S1 MTB - Gastroparesis and GI bleeding Flashcards
Slowing of the gastric emptying is known as
Gastroparesis
Basic ass pathophysiology of gastroparesis
Damage to the intrinsec cells of Cajal
Definition of gastroparesis
Syndrome defined by symptomatic delay in gastric emptying in the absence of mechanical obstruction. In 4 hours there’s still >10% of gastric contents
Common causes of gastroparesis
- Idiopathic
- Diabetic
- Post-surgical iatrogenic damage to CN X
- Hypothyroidism
- Neurological conditions like Parkinson’s
Less common causes
- Viral (rota, cito, norwalk, epstein bar varicella zoster)
- Connective tissue disorders
- Para-neoplasic syndrome
- Infiltrative disorders
- Neurological disorders (Parkinsons)
Which viruses can cause gastroparesis?
- Rotavirus
- Citovirus
- Norwalk
- Epstein bar
- Varicella zoster
Which medication can cause gastroparesis?
- Opioids
- Alfa-2 adrenergic agonists
- Tricyclic antidepressants
- Anticholinergic
Why can diabetes lead to gastroparesis
Because of the diabetic neuropathy; causes an impair in the ICC, thus resulting in an uncontrolled constriction of the stomach
Postsurgical gastroparesis is due to…
The cut of the vagus nerve (CN X)
Can ischemia lead to gastroparesis? if so, why?
Yes, due to the loss of the irrigation to the vagus nerve… butttt it is rare
Medium arcuate ligament syndrome
Rare cause of gastroparesis
Symptoms of gastroparesis
- Bloating
- Belching
- Nausea and vomiting
- Epigastric pain (mild to severe)
- Early satiety and postprandial fullness
- GERD
- Anorexia and malnutrition
- Unintended weight loss
What can be observed at physical examination of patient with gastroparesis?
Epigastric distention without guarding or rigidity
All the symptoms of gastroparesis can be reduced to
Dyspepsia
Is there a sign to gastroparesis?
There can be some weight loss, other than that, no
Studies done to diagnose gatsroparesis
- First: upper endoscopy + abdominal CT to confirm no mechanical obstruction
- Second: gold standard scintigraphic gastric emptying test
- Spirulina breath test?
Precautions to take before the scintigraphy
- Stop medications that affect gastric motility 48 H B4
- Diabetic patients should have blood sugar levels at <275 mg/dL
How does the scintigraphy work?
- Eat low fat egg-white meal + a radioactive material (technetium)
- Imaging gets done at 2 and at 4 hours
Results for delayed gastric emptying
- Mild: 10 - 15%
- Moderate: 15 - 35%
- Severe: >35%
What lab tests can be done to check the cause of the gastroparesis?
- Hemoglobin to check for anemia
- Fasting plasma glucose to check for diabetes
- Albumin to check for malnutrition (unintended weight loss)
- TSH to check for hypothyroidism
- ANA antibodies to check for an autoimmune disease
Name of the study to diagnose gastroparesis
Scintigraphy (GES)
Should gastric emptying studies be done only for 1 hour
False, they should be done and measured for a total of 4 hours
Treatment for gastroparesis
- Diet
- Glycemia control
- Medications
What changes to the diet can a patient with gastroparesis do?
- Small meals
- Low fat and high in soluble fiber
- Avoid carbonated drinks, alcohol and smoking
If mild gastroparesis:
- Hydration
- Vitamin supplementation
What medications are given to treat gastroparesis?
- Metoclopramide
- Cisapride
- Cinitaprida
- Itoprida
- Domperidone
- Macrolides {eritromicina (antibiótico)}
Order of medication therapy
- First metoclopramide (inc astral contractions and dec fundus relaxations
- Second domperidone (EKG cause risk of cardiac arrhythmia)
- Third erythromycin antibiotic (high amplitude contractions)
WTF is a Gastric Electrical Stimulation
Gastric pacemaker, its a therapeutic treatment to gastroparesis
What is a G-POEM?
Operation done using a gastroscope, cuts the muscle fibers in the pyloris/ antrum of the stomach
Complications of gastroparesis
- Wheight loss
- Anxiety
Functional dyspepsia
Theres nothing wrong with the anatomy of the patient but the symptoms are there; absence of structural disease
Management of functional dyspepsia
- Treat for H. pylori
- PPI (Proton Pump Inhibitors)
- Antidepressants (tricyclic)
- Prokinetics
Upper GI bleeding comes from…
Esophagus or stomach
Classification of upper GI bleeding
- By origin
- Severe (hemodynamic changes)
- Forrest classification
Forrest classification can tell you the risk of the patient rebleeding?
YUH
Ia and Ib don’t have active bleeding
False, they’re the ones who tent to rebleed
Causes of upper GI bleed
- Peptic ulcer
- Gastric or esophageal varix
- Esophagitis
- NO cause
- UGI tract tumor
- Angioectasia
- Mallory-Weiss Tear (tear in the muscularis mucosa due to extreme vomiting)
- Erosions
- Dieulafoy’s lesion (a big vessel that shouldn’t be there)
- Esophageal varices or perforation
- Boerhaave syndrome
Upper GI bleeding symptoms
- It can’t be visible (anemia)
- It can be in the heces or vomit (melena, hematemesis, hematoquesia, rectorragia)
- Syncope
- Hypovolemia and hypotension
What are esophageal varices and how can it cause upper GI bleed?
Dialated submucosal veins in the lower 1/3 of the muscle caused by portal hypertension
The rupture of a varice can cause life-threatening hematemesis
How can an esophageal perforation occur and how does it lead to upper GI bleeding
Due to an endoscopic procedure, a spontaneous rupture, trauma, malignancy…
The perforation may cause mediastinitis, pneumomediastinum or a subcutaneous emphysema
What is Boerhaave syndrome and how does it lead to upper GI bleeding?
Transmural distal esophageal rupture caused by a sudden increment of intraesophageal pressure
What is Mallory-Weiss syndrome and how doest it contribute to upper GI bleeding?
Its characterized by forceful vomiting that increases intra abdominal pressure that causes a LONGITUDINAL tear at the mucosa + PAINFUL hematemesis; diagnosed with an endoscopy
What is a Dieulafoy lesion and how does it lead to upper GI bleeding
An unusual dilated arteriole at the mucosa surface that all of a sudden starts bleeding.
Treated with an epinephrine injection and thermocoagulation
Mallory-Weiss syndrome is associated to
- Hiatal hernias
- Alcoholism
- Bulimia nervosa
Treatment of upper GI bleeding
- First treat shock (hydrate, PPI, airway y cross match blood type)
- PPI
- Endoscopy
How many ml of blood should be at stool for it to turn into melena?
50 ml
Lab tests done before starting treatment for upper GI bleeding
- CBG: check hemoglobin
- Electrolytes, BUN and creatinine to check dehydration or renal failure
- ALT, AST, GGT, Bilirubin and albumin to check liver function
- Coagulation studies: fibrinogen, PT, PTT and INR to rule out bleeding disorders
Whats the treatment for a hemodynamically stable patient with upper GI bleeding
Upper endoscopy within 24 hours
Whats the treatment for a hemodynamically UNSTABLE patient with upper GI bleeding
- 1) two big ass 18 gauge peripheral intravenous catheters are put in
- 2) Give 500 ml of fluids
- 3) PPI’s via IV (esomeprazole) in bolus 80 mg and then 40 mg daily 2 timer per day
Peptic ulcers can lead to upper GI bleeding, what are the main causes of a peptic ulcer?
- H. pylori infection
- Chronic use of NSAID
Treatment for upper GI bleeding due to peptic ulcer
- Thermocoagulation therapy
- Hemostatic clips
- Epinephrine injection
Whats dumping syndrome?
Rapid gastric emptying as a result of defective gastric reservoir function, impaired pyloric emptying mechanisms, or anomalous post surgery gastric motor function
What causes dumping syndrome?
- Bypass
- Gastrectomy
- Esophagectomy
- Fundiplication
- Vagotomy
- Piloroplasty
Theres two types of dumping syndrome…
- Early dumping syndrome
- Late dumping syndrome
Pathophysiology of early dumping syndrome
Rapid emptying of undiluted hyperosmolar chyme into small intestine → fluids shift to intestinal lumen → small I distention → vagal stimulation → ↑intestinal motility
Clinical manifestations of early dumping syndrome
- Dumping 15 to 30 minutes after ingestion
- Nausea and vomiting
- Diarrhea
- Cramps
- Sweating
- Flushings
- Palpitations
Whats the treatment for early dumping syndrome
- Small meals with complex carbs and protein + fat rich foods
- 30 to 60 mins of rest in supine position after meals
- Beta blockers to ease tachycardia
Pathophysiology of late dumping syndrome
Rapid emptying of GLUCOSE-containing chyme into small intestine → quick reabs of glucose → hyperglycemia → excessive release of INSULIN → hypoglycemia and release of catecholamines
Clinical manifestations of late dumping syndrome
- Dumping occurs hours after meal ingestion
- Signs of hypoglycemia → hunger, tremor, lightheadedness
- GI discomfort
What types of patients can make you suspect of late dumping syndrome?
- Previous gastric surgery
- Patients with hypoglycemia
Treatment for late dumping syndrome
- First line: dietary modifications
- Second line: octreotide
- Third line: surgery
