Upper GI Bleed -Jenkins

Question 1

What is an upper GI bleed?

Answer 1

above ligament of Treitz (right crus –> duodenum)

Question 2

What is an lower GI bleed?

Answer 2

below ligament of Teritz (jejunum, ileum)

Question 3

What is Melena? What normally causes it (including medication)? How do you tell the difference?

Answer 3

Black tarry stools (digested blood)

Usually UGIB
**can be caused by Bismuth and Iron

Guaiac* test to differentiate

Question 4

What is hematochezia?

Answer 4

Bloody stool

normally LGIB or rapid UGIB

Question 5

What are the top 5 causes of UGIB?

Answer 5

PUD (50%)

Varices (10-30%)

Gastritis (acute/chronic) (15%)

Esophagitis (10%) –covered with epigastric pain

Mallory-Weiss Tear (10%)

Question 6

What are the most common causes of peptic ulcers?

Answer 6

H. pylori infection

NSAID use

Question 7

What cells produce HCl? Why is this clinically important?

Answer 7

parietal cells

gastric bypass do not have many parietal cells and if put on a PPI –> inhibit the ones they have

Question 8

Why is H. pylori more prevalent with increasing age?

Answer 8

more exposure to it

Question 9

What tests can be done for H. Pylori?

Answer 9

• Urea breath test or serology (IgG) (doesn’t distinguish b/t active vs. chronic)
• Stool antigen test (positive if active, negative if eradicated) (must stop antibiotics, PPIs and bismuth before testing)
• Gastric biopsy (gold standard)
• Blood test

Question 10

What is the treatment for H. pylori?

Answer 10

Triple therapy: 2 antibiotics and a ppi (clarithromycin, amoxicillin)
can add bismuth (quadruple therapy)

Question 11

What complications are associated with H. pylori?

Answer 11

• Gastritis B.
• PUD
• gastric adenocarcinoma
• B cell lymphoma

Question 12

What are the characteristics of H. pylori?

Answer 12

spiral gram-negative urease producing bacterium

Produces Urease, Protease, and Cytotoxins that cause PUD and gastritis B (colonizes the mucus layer but does not invade)
-urease forms ammonia –> inc pH –> dec protection against acidic env’t

spread fecal-oral

• original infection in childhood and people only get PUD or gastritis 10-15% of the time
• Risks: low socioeconomic status, household crowding

Question 13

What percentage of peptic ulcers are duodenal? What is the major cause of this?

Answer 13

75% are Duodenal ulcers (1st part of duodenum)–> diagnose by EGD

95% of these are caused by H. pylori

Question 14

If a young person that doesn’t have a hx of NSAIDS comes in with a bleeding duodenal ulcer and a negative scope for H. pylori, what do you do?

Answer 14

TREAT FOR H PYLORI because it is 95% caused by H. pylori

Question 15

What are the complications (3) of a duodenal ulcer?

Answer 15

• Bleeding (gastroduodenal a.)
• Perforation
• Pancreatitis

Question 16

What are the 2 main causes of gastric ulcers? Where are these normally located?

Answer 16

80% H. pylori (antrum/pyloris)

20% NSAIDS

lesser curvature of the stomach

Question 17

If a patient is taking a lot of NSAIDS, what type of ulcer is more likely?

Answer 17

gastric > duodenal

Question 18

If pain is increased with food, what type of ulcer is more likely?

Answer 18

Gastric ulcer

duodenal pain decrease with food–> pain often worse at night

Question 19

What is the normal pH of the stomach?

Answer 19

1-3

Proton pump inhibitor raises pH so that H. pylori can grow

Question 20

What is the most common cause of elevated gastrin level?

Answer 20

PPI

must be off for a serum gastrin level test

Question 21

What is the most common cause of gastric polyps?

Answer 21

PPI

high levels of gastrin bombard the parietal cells–> hyperplasia –> get hyper plastic polyps

Question 22

Why would you give a PPI for acute pancreatitis?

Answer 22

elevate gastric content pH so that it will not stimulate secretin in the duodenum –> will allow the pancreas to rest

Question 23

What is the pathophysiology of Zollinger-Ellison syndrome? What medication should the patient be off of before the lab tests?
what is the most common symptom?

Answer 23

Malignant pancreatic Islet cell tumors (can also be MEN associated)–> excess gastrin –> hyperacidity

take off PPI before lab

*recurrent multiple ulcers

or PUD with diarrhea

Question 24

What is the main cause of portal HTN?

Answer 24

cirrhosis 90%

others: pre-hepatic (portal vein thrombosis), intrahepatic (fibrosis, granulomatous disease-> sarcoidosis or TB), and post-hepatic (hepatic V thrombosis, IVC thrombosis, pericarditis)

Question 25

What causes type A gastritis? Where is this normally found?

Answer 25

*autoimmune
achlorhydria
anemia (pernicious)

in body/fundus

Question 26

What is the typical presentation of Mallory weiss tears? What is the best next test?

Answer 26

alcoholic
–> n/v BEFORE hemetemesis

*EGD

Risk of Boerhaave’s syndrome (rupture of distal esophagus)

Question 27

What are the complications of gastric ulcers (3)?

Answer 27

• bleeding (left gastric A)
• perforation
• malignancy

Question 28

What should be ruled out if you see air under the diaphragm in a chest x-ray?

Answer 28

perforated peptic ulcer

Question 29

What is the most common cause of death in cirrhosis?

Answer 29

esophageal varices

Question 30

What are the clinical manifestations of portal HTN?

Answer 30

ascites, splenomegaly, shunting

gastric V–> esophageal=varices

sup rectal –> mid/inf rectal =hemorrhoids

CAPUT=periumbilical v–> sup/inf epigastric v