Gi Bleeding/ Peptic Ulcer Disease

Front 1

What defenses does the stomach have?

Back 1

pre-epithelial mucus-bicarbonate layer from mucous neck cells, surface phospholipids and a mucoid cap response to injury
epithelial: tight junctions, rapid turnover, reconstitution, regeneration, neutral intracellular pH
subepithelial: mucosal blood flow takes away H+
duodenum: pancreatic secretions --> bicarb gradient

Front 2

*What's the pathogenesis of gastric ulcer disease? How is this a cause of upper GI bleeding?

Back 2

Caused by increased gastrin (gastrinoma, G cell hyperplasia, retained gastric antrum syndome), increased histamine (leukemia, systemic mastocytosis), H. pylori (cause parietal cell stimulation, esp duodenal ulcers), head trauma/burns, iodiopathic, NSAIDs (trapped drugs is toxic, decreased PG--> decreased mucus and bicarb + less epithelial cell proliferation + decreased blood flow)

15 % of ulcers cause bleeding, esp w/ age, comorbidity, and anti-platelets. Chews through the walls?

Front 3

*What are the complications of peptic ulcers?

Back 3

15% bleeding (esp w/ age, comorbidity, anti-platelet)
perforation
penetration into adjacent organs (peptic --> colon, L hep lobe, duod --> pancreas) (rapid exsanguination)
obstruction (2 %)( functional, mechanical, reflux, satiety, abd pain, wt loss, emesis)

Front 4

*What are the management options for peptic ulcers?

Back 4

decrease acid (H2RA, PPI) (acute or maintenance)
coating agents (sucralfate, bismuth)
PGE1 analog (misoprostol) --> increased mucus/bicarb layer, increased blood flow
PPI + amox + clarithromycin or PPI + H2RA + bismuth + metro + tetracycline for H. Pylori (85-90% eradication)
Endoscopic to manage bleeding or for gastric outlet obstruction

Front 5

What are the indications for surgery for an ulcer?

Back 5

persistent bleeding, perforation, obstruction

Front 6

What causes ulcer recurrence?

Back 6

H. pylori non-eradication
surreptitious NSAID use
noncompliance
tobacco use (decreases healing)
ZE syndrome (hypergastrinemia and hyperchlorhydria)

Front 7

*What are the clinical presentation of gastric bleeding?

Back 7

overt: hematochezia, melena, hemetemesis, anemia due to rapid blood loss (syncope, chest pain, dyspnea)
occult: anemia on lab studies, symptomatic anemia (pallor, fatigue, chest pain), positive stool hemoccult test
obscure: unidentified source of bleeding

Front 8

*What are the initial steps in assessing patients with GI hemorrhage?

Back 8

look for volume lost and speed. change in position causing 20 mmHg systolic decrease, 10 mmHg diastolic increase, or 20 bpm HR increase suggests volume depletion and hemodynamic problems.

Class 1 shock: HR < 100 bpm (15 % blood lost)
Class 2 shock: HR > 100 bpm (15-30% blood lost)
Class 3 shock: BP decreases (30-40% blood lost)
Class 4 shock: confusion, lethargy (>40% blood lost)
Look for liver disease (--> highest risk of dying from acute upper GI bleed)
nasogastric aspirate: if blood in stool and red NG, increased mortality. If it's clear, least mortality.

Front 9

*What are the initial steps in resuscitation patients with GI hemorrhage?

Back 9

IV access (large bore catheters in antecubital/femoral.
saline then blood (want Hb> 10 mg/dl, consider volume overload, respiratory compromise, coagulopathy, hypocalcemia
EKG
neurologic monitoring, imagine
foley catheter, CVP to monitor

Front 10

*What's the differential diagnosis for an upper GI bleed?

Back 10

esopahgus: *Mallory Weiss. esophagitis, ulcer, vaices, neoplasia, aortoesophageal fistula.
stomach: *portal gastrpathy (blood backs up from liver and leaks into stomach), *Dielafoy lesion (artery come to surface and bleeds). gastritis, ulcer, varices, neoplasia, angiodysplasia.
duodenum: infection, ulcer, varices, neoplasia, angiodysplasia, aortoenteric fistula, hemobilia, hemosuccus pancreaticus
small bowel: ulcer, angiodysplasia, neoplasia, Meckel's diverticulum (gastric mucosa, can ulcerate)

Front 11

*What's the differential diagnosis for a lower GI bleed?

Back 11

colon: *Dieulafoy (artery comes to surface and bleeds), diverticulosis, angiodysplasia, neoplasia, colitis, hemorrhoids/fissures, portal colopathy, runner's colopathy

Front 12

*What are the options for diagnosis of patients with GI blood loss?

Back 12

rectal exam
NG lavage
endoscopy
capsule entersocopy, Meckel scan, small bowel barium, enteroscope
nuclear medicine (red cell scintigraphy, sulfur colloid scan)
angiography (highly accurate, allows options for therapy, after a positive nuclear scan study)

Front 13

*What are the options for therapy on patients with GI blood loss?

Back 13

upper GI: 1. meds (PPI, octreotide for varies, erythromycin, vasopressin (causes splanchnic vasoconstriction)). 2. endoscopic (injection to vasocontrict or ablate, electrothermal cautery, argon plasma coagulation for diffuse mucosal disease, clips, Minnesota tube (direct compression)). 3. interventional radiology (embolization, shunt for refractory varices)

lower GI: colonoscopy (low yield, can't see with bleeding), angiography (can do embolization), surgery (if others fail, have massive bleeding, recurrent bleeding)

Front 14

How do you diagnose H. Pylori?

Back 14

urease breath test (false negatives with PPI, bismuth or Abx)
biopsy-- Giemsa stain, urease (CLO) test, PCR
stool antigen testing (can also be used to confirm eradication!)
serum IgG Ab test confirms past but not current infection