Upper GI Tract Disorders Flashcards
34-year-old man presents with acute onset of sharp epigastric pain. What routine screening studies are appropriate?
CBC, urinalysis, amylase, lipase, liver function tests, obstructive series, chest x-ray
Differential diagnosis for epigastric pain.
- pancreatitis
- PUD
- Gastric ulcer
- gastroenteritis
- GERD
- Cholelithiasis
34-year-old man presents with acute onset sharp epigastric pain. Moderate tenderness in the epigastrium. What is the next step? What if the next step fails question
Abdominal ultrasound to rule out gallstones. If negative empirical treatment course with an H2 blocker or PPI treat Gerd, ulcer, gastritis
Upper G.I. endoscopy to establish a diagnosis biopsies to rule out any malignancies and to detect H. Pylori
GERD which is symptomatic even with maximal therapy. Next step in management
EGD with biopsy and esophageal manometry -need to demonstrate in tact esophageal peristalsis before surgery
What percentage of patients with GERD have a hiatal hernia?
80%
How frequently does mild to moderate esophagitis resolve with maximal medical therapy?
Responds to 8–12 weeks of treatment with proton pump inhibitors.
Complete remission in 85% of patients
Treatment for severe esophagitis, especially erosive esophagitis?
Requires an anti-reflex procedure – fundoplication
Frequency of Barrett’s esophagitis in patients with chronic gastroesophageal reflux disease?
10% – 15%
How often should you biopsy with a barrett esophagus?
Surveillance endoscopy and biopsies every 18–24 months to determine if a Barrett’s esophagus progresses to dysplasia
Next step if biopsy of distal esophagus shows barrett esophagus with severe dysplasia
High risk of occult adenocarcinoma in the distal esophagus. Esophageal resection is necessary.
Rx for type I hiatal hernia?
Sliding hiatal hernia – treatment for GERD, without surgery
What is a type II hiatal hernia?
A portion of the stomach herniates into the chest, but the GE junction remains in the normal location. Extremely dangerous because entire stomach can necrose
Treatment for a type II hernia?
Surgical repair
Type I hernia
sliding hiatal hernia
Type II hiatal hernia
Paraesophageal hiatal hernia
Rx for uncomplicated PUD if medical therapy has failed?
Highly selective vagotomy (HSV) is procedure of choice but truncal vagotomy and pyloroplasty may be used.
Measure serum gastrin levels to rule out Zollinger-Ellison syndrome
Biopsy indicating infiltrating gastric carcinoma. What is the prognosis?
-Intestinal types – form glands more favorable prognosis
Diffuse form – extend widely in submucosa, worse prognosis
Biopsy indicating infiltrating gastric carcinoma and wall of stomach that appears fixed and rigid?
Diffusely infiltrating gastric carcinoma is termed linitis plastica - or prognosis. Involves all layers of stomach wall.
Treatment for linitis plastica?
Total gastrectomy with splenectomy
Biopsy indicating gastric carcinoma at the gastroesophageal junction. Incidence? Prognosis? What is the recommendation?
40% of gastric adenocarcinomas involve the proximal stomach
prognosis is less favorable than those in the antrum
Gastric resection at least 6 cm distally beyond tumor
Free air under the diaphragm
Sign of perforation
Patient treated for perforation in the OR becomes hypotensive
Presumably secondary to sepsis. Complete the operation as quickly as possible and stabilize in ICU – IV antibiotics and omeprazole
Multiple non-ulcerating erosions in the stomach
Gastritis
Multiple linear erosions in the gastric mucosa at the GE junction
Mallory-Weiss syndrome - bleeding often stops spontaneously
Patient with cirrhosis actively bleeding esophageal varices. What measures would you take to control the bleeding?
INITIAL
-band the bleeding esophageal varices
-Correct the coagulopathy: high PT with FFP, thrombocytopenia with platelet transfusion
-IV OCTREOTIDE - to lower portal pressure
IV vasopressin - coronary vasoconstriction as side effect.
Repeat endoscopy
TIPS procedure
What is the treatment for a sigmoid volvulus?
sigmoid colectomy with diverting colostomy or resection with primary anastomosis, depending on the preoperative condition of the patient
Treatment for a Cecal volvulus?
Urgent surgical treatment: detorsion alone, cecopexy, or right colectomy
Treatment for ogilvie syndrome
the colon diameter exceeds 11-12 cm endoscopic decompression is indicated.
Many surgeons also attempt a brief trial of neostigmine, a parasympatholytic agent, which may increase colonic tone and counteract the dilation. If the neostigmine is unsuccessful, surgical decompression of the cecum or a right colectomy is necessary.
patient complains of pain and drainage in his sacrococcygeal area of the lower back. You examine him and find an abscess in that location. What management is appropriate?
This condition is a pilonidal abscess, which is an infection in a hair-containing sinus in the sacrococcygeal area. Treatment involves unroofing the abscess, removing all hair, and leaving the wound open to heal by secondary intention.
