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)