Upper GI Bleeding Flashcards
what is upper GI bleeding?
bleeding into the lumen of the proximal GI tract, proximal to the ligament of Treitz
what are the signs and symptoms of upper GI bleeding?
hematemesis, melena, syncope, shock, fatigue, coffee-ground emesis, hematochezia, epigastric discomfort, epigastric tenderness, signs of hypovolemia, guiac-positive stools
why is it possible to have hematochezia?
blood is a cathartic, and hematochezia usually indicates a vigorous rate of bleeding from the UGI source
what is the most common cause of significant UGI bleeding?
PUD - duodenal and gastric ulcers
what is the common differential diagnosis of UGI bleeding?
- acute gastritis
- duodenal ulcer
- esophageal varices
- gastric ulcer
- esophageal
- Mallory-Weiss tear
what is the diagnostic test of choice for UGI bleeding?
EGD
what are the treatment options with the endoscope during an EGD?
coagulation, injection of epinephrine, injection of sclerosis agents, vatical ligation
why is BUN elevated in UGI bleeding?
because of absorption of blood by the GI tract
what are the risk factors for death following UGI bleed?
age >60
shock
>5 units of PRBC transfusion
concomitant health problems
what is PUD?
gastric and duodenal ulcers
what are the possible consequences of PUD?
pain, hemorrhage, perforation, obstruction
which bacteria are associated with PUD?
Helicobacter pylori
what is the treatment for H. pylori?
treat H. pylori with MOC or ACO 2wk antibiotic regimens
- MOC: metronidazole, Omeprazole, Clarithromycin
- ACO: ampicillin, Clarithromycin, Omeprazole
what is the name of the sign with RLQ pain/peritonitis as a result of success collecting from a perforated peptic ulcer?
Valentino’s sign
what is the most common location of a duodenal ulcer?
most are within 2cm of the pylorus in the duodenal bulb
what is the classic pain response to food intake with a duodenal ulcer?
food classically relieves duodenal ulcer pain
what is the cause of a duodenal ulcer?
increased production of gastric acid
what syndrome must you always think of with a duodenal ulcer?
Zollinger-Ellison syndrome
what are the major symptoms of duodenal ulcer?
epigastric pain
bleeding
what are the signs of duodenal ulcer?
tenderness in epigastric area (possibly), guaiac-positive stool, melon, hematochezia, hematemesis
what is the differential diagnosis of duodenal ulcer?
acute abdomen, pancreatitis, cholecystitis, all causes of UGI bleeding, ZES, gastritis, MI, gastric ulcer, reflux
when is surgery indicated for duodenal ulcer?
I HOP
- intractibility
- hemorrhage
- obstruction
- perforation
what artery is involved with bleeding duodenal ulcers?
gastroduodenal artery
what are the common surgical options for truncal vagotomy?
pyloroplasty
what are the common surgical options for duodenal perforation?
graham patch
truncal vagotomy an d pyloroplasty incorporating ulcer
graham patch and highly selective vagotomy
truncal vagotomy and antrectomy
what are the common surgical options for duodenal ulcer intractability?
PGV
vagotomy and pyloroplasty
which is more common overall: gastric or duodenal ulcers?
duodenal ulcers are more than twice as common as gastric ulcers
what is the classic pain response to food?
food classically increases gastric ulcer pain
what is the cause of a gastric ulcer?
decreased cytoprotection or gastric protection (decreased bicarbonate/mucous production)
is gastric acid production high or low in gastric ulcers?
gastric acid production is normal or low
what are the associated risk factors for gastric ulcers?
smoking, alcohol, burns, trauma, CNS tumor/trauma, NSAIDs, steroids, shock, severe illness, male gender, advanced age
what are the symptoms of gastric ulcers?
epigastric pain +/- vomiting, anorexia, and nausea
how is the diagnosis made for gastric ulcers?
history, PE, EGD with multiple biopsoies
what is the most common location of a gastric ulcer?
lesser curvature
when and why should biopsy of a gastric ulcer be performed?
with all gastric ulcers to rule out gastric cancer
- if the ulcer does not heal in 6wks after medical treatment, rebiopsy
what is the medical treatment for gastric ulcers?
similar to that of duodenal ulcer - PPIs or H2 blockers, H.pylori tx
what are the indications for surgery for gastric ulcers?
I CHOP
- intractability
- cancer (rule out)
- hemorrhage
- obstruction
- perforation
what is the common operation for hemorrhage, obstruction, and perforation of gastric ulcers
distal gastrectomy with excision of the ulcer without vagotomy
what are the symptoms of a perforated peptic ulcer?
acute onset of upper abdominal pain
what is the differential diagnosis for a perforated peptic ulcer?
acute pancreatitis, acute cholecystitis, perforated acute appendicitis, colonic diverticulitis, MI, any perforated viscus
what type of perforated ulcer may present like acute pancreatitis?
posterior perforated duodenal ulcer into the pancreas
- epigastric pain radiating to the back; high serum amylase
what is the classic difference between duodenal and gastric ulcer symptoms as related to food ingestion?
duodenal = decreased pain gastric = increased pain
what is stress gastritis?
superficial mucosal erosions in the stressed patient
what are the risk factors for stress gastritis?
sepsis, intubation, trauma, shock, burn, brain injury
what is the prophylactic treatment of stress gastritis?
H2 blockers, PPIs, antacids, sucralfate
what are the signs/symptoms of stress gastritis?
NGT blood, painless
what is the treatment of gastritis?
lavage out blood clots, give a maximum dose of PPI in a 24hr IV drip
what is Mallory-Weiss syndrome?
postretching, postemesis longitudinal tear (submucosa and mucosa) of the stomach near the GE junction
- approximately 3/4 are in the stomach
what are the causes of a Mallory-Weiss tear?
increased gastric pressure, often aggravated by hiatal hernia
what are the risk factors for Mallory-Weiss?
retching, alcoholism, >50% of patients have hiatal hernia
what are the symptoms of Mallory-Weiss?
epigastric pain, thoracic substernal pain, emesis, hematemesis
what is the ‘classic’ history of Mallory-Weiss?
alcoholic patient after binge drinking - first vomit food and gastric contents, followed by forceful retching and bloody vomitus
what is the treatment of Mallory-Weiss?
room temperature water lavage, electrocautery, arterial embolization, or surgery for refractory bleeding
when is surgery indicated for Mallory-Weiss?
when medical/endoscopic treatment fails
what is esophageal variceal bleeding?
bleeding from formation of esophageal varies from back up of portal pressure via the coronary vein to the submucosal esophageal venous plexuses secondary to portal hypertension from liver cirrhosis
what is the ‘rule of 2/3s’ of esophageal variceal hemorrhage?
2/3s of the patients with portal hypertension develop esophageal varices
2/3s of patients with esophageal varices bleed
what are the signs/symptoms of esophageal variceal bleeding?
liver disease, portal hypertension, hematemesis, caput medusa, ascites
how is diagnosis of esophageal variceal bleeding made?
EGD (very important because only 50% of UGI bleeding in patients with known esophageal varices are bleeding from the varices)
what is the acute medical treatment of esophageal variceal bleeding?
lower portal pressure with octreotide or vasopressin
what are the treatment options of esophageal variceal bleeding?
sclerotherapy or band ligation via endoscope, TIPS, liver transplant
what is the problem with shunts for esophageal variceal bleeding?
decreased portal pressure, but increased encephalopathy
what is Boerhaave’s syndrome?
post emetic esophageal rupture
why is the esophagus susceptible to perforation and more likely to break down an anastomosis?
no serosa
what is the most common location of Boerhaave’s syndrome?
posterolateral aspect of the esophagus, 3-5cm above the GE junction
what is the cause of rupture in Boerhaave’s syndrome?
increased intraluminal pressure, usually caused by violent retching and vomiting
what are the associated risk factors for Boerhaave’s syndrome?
esophageal reflux disease
what are the symptoms of Boerhaave’s syndrome?
pain postemesis (may radiate to the back, dysphagia)
what are the signs of Boerhaave’s syndrome?
left pneumothorax, Hamman’s sign, left pleural effusion, subcutaneous/mediastinal emphysema, fever, tachypnea, tachycardia, signs of infection by 24hrs, neck crepitus, widened mediastinum on cxr
what is Mackler’s triad?
- emesis
- lower chest pain
- cervical emphysema (subQ air)
What is Hamman’s sign?
mediastinal crunch or clicking produced by the heart beating against air-filled tissue
what is the treatment of Boerhaave’s syndrome?
surgery within 24hrs to drain the mediastinum and surgically close the perforation and placement of pleural patch; broad-spectrum antibiotics
overall, what is the most common cause of esophageal perforation?
iatrogenic
