Summary of Essentials - Ch. 48- (GI)

Question 1

Most common cause of melena?

Answer 1

UGI bleed

Question 2

Presentation - bloody emesis in a patient who is critically ill and in the ICU?

Answer 2

Stress ulceration

Question 3

Presentation - bloody emesis in a patient with a history of aortic surgery?

Answer 3

Aortoenteric fistula

Question 4

Work-up for suspected aortoenteric fistula?

Answer 4

Endoscopy and CT (gas/stranding around graft)

Question 5

Dx cause of bloody emesis?

Answer 5

If unclear whether upper or lower GI - NG tube lavage

Question 6

Management of UGI bleed?

Answer 6

• ABCs, 2 large-bore IVs, type and cross
• If massive bleed, consider intubation
• Transfuse Hgb below 7
• Start PPI early
• Triple therapy for H. pylori eradication
• Admit to montored setting
• Upper endoscopy with 12 hours (most can be Rx with endoscopic techniques)
• Calculate MELD?

Question 7

When is surgery indicated in the setting of an UGI bleed?

Answer 7

Duodenal ulcer (open duodenum, 3-point ligation of ulcer), gastric ulcer (excise and close for acute vs. distal gastrectomy for chronic)

Question 8

Which type of varices are more difficult to treat and do not respond well to banding or sclerotherapy?

Answer 8

Gastric (vs. esophageal)

Question 9

In the setting of isolated gastric varices along the greater curve, consider ___ from prior pancreatitis. ___ is curative.

Answer 9

Splenic vein thrombosis; splenectomy

Question 10

What can be used to prevent recurrent bleeding from esophageal varices?

Answer 10

Propranolol

Question 11

Presentation - sudden onset severe epigastric pain that becomes diffuse, history of PUD/H. pylori/smoking/chronic NSAIDs, evidence of SIRS, lying motionless in bed, peritoneal signs

Answer 11

Perforated peptic ulcer

Question 12

What are the 5 types of gastric ulcers?

Answer 12

I - lesser curve of stomach
II - in stomach and duodenum
III - pre-pyloric
IV- proximal by the cardia
V - 2/2 NSAID use

Question 13

Work-up of suspected perforated peptic ulcer?

Answer 13

Upright CXR - free air under diaphragm

CT with oral gastrografin

Question 14

Management of perforated duodenal ulcer?

Answer 14

Primary closure with omental patch

Question 15

Management of perforated gastric ulcer?

Answer 15

Primary closure, biopsy, omental patch vs. wedge resection (must rule out malignancy)

Question 16

Rx H. pylori?

Answer 16

Triple therapy - clarithromycin, amoxicillin, PPI for 14 days

Question 17

Most common type of stomach cancer?

Answer 17

Adenocarcinoma (2 types - intestinal and diffuse)

Question 18

Most common cause of stomach cancer?

Answer 18

H. pylori infection

Question 19

This type of gastric cancer is poorly differentiated, occurs most often in the proximal stomach, and is often related to congenital disorders

Answer 19

Diffuse type

Question 20

This type of gastric cancer occurs in the distal stomach and is associated with environmental factors

Answer 20

Intestinal-type

Question 21

What is infiltration oft he entire gastric wall with cancer?

Answer 21

Linitis plastica

Question 22

What are GIST tumors?

Answer 22

Smooth, submucosal tumors that express c-KIT and CD117

Question 23

Study of choice to dx gastric cancer?

Answer 23

Endoscopy

Further staging with CT chest, A/P, and/or PET

Question 24

Management of gastric cancer?

Answer 24

Stage IB or higher - pre-operative chemo

Surgery: tumor distal to stomach - subtotal gastrectomy vs. in proximal stomach: proximal gastrectomy or total gastrectomy

Post-operative chemo and radiation

Question 25

Rx low grade MALT lymphoma? High-grade?

Answer 25

Low grade - H. pylori eradication

High grade - chemo

Question 26

Presentation - thoracic pain radiating to the lower back and aggravated by swallowing, chest pain/vomiting/subQ emphysema

Answer 26

Boerhaave’s syndrome

Question 27

Work-up of chest pain after vomiting?

Answer 27

Initial study - CXR (look for L pleural effusion and atelectasis, pneumomediastinum is pathognomonic)

Gastrografin esophogram or CT chest with water-soluble oral contrast to confirm

Question 28

Management of Boerhaave’s syndrome?

Answer 28

Conservative (consider in healthy patients with mild sepsis and a contained rupture within the mediastinum) - continuous NG suction, IV broad-spectrum ABX, parenteral nutrition

Surgery within 24 hours - debride necrotic tissue, primary suture closure, coverage with pedicle flap