Upper Gi

Front 1

sharp epigastric pain - differential?

Back 1

PUD, pancreatitis, gastric cancer, GERD, gastroenteritis, cholelithiasis

Front 2

Initial workup for epigastric pain?

Back 2

amylase, lipase, CBC (fro elevated white count), urinalysis, LFTs, ?U/S

Front 3

LabsU/S unremearkable for epigastric pain - next step?

Back 3

empiric treatment with PPI (or H2 blocker)

Front 4

lifestyle modifications important to compliment PPI in suspcted GERD?

Back 4

smoking cessation, decreased caffeine, stoppage of NSAIDs

Front 5

epigastric pain that is unresponsive to PPI empiric therapy - next step?

Back 5

EGD (biopsies to rule of gastric CA, detect H. pylori)

Front 6

10-15% of GERD is refractory to medical therapy - preop measures (2) and standard operation c description?

Back 6

preop:
1. esophageal manometry (to ensure normal peristalsis),
2. EGD with biopsy
operation:
surgery: Nissen fundoplication (wrapping segment of stomach around distal esophagus) - augments LES tone

Front 7

GERD facts:
1. 80% of GERD patients have what?
2. Barrets esophagus is complication of what?
3. change of what tissue in Barrets?
4. management for erosive esophagitis?

Back 7

1. hiatal hernia
2. espagitis (from chronic GERD)
3. squamous to columnar (---> inc risk for adenoCA)
4. procedure (Nissen fundoplication)

Front 8

management of Barretts?

Back 8

surveillence endoscopy and biopsies every 1.5-2 yrs

Front 9

management for high grade dysplasia in barretts?

Back 9

esophageal resection due to hi rsk for adenocarcinoma

Front 10

type 1 hiatal hernia?

Back 10

sliding (often asymptomatic)

Front 11

Type II hiatal hernia? Where is GE jnxn? what is risk?

Back 11

paraesophageal; GE nxn below diaphragm; gastric volvulus (necrosis)

Front 12

Type I versus Type II hiatal hernia management?

Back 12

Type I: GERD treatment (if symptomatic)
Type II: elective repair.
(unless they present with hypotension and acidosis suggestive of strangulation/necrosis --> surgical emergency)

Front 13

most peptic ulcers due to ___. how to make diagnosis (3)? treatment?

Back 13

1. H. pylori
2. serum antibody, gastric biopsy, urease breath test
3. triple therapy (PPI, metronidazole, ampicillin/clarithromycin)

Front 14

after treating suspected PUD for 4-6 weeks, very little improvement in symptoms. next step?

Back 14

EGD

Front 15

Duodenal ulcer nonresponsive to PPI - EGD reveals enlargement of ulcer - procedure of choice? what else needs to be ruled out?

Back 15

highly selective vagotomy (gastric body and fundus denervated); Zollinger-Ellison syndrome (gastrin-producing tumor)

Front 16

58 yo male with epigastic pain unresolved with medical therapy - gastric ulcer on EGD; management - diagnostic, treatments (medical and surgical)?

Back 16

1. multiple biopsies of ulcer edge (r/o gastric cancer)
2. if benign, treatment with H2 blockers, antacids
3. surgical rsx if ulcer unhealed >18 wks

Front 17

1. what is indication (and why) for surgical removal (e.g. partial gastrectomy) for gastric ulcer?
2. Is vagotomy also performed? Explain when yes and when no.

Back 17

1. unhealed > 18 wks (concern for unrecognized cancer); ALSO: if cancer is present, hemorrhage, obstruction, perforation.
2. vagotomy usually only performed if type II or III ulcer (+ duodenal ulcer or prepyloric), not I or IV (lessser curvature or GE jnxn location)

Front 18

30 yo F with PNA in ICU. had ileus, req NGT; on rounds, note NG drainage has coffee ground-material with blood streaks.
1. Most likely diagnosis and treatment?
2. How might this have been prevented?
3. management of this GI bleed (3 steps)?

Back 18

1. bleeding ulcer; sucralfate, antacids, H2 blockers
2. ulcer prophylaxis (ICU patients - stress gastritis) - use H2 blockers
3. 2 large bore IVs with fluid resuscitation, NG lavage, EGD
(stabilize, then investigate)

Front 19

management of upper GI bleed of ulcer with following findings on EGD?
1. clean, white base - no active bleed
2. duodenal ulcer with fresh clot adherent to it
3. duodenal ulcer with fresh adherent clot and visible artery at base
4. duodenal ulcer with fresh bleeding / hypotensive patient

Back 19

1. no endoscopic treatment, H2blocker/PPI
2. hemostatic therapy
3. hemostatic therapy followed by surgical excision
4. reuscitation, pRBCs, to OR

Front 20

management of upper GI bleed with following findings on EGD?
1. gastric ulcer (as compared to duodenal ulcer)?
2. gastritis
3. gastritis and gastric varices, hx of alcoholic cirrhosis
4. gastritis and gastric varices, hx of acute panc

Back 20

1. same as duod managment, but biopsy in addition (EGD: epi, sclerosing agent, banding, suturing, laser therapy)
2. Maintain ph>5 with PPIs, H2, sucralfate. Subtotal gastrectomy if refractory (bc multiple sites)
3. Gastric varices harder to treat than esophageal. Consider TIPS, portosystemic shunt, splenectomy
4. Splenectomy (may be dt splenic vein thrombosis)

Front 21

hemostatic therapeutic option for ulcer in EGD (4)?

Back 21

epinephrine injection, thermal contact, laser therapy, suturing (newer)

Front 22

artery visualized in duoedenal ulcer with adherent thrombus
1. most lilkely artery?
2. why operative management indicated?

Back 22

1. gastroduodenal artery
2. risk of rebleeding so high (~40%) - suture, ligate, coagulate it

Front 23

management of upper GI bleed of duod ulcer with acute renal failure, Cr=6
1. risk
2. management (2)?

Back 23

1. platelet dysfunction (from uremia)
2. ddAVP (demopressin), dialysis

Front 24

action of desmopressin in preventing bleeding (not the antidiuretic effect)?

Back 24

promotes release of of vWF and Factor 8

Front 25

management of upper GI bleed of duod ulcer with chronic alcoholic cirrhosis
1. risk
2. management of this problem?

Back 25

1. elevated PT due to clotting factors deficiency (inc bleeding)
2. FFP

Front 26

gastritis with bleeding (risk in vent dependence, major trauma, sepsis, burns) - high mortality no matter what treatment (keep in mind)
1. what is gastritis?
2. management?

Back 26

1. multiple, nonulcerating erosions in stomach
2. medical managgement (H2 blockers, antacids, PPIs)

Front 27

gastric varices respond to similar therapy as esophageal varices (banding or scleroptherapy) (True/False)

Back 27

False
Management Esophageal Varices: Banding (+/- octreotide, vasopressin, b blockade), portosyemic shunt, balloon tamponade (if intubated), TIPS
Management of gastric varices: cyanoacrylate glue, TIPS, splenectomy

Front 28

management for gastric varices:
1. hx of cirrhosis?
2. hx of pancreatitis?

Back 28

1. TIPS procedure (transjugular intrahepatic portosystemic shunt OR splenectomy
2. splenectomy if persistent bleeding

Front 29

35 yo M with cirrhosis in ED with profuse upper GI bleed; initial steps in management (4)?

Back 29

1. volume resuscitation
2. EGD (stop bleeding via sclerotherapy or banding)
3. fix PT via FFP and thrombocytopenia via platelet transfusion
4. medical management: IV octeotride (lowers portal pressure)

Front 30

42 yo alcoholic with upper GI bleed - EGD reveals multiple linear erosion at GE jnxn
1. diagnosis?
2. management?

Back 30

1. Mallory-weiss syndrome (longitudinal tears thru mucosa from forceful vomiting)
2. bleeding usually stops spontanseuously (electrocutery or surgery for severe cases)

Front 31

in patient with persistent bleeding from esophageal varices despite repeat endoscopic treatment and medical therapy, next options (3)

Back 31

Surgical (3)
1. portocaval shunt (~50% mortality
2. balloon tamponade (only in intubated patient)
3. TIPS (artificial perc connection b/w hepatic vein and portal vein branch)

Front 32

portocaval shunts usually not well tolerated in what patients?

Back 32

with poor hepatic synthetic function