Stomach, Esophagus, and GI Bleeds

Question 1

aching or gnawing epigastric
pain, either relieved or
exacerbated by eating

Dx?

Answer 1

PUD
relieved = duodenal
exacerbated = gastric

Dx with EGD

Question 2

pathophys and specific locations of duodenal vs gastric ulcers

Answer 2

Duodenal ulcers: due to ↑acid
secretion; most commonly in 1st
part of duodenum, DU in 2nd
-4th part indicates Z-E syndrome

Gastric ulcers: due to ↓mucosal
protection; 
type I – lesser
curvature
type II – duodenum and stomach 
type III – pylorus,
type IV – GE junction

Question 3

Tx for duodenal vs gastic ulcers

Answer 3

Duodenal = triple therapy if ulcer persists, surgery (HSV) + get serum gastrin levels to r/o Z-E

Gastric: Tx PPIs → if ulcer persists for 6 wks, EGD w/ bx to r/o gastric cancer → if ulcer persists for 18 wks, surgery (wedge resection or distal gastrectomy)

Question 4

Etiologies of PUD

Answer 4

NSAIDs and H. pylori (MCC); EtOH, uremia, burns (Curling), smoking, stress, head injury (Cushing)

Question 5

gastrinoma → ↑gastrin →
parietal cell stimulation → ↑HCl
→ ulcer formation

Answer 5

Zollinger-Ellison syndrome

Question 6

inflammation of gastric mucosa
→ aching or gnawing epigastric
pain

Dx and Tx?

Answer 6

acute gastritis

• Dx EGD w/ bx
• Tx d/c NSAIDs, triple therapy for H. pylori

Question 7

complications of acute gastritis

Answer 7

PUD, gastric adenocarconoma or lymphoma

Question 8

presents as epigastric abd pain,

weight loss, early satiety, etc.

Answer 8

gastric adenocarcinoma and gastric lymphoma

Question 9

What are ...
Krukenberg tumor?
Blumer shelf?
SMJ node?
Virchow node?
Irish node?

Answer 9

Krukenberg tumor: ovarian mets
(bx shows “signet ring” cells)

Blumer shelf: rectal mets

SMJ node: periumbilical LN mets

Virchow node: left supraclavicular
LN mets

Irish node: left axillary LN mets

Question 10

What are RF for developing gastric adenocarcinoma?

Answer 10

type A blood, smoked foods (japanese)

Question 11

dysphagia of solids > liquids +
weight loss ± odynophagia (if
severe)

Answer 11

esophageal cancer

Question 12

where is SCC vs adenocarcinoma of esopahgus found?

Answer 12

SCC: found in upper 2/3, due to
smoking and EtOH abuse

Adenocarcinoma: found in
lower 1/3, due to GERD/Barrett’s

Question 13

How to work up suspected esophageal cancer?

Answer 13

Dx esophagoscopy w/ bx, then staging via endoscopic U/S + CT scan

Question 14

treatment for esophageal cancer

Answer 14

• upper 1/3 → Tx chemo + radiation
• middle 1/3 → Tx chemo + radiation, then esophagectomy
• lower 1/3 → Tx esophagectomy + proximal gastrectomy

Question 15

hypertonic and nonrelaxing LES
w/ poorly relaxing esophagus
→ dysphagia of liquids > solids

How to dx and treat?

Answer 15

Achalasia

• Dx screen w/ barium swallow (bird’s beak), confirm w/ manometry (↑LES pressure)
• Tx botox vs. Heller myotomy

Question 16

uncoordinated esophageal
peristalsis → dysphagia +
angina-like chest pain

dx and treatment?

Answer 16

diffuse esophageal spasm

• Dx screen w/ barium swallow (corkscrew), confirm w/ manometry (uncoordinated)
• Tx nifedipine, nitrates

Question 17

type I vs 2 vs 3 hiatal hernias + Txs

Answer 17

Type 1 HH: sliding hernia, can
present as GERD or reflux
esophagitis
Tx w/ PPI then lap nissen

Type 2 HH: paraesophageal
hernia, high risk of incarceration
and strangulation
Tx with surg repair

Type 3 HH: both type 1+2
Tx with surgical repair

Question 18

Pathophys of Mallory weiss vs boerhave syndrome

Answer 18

mallory weiss = retching then LACERATION of esophagus –> UGIB

Boerhave = retching then PERFORATION of esophagus –> epigastric pain, fever, pneumomediastinum

Question 19

Diagnosis and management of mallor vs boerhave

Answer 19

Mallory: Dx with upper GI endoscopy and treat with observation as usually stops bleeding on its own

Boerhave = Dx with barium swallow and Tx is emergent surgical repair

Question 20

iron deficiency → anemia,
upper esophageal webs
(dysphagia), koilonychia

Tx?

Answer 20

plummer vinson syndrome

esophageal dilation + PO iron supplementation

Question 21

ingestion of acids, alkali, bleach,
or detergents → lower
esophageal webs → usually asx,
dysphagia if severe

Tx

Answer 21

schatzki ring

• dysphagia → Tx esophageal dilatation
• full-thickness necrosis → Tx esophagectomy

Question 22

lack of cricopharyngeal relaxation → diverticulum at upper
esophagus → food gets stuck
→ halitosis + dysphagia

Answer 22

Zenker Diverticulum

Dx with barium swallow

Question 23

TB or cancer → LN-opathy → traction → diverticulum at middle

esophagus

Answer 23

Traction diverticulum

Dx with barium swallow

Question 24

esophageal motility d/o →
diverticulum at lower
esophagus

Answer 24

Epiphrenic diverticulum

Dx with bariu swallow

Question 25

Work up for GI bleed

Answer 25

NG tube to suction:
+blood/±bile is UGIB
–blood/+bile is LGIB
–blood/–bile is indeterminate

Upper–> get EGD
Lower –> get colonoscopy

Question 26

GI bleed wont stop, next step?

Answer 26

Dx tagged RBCs or angiography to localize site of bleeding

Question 27

how to define “hemodynamic instability despite

transfusion”,

Answer 27

loss of 4-6 units in 24 hrs, or 8-10 units in 48 hrs, next step is ex lap

Question 28

top 3 causes of UGIB

Answer 28

PUD (#1), NSAID use

#2), esophageal varices (#3

Question 29

Top 3 causes of LGIB

in a kid?

Answer 29

diverticulosis (#1), AVM
(#1), colon cancer (#3)

kid = meckels diverticulum

Question 30

UGIB in ICU pt =

Answer 30

stress ulcer

Question 31

UGIB in alcoholic =

Answer 31

esophageal varices, Mallory-Weiss tear, Boerhaave syndrome

Question 32

UGIB s/p aortic graft

Answer 32

aortoenteric fistula (small herald bleed followed by massive UGIB)