UGIB Flashcards
UGIB
Bleeding into the lumen of the proximal GI tract, proximal to the ligament of Treitz
UGIB signs and symptoms
Hematemesis, melena, syncope, shock, fatigue, coffee-ground emesis,
hematochezia, epigastric discomfort, epigastric tenderness, signs of hypovolemia, guaiac-positive stools
PUD
MC cause of significant UGIB
Bacteria associated w/ PUD
H. pylori
Treatment PUD
MOC - metronidazole, omeprazole, clarithromycin
ACO - ampicillin, clarithromycin, omeprazole
Valentino’s sign
RLQ pain/peritonitis as a result of succus collecting
from a perforated peptic ulcer
Duodenal Ulcers
pain relieves by food
Cause of DU
increased production of gastric acid
DU associated syndrome
Zollinger-Ellison syndrome
DU risk factors
Male gender, smoking, aspirin and other NSAIDs, uremia, Z-E syndrome, H. pylori, trauma, burn injury
DU symptoms
Epigastric pain—burning or aching, usually several hours after a meal (food, milk, or antacids initially relieve pain) Bleeding Back pain Nausea, vomiting, and anorexia ↓ appetite
DU signs
tenderness in epigastric area (possibly) guaiac-positive stool melena hematochezia hematemesis
EGD findings associated w/ rebleeding
Visible vessel in the ulcer crater, recent clot, active oozing
DU medical treatment
PPIs (proton pump inhibitors) or H2 receptor antagonists—heal ulcers in
4 to 6 weeks in most cases
DU indications for surgery
Intractability
Hemorrhage (massive or relentless)
Obstruction (gastric outlet obstruction)
Perforation
Artery involved in bleeding duodenal ulcers
Gastroduodenal artery
Truncal vagotomy
Pyloroplasty
Duodenal perforation
Graham patch (poor candidates, shock, prolonged perforation)
Truncal vagotomy and pyloroplasty incorporating ulcer
Graham patch and highly selective vagotomy
Truncal vagotomy and antrectomy (higher mortality rate, but lowest recurrence rate)
DU intractability
PGV (highly selective
vagotomy)
vagotomy and pyloroplasty
Vagotomy and antrectomy BI or BII (especially if there is a coexistent pyloric/prepyloric ulcer) but associated with a higher mortality
Ulcer operation has the HIGHEST ulcer recurrence
rate and the LOWEST dumping syndrome rate
PGV (proximal gastric vagotomy)
Ulcer operation has
the LOWEST ulcer recurrence rate and the HIGHEST dumping syndrome rate
Vagotomy and antrectomy
Why must you perform a
(pyloroplasty, antrectomy)
after a truncal vagotomy?
Pylorus will not open after a truncal drainage procedure vagotomy
DU with lowest mortality rate
PGV (1/200 mortality), truncal vagotomy and pyloroplasty (1–2/200), vagotomy and antrectomy (1%–2% mortality)
Gastric Ulcers
40–70 years old (older than the duodenal ulcer population)
food increases GU pain
Cause of GU
DECREASED CRYOPROTECTION or gastric
protection (i.e., decreased bicarbonate/ mucous production)
GU associated increased gastric acid
prepyloric
pyloric
coexist w/ DU
GU risk factors
Smoking, alcohol, burns, trauma, CNS tumor/trauma, NSAIDs, steroids, shock,
severe illness, male gender, advanced age
GU symptoms
Epigastric pain
+/-Vomiting, anorexia, and nausea
GU diagnosis
History, PE, EGD with multiple biopsy (r/o gastric cancer)
GU MC location
lesser curvature - 70%
Options for concomitant duodenal and gastric ulcers
Resect (BI, BII) and TRUNCAL VAGOTOMY
Common option for surgical treatment of a PYLORIC gastric ulcer?
Truncal vagotomy and antrectomy (i.e., BI or BII)
Common option for a poor operative candidate
with a perforated gastric ulcer
Graham patch
Cushing ulcer
PUD/gastritis associated with NEUROLOGIC TRAUMA/TUMOR
Curling’s ulcer
PUD/gastritis associated with MAJOR BURN INJURY
Marginal ulcer
Ulcer at the margin of a GI anastomosis
Dieulafoy’s ulcer
Pinpoint gastric mucosal defect bleeding from an underlying VASCULAR MALFORMATION
Perforated Peptic Ulcer
Acute onset of upper abdominal pain
Perforated Peptic Ulcer signs
Decreased bowel sounds
tympanic sound over the liver (air)
peritoneal signs
tender abdomen
Signs of posterior duodenal erosion/ perforation
Bleeding from gastroduodenal artery (and possibly acute pancreatitis)
Sign indicates anterior duodenal perforation
Free air (anterior perforation is more common than posterior)
Perforated Peptic Ulcer associated lab findings
Leukocytosis
high amylase serum (secondary to absorption into the blood stream from the peritoneum)
Perforated Peptic Ulcer initial treatment
NPO: NGT (↓ contamination of the peritoneal cavity)
IVF/Foley catheter
Antibiotics/PPIs
Surgery
Piece of omentum incorporated into the suture closure of perforation
Graham patch
Surgical options for treatment of a duodenal perforation?
Graham patch (open or laparoscopic)
Truncal vagotomy and pyloroplasty incorporating ulcer
Graham patch and highly selective vagotomy
Surgical options
for perforated gastric ulcer?
Antrectomy incorporating perforated ulcer, Graham patch or wedge resection
in unstable/poor operative candidates
Significance of
hemorrhage and perforation
with duodenal ulcer?
may indicate two ulcers (kissing); posterior is bleeding and anterior is perforated with free air
Graham patch
For treatment of DUODENAL PERFORATION in poor operative candidates/unstable patients
Place viable omentum over perforation and tack into place with sutures
Truncal vagotomy
Resection of a 1- to 2-cm segment of each vagal trunk as it enters the abdomen on the distal esophagus,
decreasing gastric acid secretion
Other procedure must
be performed along with a
truncal vagotomy?
“Drainage procedure” (pyloroplasty, antrectomy, or gastrojejunostomy), because vagal fibers provide relaxation of the pylorus, and, if you cut them, the pylorus will not open
Vagotomy and Pyloroplasty
Pyloroplasty performed with vagotomy to compensate for decreased gastric emptying
Vagotomy and antrectomy
Remove antrum and pylorus in addition to vagotomy; reconstruct as a Billroth I or II
Advantage of proximal gastric vagotomy (highly selective vagotomy)
No drainage procedure is needed; vagal fibers to the pylorus are preserved; rate of dumping syndrome is low
Billroth I
Truncal vagotomy, antrectomy, and gastroduodenostomy
Billroth I Contraindications
Gastric cancer or suspicion of gastric cancer
Billroth II
Truncal vagotomy, antrectomy, and gastrojejunostomy
Kocher Maneuver
Dissect the left lateral peritoneal attachments to the duodenum to allow visualization of posterior duodenum
Stress gastritis
SUPERFICIAL mucosal erosions in the stressed patient
Stress gastritis Risk factors
Sepsis, intubation, trauma, shock, burn, brain injury
Stress gastritis prophylactic treatment
H2 blockers, PPIs, antacids, sucralfate
Stress gastritis signs and symptoms
NGT blood (usually), painless (usually)
Stress gastritis diagnosis
EGD - if bleeding is significant
Stress gastritis treatment
LAVAGE out blood clots, give a maximum dose of PPI in a 24-hour IV drip
Mallory Weiss Syndrome
Post-retching, postemesis longitudinal tear (submucosa and mucosa) of the stomach near the GE junction
~ 3/4 are in the stomach
d.t. Increased gastric pressure, often aggravated by hiatal hernia
Mallory Weiss Syndrome Risk Factors
Retching, alcoholism (50%), 50% of patients have hiatal hernia
Mallory Weiss Syndrome symptoms
epigastric pain
thoracic substernal pain
emesis
hematemesis
Mallory Weiss Syndrome diagnosis
EGD
Mallory Weiss Syndrome “classic” history
Alcoholic patient after binge drinking— first, vomit food and gastric contents,
followed by forceful retching and bloody vomitus
Mallory Weiss Syndrome “classic” treatment
Room temperature water lavage (90% of patients stop bleeding)
electrocautery
arterial embolization
surgery for refractory bleeding
Esophageal Variceal Bleeding
Bleeding from formation of esophageal varices from back up of portal pressure via the coronary vein to the submucosal esophageal venous plexuses secondary to portal hypertension from liver cirrhosis
2/3 of patients with portal
thirds” of esophageal hypertension develop esophageal varices
2/3 of patients with esophageal varices bleed
Esophageal Variceal Bleeding signs and symptoms
Liver disease portal hypertension hematemesis caput medusa ascites
Esophageal Variceal Bleeding diagnosis
EGD
Esophageal Variceal Bleeding medical treatment
Lower portal pressure with somatostatin and vasopressin
Esophageal Variceal Bleeding surgical options
Sclerotherapy or band ligation via endoscope
TIPS
liver transplant
Sengstaken- Blakemore balloon
Tamponades with an esophageal balloon and a gastric balloon
Boerhaave’s syndrome
Postemetic esophageal rupture
posterolateral aspect of the esophagus (on location? the left), 3 to 5 cm above the GE junction - MC location
Boerhaave’s syndrome cause of rupture
Increased intraluminal pressure, usually caused by violent retching and vomiting
Boerhaave’s syndrome associated risk
Esophageal reflux disease (50%)
Boerhaave’s syndrome symptoms
Pain postemesis (may radiate to the back, dysphagia)
Boerhaave’s syndrome signs
Left pneumothorax Hamman’s sign left pleural effusion subcutaneous/mediastinal emphysema fever tachypnea tachycardia signs of infection by 24 hours neck crepitus widened mediastinum on CXR
Mackler’s triad
emesis
lower chest pain
cervical emphysema (subQ air)
Hamman’ sign
“Mediastinal crunch or clicking” produced by the heart beating against air-filled tissues
Boerhaave’s syndrome treatment
Surgery within 24 hours to drain the mediastinum and surgically close the perforation and placement of pleural patch; broad spectrum antibiotics
MC cause of esophageal perforation
Iatrogenic (most commonly cervical esophagus)
