PUD and GI Bleeds -Davis

Question 1

What are the classifications of PUD?

Answer 1

• Type I: along the lesser curve at incisura angularis. due to decreased mucosal protection
• type II: 2 ulcers. 1 in the body lesser curve and duodenal ulcers. Acid over secretion
• Type III: pre pyloric channel (acid over secretion)
• type IV: proximal gastroesophageal ulcer along cardia. decreased mucosal protection
• Type V: throughout stomach. Chronic NSAID use

Question 2

When is surgery indicated for PUD?(5)

Answer 2

• Bleeding- gastroduodenal artery . posterior (MOST COMMON COMPLICATION)
• Perforation- anterior
• Obstruction- long standing disease
• Intractability- > 3months tx no relief on proton pump inhibitor or recurrence , <1 yr from tx
• Can not exclude malignancy- ulcer remains despite treatment

Question 3

What is penetration?

Answer 3

A form of perforation in which the ulcer bed tunnels into an adjacent organ

Question 4

What x-ray findings can be seen with a perforated peptic ulcer?

Answer 4

free air under the diaphragm

Question 5

What surgical treatment is best for prevention of recurrence of PUD?

Answer 5

Truncal vagotomy & antrectomy with Bilroth II

Question 6

What surgical treatment for PUD has the lowest post-op complications?

Answer 6

Highly selective vagotomy

Question 7

How does the treatment for PUD differ for ZE syndrome? What lab value is diagnostic for ZES?

Answer 7

• ZES=Most common pancreatic islet cell tumor in MEN 1
• If 2cm resection
• serum gastrin > 1000

Question 8

What is the surgical management of gastric carcinoma? What does this depend on?

Answer 8

• Hemigastrectomy- 50% stomach removed
• Subtotal gastrectomy- 75% stomach removed

location*
-Antrum- subtotal or hemi
-Midbody-total gastrectomy
-Proximal- total gastrectomy
(10% 5 year survival)

Question 9

What is an aortic-enteric fistula? When should this be assumed?

Answer 9

aortic aneurysm to duodenum
-assumed when GI bleeding in the presence of an AAA

-can be secondary to previous aortic grafts

Question 10

What is the initial treatment for esophageal varices? Continued treatment?

Answer 10

Initial: stop bleeding

• balloon tamponade
• EGD with sclerotherapy (meds that tighten blood vessels), rubber band or clip therapy

continued: beta blockers dec risk of recurrence

surgical TIPS to create new portal connections to decrease P in veins

Question 11

When should a NG lavage be done in GI bleeds? Why?

Answer 11

Nasogastric lavage should be performed in patients passing large amounts of bright red- to dark maroon-colored stool because 10 to 15 percent of such hemorrhage is from an upper GI source

Question 12

Is Meckel’s diverticulum a true diverticulum? What does that mean?

Answer 12

Yes

it contains all layers of the bowel wall

Question 13

What are internal vs external hemorrhoids covered with?

Answer 13

Internal =covered with mucous membrane

external =covered with skin

Question 14

What are the 1st and 2nd leading causes of lower GI bleeding in >60 yo?

Answer 14

1=diverticulosis

2=angiodysplagia

Question 15

What is the typical presentation of Ischemic colitis?

Answer 15

Self-limited, bloody diarrhea followed by acute lower abdominal pain in patients with cardiac risk factors

Question 16

What are the differences in acute vs chronic radiation injuries?

Answer 16

acute=injury to mitotically active intestinal crypt cells

chronic=injury to vascular capillary endothelial causing impairment to the blood supply (obliterative arteritis and thromboses of vessels –> ischemia or necrosis)