PPIs
Test and Tx H. Pylori
What surgical procedures exist for PUD?
Complications
Antrectomy, vagotomy, Billroth I or II.
Dumping syndrome, post prandial hypoglycemia, afferent loop syndrome, bacteria overgrowth, vitamin deficiencies (b12/ iron), anemia
Symptoms of dumping syndrome
Weakness
Dizziness
Sweating
N/V after eating
Symptoms of Afferent Loop Syndrome
Bilious vomiting after a meal relieves pain.
Most likely diagnosis of epigastric pain with no other symptoms
Functional dyspepsia.
most common cause of epigastric pain,
age <60
Most likely diagnosis of epigastric pain with bad taste, cough and hoarseness?
GERD
Most likely diagnosis of epigastric pain with diabetes and bloating
gastroparesis
Causes of Gastritis
“inflammation or erosion of gastric lining”
- Alcohol
- NSAIDs
- H. Pylori
- Portal Hypertension
- Systemic stress (burns, trauma, sepsis, multi organ failure)
presentation of gastritis and diagnosis
GI bleed without pain. (coffee ground/ red blood emesis, black stool).
Cannot diagnose on history alone. EGD shows erosive gastritis. Rule out H. pylori.
Most accurate test for H. Pylori
other tests for H.pylori
Most accurate: Endo biospa
other: serology (can identify current vs past), urea breath, stool antigen
H. Pylori treatment
Triple therapy: PPI, Clarithromycin, Amoxicillin (metro if penicillin allergy)
If no response: levo, or tetracycline (only use of tetracycline).
Add Bismuth
Causes of H.pylori tx failure
Bacterial resistance nonadherance alcohol tobacco NSAID
when should you scope for dyspepsia
age >60,
alarm symptoms (dysphagia, weight loss, anemia)
PPIs fail
Characteristics of gastronome (ZE) ulcers.
Large >1-2cm
Recurrent after H. pylori eradication
Distal Duodenum
Multiple
Associated with increase somatostatin receptors in abdomen.
Gastrinoma (ZE) diagnostic tests
Initial: Endoscopy
Most accurate tests: Functional response to secretin (high gastrin)
Other:
-Somatostatin receptor scintigraphy (nuclear octreotide scan) with endo U/S to exclude metastatic disease
Treatment of gastrimnoma (ZE)
Local- surgical removal
metastatic is unresectable. Life long PPI.
define and symptoms of diabetic gastroperesis
Autonomic neuropathy leading to dysmotility caused by inability to sense stretch in GI tract.
Chronic dyscomfort Bloating Constipation Anorexia N/V Early Satiety
Best initial test for DM gastroparesis
most accurate
BIT: upper endoscopy or abd CT (exclude mass)
Most Accurate: Bolus of food tagged with technetium (shows delay in emptying)
Tx DM gastroparesis
Initial: Fluids, correct potassium and glucose, blederized foods.
Metoclopramide or erythromycin (gastric motility)
Gastric electrical stimulation (gastric pacemaker)
Define achlorhydria
The absence of hydrochloric acid (HCL) secretion.
Most commonly due to pernicious anemia. Associated with other autoimmune.
Can also be caused by surgical gastric resection
Mechanism of pernicious anemia and achlorhydria
Antiparietal cell antibodies destroy acid-secreting parietal cell causing achorhydria and Vit B12 deficiency.
Characteristics of Upper GI Bleed:
- Location
- Stool
- NGT aspirate
- Most Common cause
- other causes
- proximal to the ligament of Treitz
- Tarry, black stool (melena)
- NGT positive for blood
- MCC: Ulcer
- Causes: gastritis, varices, esophagitis, duodenitis, cancer
Characteristics of Lower` GI Bleed:
- Location
- Stool
- NGT aspirate
- Most Common cause
- other causes
- distal to the ligament of Treitz
- Bright red blood in stool (hematochezia)
- NGT negative for blood
- MCC: diverticulosis
- Causes: Hemorrhoids, angiodysplasia, polyps, IBD, vascular ectasia, colitis, cancer.
Patient with GI bleed and BP 94/62. Best next step in management
Fluid resuscitation prior to identifying etiology of bleed.
Assessing BP is the most important initial management for GI bleed.
Normal saline or lactated ringers.
Tx GI bleed
- check patient is stable. ABCs & replenish
- place NG tube and test aspirate
- Start PPI
- Perform endoscope (upper or lower depending on symptoms and NGT aspirate). Treat lesions.
- Run H&H/ coagulation tests (PT, INR). for sever bleed prioritize
What radiologic imaging studies can be done to localize a GI bleed?
Radionuclide scenic can detect slow or intermediate bleed.
Angiography can defect rapid bleed. Embolization of bleeding can be done.
Surgery is reserved for resistant bleed and typically involved resection of bowel (usually colon).
Define Ischemic colitis
hypoperfusion of the large bowel, which is mostly transient and self-limiting (nongangrenous form), but can also lead to severe acute ischemia with bowel infarction (gangrenous form)
Signs and symptoms of ischemic colitis
LLQ pain
mucosal friability on scope
clear demarcation between normal and ischemic tissue
Self limiting
bleeding resolved without specific treatment
Hx: DM, HTN, or vascular disease.
Additional tx for GI bleeding due to esophageal or gastric varices
- octreotide (decrease portal pressure)
- banding
- TIPS (transjugular intrahepatic portosystemic shunting)
- Propanolol or nadolol (prevention future episodes)
- Abx prevents spontaneous bacterial peritonitis (ascites)
Bowel contrast with suspected GI perf?
For all GI studies barium is preferred. However is GI perf is suspected, barium can cause chemical peritonitis or mediastinitis. Use water soluble contrast.
Caution is aspiration risk as water soluble will cause chemical pneumonitis. when in doubt use water. barium once perf if excluded.
Retroperitoneal structures
SAD PUCKER: Suprarrenal (adrenal) glands Aorta & inferior vena cava Duodenum Pancreas Ureters Colon (ascending & descending) Kidneys Esophagus Rectum
