Vascular GI Dz: Tombazzi

Question 1

All blood to the small bowel comes from this branch off the abdominal aorta:

Answer 1

SMA

Question 2

Which is worse, ischemia of arteries supplying the colon or small bowel? Why?

Answer 2

Small bowel worse bc less collateral blood supply and far fewer anastomosing arteries.

Question 3

Discuss the progressive pathophysiology of ischemic bowel.

Answer 3

Decr. mesenteric flow

• -> vasospasm, cytokine release
• -> mucosal hypoxia
• -> Necrosis of villi, bleeding
• -> edema of LP, pain w/o ileus
• -> infarction–> ileus, sepsis

Question 4

Ischemic colitis
Presentation:
Physical exam:
Dx:
Tx: 
Outcome:

Answer 4

Presentation: hematochezia, abd. pain, diarrhea. Pts. over 60
Physical exam: abd. tenderness early
Dx: abd. CT shows thickening (edema) , colonoscopy
Tx: conservative, achieve hemodynamic stability
Outcome: generally benign

Question 5

Acute mesenteric ischemia
Presentation:
Dx:
Tx: 
Outcome:

Answer 5

med/surg emergency! dx and tx immediately
Presentation: early abd. pain out of proportion to physical exam w/o ileus. Peritoneal signs in advanced dz. Bleeding uncommon.
Dx: X-ray, CT (thickened bowel wall, ileus, portal vein gas due to necrosis), MRI. Angiography. Colonoscopy NOT helpful.
Tx: ICU management, vasodilation, surg.
Outcome: Poor

Question 6

Describe the microscopic findings of ischemic colitis.

Answer 6

Superficial mucosal necrosis
Hyalinized LP
Atrophic crypts
Pseudomembranes
Chronic ulcers, strictures

Question 7

How do you tell ischemic colitis apart from pseudomembranous colitis?

Answer 7

IC- has hyalinization of LP

PC- has erupting volcano appearance

Question 8

Chronic ischemia of bowel is usually caused by:
Clinical presentation?
Tx:

Answer 8

At least 2 of the 3 splanchnic arteries (Celiac, SMA, IMA) have sign. occlusive dz.
Presents w/ SEVERE weight loss (80 lbs). Abd. pain after eating causes pts not to eat –> weight loss.
Tx: angioplasty, stent, surgery.

Question 9

Venous mesenteric ischemia
Association:
Dx:

Answer 9

Assoc: hypercoagulable state
Dx: Abd. CT, angiography, MRI
Tx: stent, anti-coagulation therapy, surg.

Question 10

Discuss the general management of GI bleeding.

Answer 10

Initial eval: Hx, PE, hemodynamic stability, IV access, labs
Transfusions (Hb > 7), optimize coagulation profile.
PPI in PUD, Octreotide in portal hypertension
Endoscopy
Angiography w/ embolization, surg.

Question 11

Mortality of esophageal variceal bleeding?
Causes?
Tx?

Answer 11

30-50%
Cirrhosis, hepatic schistosomiasis (parasite)
Tx: variceal banding

Question 12

Tx of gastric varices? How does it differ from esophageal tx?

Answer 12

Banding doesn’t work in gastric varices.
TIPS (shunt btwn portal vein/hepatic vein)- possible complication: encephalopathy
Glue injection at site to block flow.

Question 13

Differentiate Mallory-Weiss tears and Boerhaave’s syndrome.

Answer 13

M-W: superficial tears secondary to vomiting. Limited blood loss, self-limiting.
Boerhaave- full thickness tear of esophagus that can result in massive blood loss.

Question 14

List vascular malformations known to cause gastric bleeding.
Tx?

Answer 14

Vascular ectasias
Dieulafoi lesion
Gastric Antral Vascular Ectasia (GAVE)- watermelon stomach
Tx: cauterize

Question 15

MCC of acute lower GI bleeding:

MCC of chronic lower GI bleeding:

Answer 15

Acute: Diverticulosis (not itis) and angiodysplasia (AVM)
Chronic: Hemorrhoids, neoplasia

Question 16

Angiodysplasia
MC Locations
MC age
Severity of blood loss
Pathophys

Answer 16

Cecum/right side of colon
2/3rds of pts over 70
Slow blood loss
Malformed mucosal/submucosal BVs. Like hemorrhoids, but different location.

Question 17

Most important thing to rule out in cases of GI bleeding:

Answer 17

Colon cancer!