Upper GI Flashcards
What are key items in the differential for upper GI bleed?
Gastritis Gastric ulcer Duodenal ulcer Erosive esophagitis Mallory-Weiss tear Esophageal varices Gastric cancer Angiodysplasia Isolated gastric varies Aortoenteric fistula
What are key lifestyle factors that must be asked about in upper GI bleed?
Alcohol use
NSAID use
What does bright-red bloody emesis tell you about location of the bleed?
UGI
What does coffee ground emesis tell you about location of the bleed?
UGI
What does black, tarry, foul-smelling stool (melon) tell you about location of the bleed?
UGI usually, LGI possible
What does bright red bloody stool tell you about the location of the bleed?
LGI probably, may be UGI
What does maroon colored stool tell you about the location of the bleed?
UGI (probably)
LGI (maybe)
What causes esophageal varies?
Cirrhosis: portal vein has more difficulty draining its blood into the scarred liver duh that blood flows retrograde under high pressure back into esophagus
What is acute vs. chronic gastritis?
Acute: erosive, superficial inflammation in stomach lining due to dysfunction of mucosal defenses
Chronic: Non erosive inflammation of gastric mucosa: due to inflammation
What is a Dieulafoy’s lesion?
rare cause upper GI bleed: vascular malformation: large tortuous artery in the submucosa is eroded by gastric acid
What causes acute gastritis?
NSAID abuse
Alcohol
Steroids
Uremia
What causes chronic gastritis?
Pernicious anemia, H. pylori
What artery can be behind a gastric ulcer in the posterior wall of stomach?
Splenic
What artery can be behind a gastric ulcer in the lesser curvature of the stomach?
Left gastric artery
What artery can be behind a duodenal ulcer in the posterior wall of 1st portion of duodenum?
Gastroduodenal artery
Where is UGI bleeding coming from?
Proximal to ligament of Treitz
Why can Hb or hematocrit be normal in spite of major GI bleed?
Because of loss of all portions of blood at same rate: do not see drop until 12-24 hours later once kidney begins to conserve Na and water
What happens to BUN/Cr during UGI bleed?
Increases to >36 signifies UGI bleed
How can bloody emesis and bright red blood per rectum present together?
UGI bleed: very fast transit through GI tract - no time for digestion
What is difference between obscure and occult GI bleeding?
Occult: not known to patient
Obscure: obvious bleeding to patient, but hard to identify source on endoscopy (usually due to bleeding in small bowel)
What are first steps in management of UGI bleed?
2 large bore IVs IVF resuscitation NGT Blood: type and cross Admit
Why place NGT in UGI bleed?
Differentiate between UGI and LGI bleed
What is difference between “type & screen” vs. “type & cross”?
Type and screen: no likely blood transfusion.
Type and cross: likelihood of needing blood is high
What does blood typing determine?
ABO and Rh status
What does blood screening determine?
Presence of alloantibodies in recipient’s blood that may react with donor blood
What does blood crossmatching determine?
Recipient blood tested against donor packed cells to determine if there is clinically sig response to antigens on donor cells
After admission for UGI bleed, what is the next step to determine source of bleeding? In what window?
Endoscopy w/in 12 hours
After admission for UGI bleed, if endoscopy is negative, what do we do?
Look in small bowel: capsule endoscopy, push enteroscopy, angiography, look in LGI
When do we give blood transfusion ?
Only when Hb < 7
Where in the hospital do we manage UGI bleed?
ICU
How do we position bed in patient who is vomiting blood?
Head of bed to 30 degrees unless ongoing hypotension
After resuscitation for UGI bleed, what is next step?
- Correct coagulopathy w/ blood/platelets/FFP if needed
- Reverse anticoagulants
- Start PPI
What are endoscopic therapeutic options for UGI bleed?
Inject epi
Bipolar electrocoagulation
Endoscopic clips
Plasma coagulator
When do we take UGI bleed patients to surgery?
- Failure of endoscopic therapy (>twice)
- Persistent hemodynamic instability despite aggressive resuscitation
- CV dz w poor predictive response to hypotension
- Hemorrhagic shock
What are surgical options for bleeding ulcer that fails medical management?
Duodenal: open duodenum, 3-point ligation of ulcer
Gastric: excise and close for acute vs. distal gastrectomy for chronic history of ulcer dz
If ulcer or gastritis is found on endoscopy, what else do we test for?
H. pylori - Tx with PPI, clarithromycin, amoxicillin
How do we test for H. pylori?
Urea breath test: test for ammonia labeled with c isotope in breath that the patient eats
How do we manage UGI bleed for esophageal varies?
- Short term AB prophylaxis
- Esophageal band ligation is best option
- Repeat endoscopy to band any remaining vessels
What is the best way to prevent recurrent UGI bleed from esophageal varies?
beta blockers (propranolol)
How do we manage UGI bleed from Mallory-Weiss tear?
Self limited - very rarely need sclerosis therapy or electrocautery
In alcoholic patient, what is important to calculate before surgery?
MELD: Model for End Stage Liver Disease which can influence surgical decision making
What do we think of with isolated gastric varies along the greater curve of stomach?
Splenic vein thrombosis from prior pancreatitis: splenectomy is curative
For patients with chronic NSAID therapy, what can we use to prevent ulcers?
PPIs
What does free air under the diaphragm indicate?
Perforated viscus
What are most common causes of free air under diaphragm?
Perforated ulcers
Perforated diverticulitis
What are most common symptoms in a patient with PUD?
Burning in epigastric region, non radiating
How do patients with perforated peptic ulcers present?
- Acute onset sharp abdominal pain in epigastrium that rapidly becomes diffuse
- Shoulder pain
- Peritonitis: exquisite tenderness to palpation, abdominal guarding and rigidity
- SIRS
What are most common cause of peptic ulcers?
H. pylori
How do NSAIDs lead to peptic ulcers?
Inhibit production of prostaglandins that regulate inflammation in gastric mucosa and reduce acid production
What factors can lead to peptic ulcers?
NSAID use
Smoking
Alcohol
High stress environments
What are type I peptic ulcers?
Lesser curvature, no acid hypersecretion (disruption in mucosal defense)
What are type II peptic ulcers?
Lesser curvature/duodenum with acid hypersecretion
What are type III peptic ulcers?
Prepyloric with acid hypersecretion
What are type IV peptic ulcers?
Gastric cardia without acid hypersecretion (disruption in mucosal defense)
What are type V peptic ulcers?
Any location in stomach: associated with NSAID use so no acid hypersecretion (disruption in mucosal defense)
How id diagnosis of perforated PUD established?
Clinical exam: guarding with palpation and muscle rigidity
Confirmed by radiology findings
What labs do we send in suspected perforated PUD?
CBC Blood chemistry - Look for elevated WBC, CRP, decreased albumin, elevated BUN/Cr - Amylase/Lipase to r/o pancreatitis - LFTs: cholecystitis or cholelithiasis
What imaging do we order for suspected perforated PUD?
Acute abdominal series or upright CXR
What is the classic finding on abdominal or chest XR in perforated PUD?
Pneumoperitoneum: hyperlucent area under one or both hemidiaphragms
- Also look retroperitoneal for posterior gastric!
What studies are contraindicated in suspected perforated PUD?
- Barium UGI series (causes barium peritonitis)
- Upper endoscopy (can exacerbate with air)
What is the role of CT scan in workup of perforated peritonitis?
CT scan with gastrografin: Diagnose pneumoperitoneum and confirm diagnosis
- Also can tell if spontaneously sealed itself
What is morbidity and mortality of perforated peptic ulcer?
> 25%
What is definitive management of perforated peptic ulcer?
- ICU admission
- Volume resuscitation
- NGT placement
- Antibiotics for sepsis
- Triple therapy if H pylori positive
How do we treat duodenal ulcer perforation?
Primary closure with omental patch
How do we treat gastric ulcer perforation?
Primary closure, biopsy omental patch vs. wedge resection
What is important to rule out in patient with any gastric ulcer?
Malignancy
What are two possible causes of ulcers?
Acid hypersecretion
Mucosal defense hyposecretion
What are the key findings in perforated ulcer? PE, labs, imaging
PE: acute abdomen with diffuse peritonitis
Labs: Elevated WBC
Imaging: free air under diaphragm (XR) and CT
What are key features of Boerhaave’s syndrome?
- CP after forceful vomiting
- Crepitus with palpation around the sternum
- L sided pleural effusion
- SIRS
What are the risk factors for Boerhaave’s syndrome?
- Alcoholics
- Overeating –> aggressive vomiting
Why is Boerhaave’s syndrome so often unrecognized?
CP has such a large differential
What is Mackler’s triad? what’s it for?
Vomiting
Thoracic pain
SubQ emphysema
- Suggests Boerhaave’s
What are clinical signs most often observed in Boerhaave’s?
Vomiting > thoracic pain > dyspnea ? epigastric pain ? dysphagia
What is most specific sign of an esophageal rupture?
SubQ emphysema = pathognomonic
How does Boerhaave’s present differently than Mallory Weiss?
Boerhaave’s: thoracic pain radiating to back, L pleural effusion, sepsis
M-w: Upper GI bleed
What are most common causes of esophageal perforation?
- Iatrogenic injury during upper endoscopy: most common
- Blunt or penetrating trauma
- Foreign body ingestion
- Perforating malignancy
- Only 10-20% Boerhaave’s
How does Boerhaave’s most commonly present?
Thoracic pain radiating to the lower back and aggravated by swallowing
What is the pathophysiology of Boerhaave’s?
Transmural esophageal perforation 2/2 increased intragastric pressure induced by vomiting
Why do patients with Boerhaave’s become so septic?
- Gross contamination of mediastinum
- Often leads to rupture of pleura as well: 2/2 gastric and bilious contents eroding through the lining
- Once pleura disrupted, gross contamination of pleural cavity also occurs
- Mediastinitis / pleuritis eventually lead to sepsis
What is first step in workup of suspected Boerhaave’s?
CXR: should see L pleural effusion and atelectasis, but can be normal if it has not been > 1 hour
If CXR is questionable in suspected Boerhaave’s, what is the next diagnostic step?
CT with oral contrast:
- Identify extent of perforation
- Assists in decision on surgical approach
- If not Boerhaave’s, helps id another differential
Is there a role for endoscopy in Boerhaave’s?
No: more air into esophagus can enlarge the opening/hole
What are the initial steps in management of a Boerhaave’s patient?
- IVF resuscitation
- NPO
- Antibiotics to over oral bacteria + fungal
- PPI to reduce secretions
- Place arterial line if hemodynamically unstable
What is the key timeframe for detection and treatment in Boerhaave’s?
Within 24 hours!
Who gets conservative management with Boerhaave’s? What is conservative?
Contained leak w/in mediastinum:
- NPO
- NGT
- IV antibiotics / fluids
- Parenteral nutrition
What is the goal for surgery for Boerhaave’s?
Within 24 hours
What is standard treatment(surgery) for Boerhaave’s?
- Debride necrotic tissue around perforation
- Primary suture closure
- Cover with pedicle flap
What causes death in Boerhaave’s?
Contamination of mediastinum and pleura: leads to sepsis, shock and multi organ failure
In which patients is conservative management considered for Boerhaave’s?
Minimal comorbidites
No signs of sepsis / shock
Perforation < 24 h
Leak that is small/contained or has self-sealed
What is the mortality of Boerhaave’s?
50%
What is the differential for vague abdominal pain, weight loss, difficulty eating and melena?
PUD GERD Panreatitis Cholelithiasis Hiatal hernia Gastric outlet obstruction SBO Gastric cancer
What to think: weight loss and positive FOBT?
Malignancy until proven otherwise
What is triple therapy for H. pylori?
Amoxicillin
Clarithromycin
Omeprazole
Why don’t we screen for gastric cancer?
Not cost effective due to low rate in US
Why is mortality rate so high for gastric cancer?
- No screening
- By the time sx appear, already stage III to IV
- Sx of gastric cancer are vague
What are most common symptoms for a patient with gastric cancer?
1 Weight loss
2 Abdominal pain
Perhaps dyphagia, nausea, early satiety, rarely a palpable mass
Are there specific findings on physical exam for gastric cancer?
Usually non specific, often absent
If present:
- Palpable L supraclavicular nodes (Virchow’s nodes)
- Periumbilical lymphadenopathy (SMJ nodes)
- Left axillary node (Irish’s node)
What are the 2 types of gastric adenocarcinoma?
1 Intestinal type
2 Diffuse type
What are hallmark features of intestinal type gastric adenocarcinoma?
- Arises from gastric mucosa usually in distal stomach
- Sporadic: high exposure to tobacco, alcohol, poor diet
- Largely decreased due to H. pylori eradication
What are hallmark features of diffuse type gastric adenocarcinoma?
- Arises from lamina propria and grows in infiltrative, submucosal pattern
- Leads to gastric thickening without discrete mass often in proximal stomach
What is linitis plastica?
Diffuse type gastric cancer: if it infiltrates the entire gastric wall / esophagus / duodenum = linitis plastica.
- High mortality rate!
What is the vascular supply to the stomach and where do those arteries branch from?
L/R gastrics: lesser curve L/R gastroepiploics: greater curve L gastric: celiac R gastric: common hepatic L gastroepiploic: splenic R gastroepiploic: R gastric / common hepatic
Why do patients with gastric cancer get iron deficiency anemia?
slow intermittent bleeding of the tumor
What is the best way to diagnose a patient with suspected gastric cancer?
Upper endoscopy: visualize and biopsy lesion
Once diagnosis of gastric cancer is established, what further workup is recommended?
1 Endoscopic ultrasound: assess tumor size, depth and lymph node involvement for TNM staging
2 CT abdomen to see if surgical candidate, r/o liver mets
3 PET scan: look for mets and nodes
Why is staging of gastric tumor important?
To determine intervention: surgery vs. chemo vs. radiation
When do we use chemotherapy in locally advanced gastric cancer?
Before surgery!
What stages of gastric cancer get preoperative chemotherapy?
Stage 1B or higher
What is the benefit of postoperative chemo and radiation in gastric cancer?
Improved overall survival
What is the surgical approach for gastric cancer in the distal stomach?
Subtotal gastrectomy
What is the surgical approach for gastric cancer in the proximal stomach?
Proximal or total gastrectomy
What are the margins of gastric cancer stage R0 resection?
5cm
How many lymph nodes should be taken in gastric cancer surgery? Why?
> 15 to properly stage
How do we treat MALT lymphoma in the stomach?
- Low grade: H. pylori eradication
2. High grade: chemo
Why does the 5 year mortality remain high for gastric cancer?
Advanced disease present at diagnosis
What gene mutation has been shown to often be present in gastric cancers?
HER2 - do genetic testing before induction chemotherapy
What other types of gastric cancers are there, besides adeno?
GIST: mesenchymal tumors
Gastric carcinoids
Gastric lymphoma
Why do patients get dumping syndrome after gastric resection?
Absence of regulatory effect of the pyloric sphincter: hyperosmolar state in the small intestine leads to increased water secretion into the lumen, leading to diarrhea and hypotension
What are common complications after a gastric resection?
Diarrhea Darly satiety Dumping syndrome Anastomotic leak SBO Internal hernia
How are anastomotic leaks identified?
- Presentation: peritonitis, fevers, tachycardia, leukocytosis, sepsis
- Confirm with upper GI with gastrografin: will see contrast extravasation
How do we treat anastomotic leak?
- Source control: reoperate to repair suture line and abdominal washout/drainage
- Post op: NPO with TPN, NGT to reduce gastric contents
What do we NOT do as first treatment for anastomotic leak?
Resection and revision of anastomosis: control it to try and salvage initial operation!
What are GIST tumors?
Smooth, submucosal tumors that express C-KIT and CD117
