Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
124 Cards in this Set
- Front
- Back
|
what is upper GI bleeding?
|
bleeding into the lumen of the proximal GI tract, proximal to the ligament of treitz
|
|
|
what are the signs/sx 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 fate of bleeding from the UGI source
|
|
|
are stools melenic or melanotic?
|
melenic (melanotic is incorrect)
|
|
|
how much blood do you need to have melena?
|
>50 cc of blood
|
|
|
what are the risk factors for upper GI bleeding?
|
alcohol, cigarettes, liver disease, burn/trauma, aspirin/NSAIDs, vomiting, sepsis, steroids, previous UGI bleeding, history of PUD, esophageal varices, portal HTN, splenic vein thrombosis, abdominal aortic aneurysm repair (aortoenteric fistula), burn injury, trauma
|
|
|
what is the most common cause of significant UGI bleeding?
|
PUD -- duodenal and gastric ulcers (50%)
|
|
|
what is the common DDx of UGI bleeding?
|
acute gastritis, duodenal ulcer, esophageal varices, gastric ulcer, esophageal, mallory-weiss tear
|
|
|
what is the UNCOMMON DDx of UGI bleeding?
|
gastric cancer, hemobilia, duodenal diverticular, gastric volvulus, boerhaave's syndrome, aortoenteric fistula, paraesophageal hiatal hernia, epistaxis, NGT irritation, dieulafoy's ulcer, angiodysplasia
|
|
|
what diagnostic tests are useful?
|
history, NGT aspirate, abdominal x-ray, endoscopy (EGD)
|
|
|
what are the treatment options w/the endoscope during an EGD?
|
coagulation, injection of epinephrine (for vasoconstriction), injection of sclerosing agents (varices), variceal ligation (banding)
|
|
|
what is the diagnostic test of choice w/UGI bleeding?
|
EGD (>95% diagnosis rate)
|
|
|
which lab tests should be performed?
|
chem-7, bilirubin, LFTs, CBC, TYPE & CROSS, PT/PTT, amylase
|
|
|
why is BUN elevated?
|
b/c of absorption of blood by the GI tract
|
|
|
what is the initial treatment?
|
1. IVFs (16 G or larger peripheral IVs x2), Foley cath (monitor fluid status). 2. NGT suction (determie rate and amt of blood) 3. water lavage (use warm H2O -- will remove clots) 4. EGD: endoscopy (determine etiology/location of bleeding and possible tx - coagulate bleeders)
|
|
|
why irrigate an upper GI bleed?
|
to remove the blood clot so you can see the mucosa
|
|
|
what test may help identify the site of massive UGI bleeding when EGD fails to dx cause and blood continues per NGT?
|
selective mesenteric angiography
|
|
|
what are the indications for surgical intervention in UGI bleeding?
|
refractory or recurrent bleeding and site known, >3 u PRBCs to stabilize or >6 u PRBCs overall
|
|
|
what % of patients require surgery? what % spontaneously stop bleeding?
|
10% require surgery. 80-85% stop spontaneously
|
|
|
what is the mortality of acute UGI bleeding?
|
overall 10%, 60-80yo 15%, >80yo 25%
|
|
|
what are the risk factors for death following UGI bleed?
|
age older than 60yo, shock, >5 units of PRBC transfusion, concomitant health problems
|
|
|
what is peptic ulcer disease? what are the possible consequences of PUD?
|
gastric and duodenal ulcers. consequences: pain, hemorrhage, perforation, obstruction
|
|
|
what is the incidence of PUD in the US? what % of patients w/PUD develops bleeding from the ulcer?
|
~10% of the population will suffer from PUD in their lifetime. ~20% develop bleeding
|
|
|
what bacteria are assoc w/PUD?
|
helicobacter pylori
|
|
|
what is the tx of PUD
|
treat h. pylori w/MOC or ACO. 2-wk antibiotic regiments: metronidazole, omeprazole, clarithromycin (MOC) or ampicillin, clarithromycin, omeprazole (ACO)
|
|
|
what is the name of the sign w/RLQ pain/peritonitis as a result of succus collecting from a perforated peptic ulcer?
|
valentino's sign
|
|
|
in which age group are duodenal ulcers most common? what is the ratio of male to female patients?
|
40-65 yrs of age (younger than patients w/gastric ulcer). men>women (3:1)
|
|
|
what is the classic pain response to food intake w/duodenal ulcer?
|
food classically relieves duodenal ulcer
|
|
|
what is the most common location of duodenal ulcers?
|
most are w/in 2cm of the pylorus in the duodenal bulb
|
|
|
what syndrome must you always think of w/a duodenal ulcer?
|
zollinger-ellison syndrome
|
|
|
what are the assoc risk factors for duodenal ulcer?
|
male gender, smoking, aspirin and other NSAIDs, uremia, Z-E syndrome, h. pylori, trauma, burn injury
|
|
|
what are the sx of duodenal ulcer?
|
epigastric pain - burning or aching, usually several hours after a meal (food, milk, or antacids initially relieve pain); bleeding; back pain; nausea, vomiting, and anorexia; decreased appetite
|
|
|
what are the signs of duodenal ulcer?
|
tenderness in epigastric area (possibly), guiac-positve stool, elena, hematochezie, hematemesis
|
|
|
what is the DDx of duodenal ulcer?
|
acute abdomen, pancreatitis, cholecystitis, all causes of UGI bleeding, Z-E syndrome, gastritis, MI, gastric ulcer, reflux
|
|
|
how is the dx of duodenal ulcer made?
|
history, PE, EGD, UGI series (if patient is not actively bleeding)
|
|
|
when is surgery indicated w/a bleeding duodenal ulcer>
|
most surgeons use: >6 u PRBC transfusions, >3 u PRBCs needed to stabilize, or significant rebleed
|
|
|
what EGD finding is assoc w/rebleeding?
|
visible vessel in the ulcer crater, recent clot, active oozing
|
|
|
what is the medical tx for duodenal ulcers?
|
PPIs or H2 receptor antagonists - heal ulcers in 4-6wks for most cases. treatment for h. pylori
|
|
|
when is surgery indicated in duodenal ulcers?
|
IHOP: intractability, hemorrhage (massive or relentless), obstruction (gastric outlet obstruction), perforation
|
|
|
how is a bleeding duodenal ulcer surgically corrected?
|
opening of the duodenum through the pylorus, oversewing of the bleeding vessel
|
|
|
what artery is involved w/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 (poor candidates, shock, prolonged perforation), truncal vagotomy and pyloroplasty incorporating ulcer, graham patch and highly selective vagotomy, truncal vagotomy and antrectomy (higher mortality rate but lowest recurrence rate)
|
|
|
what are the common surgical options for duodenal obstruction resulting from duodenal ulcer scarring (gastric outlet obstruction)?
|
truncal vagotomy, antrectomy, and gastroduodenostomy (BI or BII), truncal vagotomy and drainage procedure (gastrojejunostomy)
|
|
|
what are the common surgical options for duodenal ulcer intractability?
|
PGV (highly selective vagotomy), vagotomy and pyloroplasty, vagotomy and antrectomy BI or BII (especially if there is a coexistent pyloric/prepyloric ulcer) but assoc w/a higher mortality
|
|
|
which ulcer operation has the highest ulcer recurrence rate and the lowest dumping syndrome rate? which ulcer operation has the lowest ulcer recurrence rate and the highest dumping syndrome rate?
|
highest recurrence: PGV (proximal gastric vagotomy). lowest: vagotomy and antrectomy
|
|
|
which duodenal ulcer operation has the lowest mortality rate?
|
PGV (1/200 mortality), truncal vagotomy and pyloroplasty (1-2/200), vagotomy and antrectomy (1%-2% mortality) --> PGV is the operation of choice for intractable duodenal ulcers w/the cost of increased risk of ulcer recurrence
|
|
|
why must you perform a drainage procedure (pyloroplasty, antrectomy) after a truncal vagotomy?
|
pylorus will not open after a truncal vagotomy
|
|
|
what is a kissing ulcer?
|
2 ulcers, each on opposite sides of the lumen so that they can kiss
|
|
|
why may a duodenal rupture be initially painless? why may a perforated duodenal ulcer present as lower quadrant abdominal pain?
|
painless: fluid can be sterile w/a nonirritating pH of 7.0 initially. lower quad abd pain: fluid from stomach/bile drains down paracolic gutters to lower quadrants and causes localized irritation
|
|
|
in which age group are gastric ulcers most common? how does the incidence in men compare w/that of women?
|
40-70 yrs old (older than the duodenal ulcer population), rare in patients younger than 40yrs. men>women
|
|
|
which is more common overall: gastric or duodenal ulcers?
|
duodenal ulcers are more than 2x as common as gastric ulcers
|
|
|
what is the classic pain response to food w/gastric ulcers?
|
food classically increases gastric ulcer pain
|
|
|
what is the cause of gastric ulcers?
|
decreased cytoprotection or gastric protection (i.e., decreased bicarbonate/mucous production)
|
|
|
is gastric acid production high or low in gastric ulcers?
|
gastric acid production is normal or low!
|
|
|
which gastric ulcers are assoc w/increased gastric acid?
|
prepyloric, pyloric, coexist w/duodenal ulcers
|
|
|
what are the assoc risk factors for gastric ulcers?
|
smoking, EtOH, burns, trauma, CNS tumor/trauma, NSAIDs, steroids, shock, severe illness, male gender, advanced age
|
|
|
what are the sx of gastric ulcers?
|
epigastric pain +/- vomiting, anorexia, and nausea
|
|
|
how is the dx of gastric ulcers made? when and why should biopsy be performed?
|
history, PE, EGD w/multiple biopsy (looking for gastric cancer). biopsy should be performed with ALL gastric ulcers to rule out gastric cancer. if the ulcer does not heal in 6 wks after medical treatment, rebiopsy (always biopsy in OR also) must be performed
|
|
|
what is the most common location for gastric ulcers?
|
~70% are on the lesser curvature, 5% on the greater curvature
|
|
|
what is the medical tx for gastric ulcers?
|
similar to that of duodenal ulcer - PPIs or H2 blockers, h. pylori treatment
|
|
|
when do patients w/gastric ulcers need to have an EGD?
|
1. for dx w/biopsies 2. 6 wks postdx to confirm healing and r/o gastric cancer
|
|
|
what are the indications for surgery w/gastric ulcers?
|
ICHOP: intractability, cancer (rule out), hemorrhage (massive or relentless), obstruction (gastric outlet obstruction), perforation. note: surgery is indicated if gastric cancer cannot be ruled out
|
|
|
what is the common operation for hemorrhage, obstruction, and perforation?
|
distal gastrectomy w/excision of the ulcer w/o vagotomy unless there is duodenal disease (i.e., BI or BII)
|
|
|
what are the options for concomitant duodenal and gastric ulcers?
|
resect (BI, BII) and TRUNCAL VAGOTOMY
|
|
|
what is a common option for surgical treatment of a pyloric gastric ulcer?
|
truncal vagotomy and antrectomy (i.e., BI or BII)
|
|
|
what is a common option for a poor operative candidate w/a perforated gastric ulcer?
|
graham patch
|
|
|
what must be performed in every operation for gastric ulcers?
|
biopsy looking for gastric cancer
|
|
|
cushing's ulcer
|
PUD/gastritis assoc w/neurologic trauma or tumor
|
|
|
curling's ulcer
|
PUD/gastritis assoc w/major burn injury
|
|
|
marginal ulcer
|
ulcer at the margin of a GI anastomosis
|
|
|
dieulafoy's ulcer
|
pinpoint gastric mucosal defect bleeding from an underlying vascular malformation
|
|
|
what are the sx of perforated peptic ulcer? what are the signs?
|
acute onset of upper abdominal pain. signs: decreased bowel sounds, tympanic sound over the liver (air), peritoneal signs, tender abdomen
|
|
|
what are the signs of posterior duodenal erosion/perforation? what sign indicates anterior duodenal perforation?
|
posterior: bleeding from gastroduodenal artery (and possibly acute pancreatitis). anterior: free air (anterior perf is more common than posterior perf)
|
|
|
what causes pain in the lower quadrants w/perforated peptic ulcer?
|
passage of perforated fluid along colic gutters
|
|
|
what is the DDx for perforated peptic ulcer?
|
acute pancreatitis, acute cholecystitis, perforated acute appendicitis, colonic diverticulitis, MI, any perforated viscus
|
|
|
which diagnostic tests are indicated for perforated peptic ulcer? what are the assoc lab findings?
|
tests: x-ray (free air under diaphragm or in lesser sac in an upright CXR, or LL decub). labs: leukocytosis, high amylase serum (secondary to absorption into the blood stream from the peritoneum)
|
|
|
what is the initial treatment of a perforated peptic ulcer?
|
NPO: NGT (decreased contamination of the peritoneal cavity). IVF/foley catheter. antibiotics/PPIs. surgery.
|
|
|
what is a graham patch?
|
piece of omentum incorporated into the suture closure of perforation
|
|
|
what are the surgical options for treatment of a duodenal perforation? for perforated gastric ulcer?
|
duodenal perf: graham patch (open or laparoscopic), truncal vagotomy and pyloroplasty incorporating ulcer, graham patch and highly selective vagotomy. gastric perf: antrectomy incorporating perforated ulcer, graham patch or wedge resection in unstable/poor operative candidates
|
|
|
what is the significance of hemorrhage and perforation w/duodenal ulcer?
|
may indicated 2 ulcers (kissing); posterior is bleeding and anterior is perforated w/free air
|
|
|
what type of perforated ulcer may present just like acute pancreatitis?
|
posterior perforated duodenal ulcer into the pancreas (i.e., epigastric pain radiating to the back; high serum amylase)
|
|
|
what is the classic difference b/w duodenal and gastric ulcer sx as related to food ingestion?
|
duodenal=decreased pain, gastric=increased pain
|
|
|
define graham patch
|
for treatment of duodenal perforation in poor operative candidates/unstable patients, place viable omentum over perforation and tack into place w/sutures
|
|
|
truncal vagotomy
|
resection of a 1-2cm setment of each vagal trunk as it enters the abdomen on the distal esophagus, decreasing gastric acid secretion
|
|
|
what other procedure must be performed along w/a truncal vagotomy
|
drainage procedure (pyloroplasty, antrectomy, or gastrojejunostomy) b/c vagal fibers provide relaxation of the pylorus and if you cut them the pylorus will not open
|
|
|
define: vagotomy and pyloroplasty, vagotomy and antrectomy
|
v+p: pyloroplasty performed w/vagotomy to compensate for decreased gastric emptying. v+a: remove antrum and pylorus in addition to vagotomy, reconstruct as a billroth I or II
|
|
|
what is the goal of duodenal ulcer surgery?
|
decrease gastric acid secretion (and fix IHOP)
|
|
|
what is the advantage of proximal gastric vagotomy (highly selective vagotomy)?
|
no drainage procedure is needed; vagal fibers to the pylorus are preserved; rate of dumping syndrome is low
|
|
|
what is a billroth I (BI)?
|
truncal vagotomy, antrectomy, and gastroduodenostomy (think bI=1 limb off of the stomach remnant)
|
|
|
what are the contraindications for a billroth I?
|
gastric cancer or suspicion of gastric cancer
|
|
|
what is a billroth II (BII)?
|
truncal vagotomy, antrectomy, and gastrojejunostomy (BII=2 limbs off the stomach remnant)
|
|
|
what is the kocher maneuver?
|
dissect the L lateral peritoneal attachments to the duodenum to allow visualization of posterior duodenum
|
|
|
what is stress gastritis? how is it diagnosed?
|
superficial mucosal erosions in the stressed patient. diagnosed w/EGD if bleeding is significant
|
|
|
what are the risk factors for stress gastritis?
|
sepsis, intubation, trauma, shock, burn, brain injury
|
|
|
what is the prophylactic treatment of stress gastritis? what is the treatment for gastritis?
|
prophylaxis: H2 blockers, PPIs, antacids, sucralfate. treatment: LAVAGE out blood clots, give a max dose of PPI in a 24-hr IV drip
|
|
|
what are the signs/sx of stress gastritis?
|
NGT blood (usually), painless (usually)
|
|
|
what is mallory-weiss syndrome?
|
post-retching, postemesis longitudinal tear (submucosa and mucosa) of the stomach near the GE junction; approx 3/4 are in the stomach
|
|
|
for what % of all upper GI bleeds does mallory-weiss syndrome account?
|
~10%
|
|
|
what are the causes of a tear? what are the risk factors for mallory-weiss syndrome?
|
causes: increased gastric pressure, often aggravated by hiatal hernia. risk factors: retching, alcoholism (50%), >50% have hiatal hernia
|
|
|
what are the sx of mallory-weiss syndrome? what % of patients will have hematemesis?
|
sx: epigastric pain, thoracic substernal pain, emesis, hematemesis. 85% will have hematemesis
|
|
|
how is the dx of mallory-weiss syndrome made?
|
EGD
|
|
|
what is the classic history for mallory-weiss syndrome?
|
alcoholic patient after binge drinking - first vomit food and gastric contents, followed by forceful retching and bloody vomitus
|
|
|
what is the tx for mallory-weiss syndrome? when is surgery indicated?
|
tx: room temp water lavage (90% of patients stop bleeding), electrocautery, arterial embolization, or surgery for refractory bleeding. surgery indicated when medical/endoscopic tx fails (>6 u PRBCs infused)
|
|
|
what is esophageal variceal bleeding?
|
bleeding from formation of esophageal varices from back up of portal pressure via the coronary vein to the submucosal esophageal venous plexuses secondary to portal HTN from liver cirrhosis
|
|
|
can the sengstaken-blakemore tamponade balloon be used for tx of mallory-weiss tear after bleeding?
|
no, it makes bleeding worse. use the balloon only for bleeding from esophageal varices
|
|
|
what is the rule of 2/3 of esophageal variceal hemorrhage?
|
2/3 of patients w/portal HTN develop esophageal varices, 2/3 of patients w/esophageal varices bleed
|
|
|
what are the signs/sx of esophageal varices?
|
liver disease, portal HTN, hematemesis, caput medusa, ascitis
|
|
|
how is the dx of UGI bleeding from esophageal varices made?
|
EGD (very important b/c only 50% of UGI bleeding in patients w/known esophageal varices are bleeding from the varices, the other 50% have bleeding from ulcers etc.)
|
|
|
what is the acute medical treatment of UGI bleeding from esophageal varices made?
|
lower portal pressure w/somatostatin and vasopressin
|
|
|
in the patient w/CAD, what must you give in addition to the vasopressin?
|
nitroglycerin - to prevent coronary artery vasoconstriction that may result in an MI
|
|
|
what are the tx options for esophageal varices? what is the sengstaken-blakemore balloon?
|
tx: sclerotherapy or band ligation via endoscope, TIPS, liver transplant. sengstaken blakemore balloon: tamponades w/an esophageal balloon and a gastric balloon
|
|
|
what is the problem w/shunts in esophageal varices?
|
decreased portal pressure but increased encephalopathy
|
|
|
what is boerhaave's syndrome? who was dr. boerhaave?
|
postemetic esophageal rupture. dr. boerhaave was a dutch physician who 1st described the syndrome in the dutch grand admiral van wassenaer in 1724.
|
|
|
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 (on the L), 3-5cm above the GE jcn
|
|
|
what is the cause of esophageal rupture? what is the assoc risk factor?
|
increased intraluminal pressure, usually caused by violent retching and ovmiting. esophageal reflux dz is assoc risk factor (50%)
|
|
|
what are the sx of boerhaave's syndrome? signs?
|
pain postemesis (may radiate to the back, dysphagia). signs: left pneumothorax, hamman's sign, L pleural effusion, subcutaneous/mediastinal emphysema, fever, tachypnea, tachycardia, signs of infection by 24 hrs, neck crepitus, widened mediastinum on CXR
|
|
|
what is mackler's triad? (boerhaave's syndrome)
|
1. emesis 2. lower chest pain 3. cervical emphysema (subQ air)
|
|
|
how is the dx of boerhaave's syndrome made?
|
history, PE, CXR, esophagram w/water-soluble contrast
|
|
|
what is hamman's sign? (boerhaave's syndrome)
|
mediastinal crunch or clicking --> produced by heart beating against air-filled tissues
|
|
|
what is the mortality rate if less than 24 hrs until surgery for perforated esophagus? if more than 24 hrs?
|
<24 hrs: ~15%. >24 hrs: ~33%
|
|
|
what is the tx for boerhaave's syndrome?
|
surgery w/in 24 hrs 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 (most commonly cervical esophagus)
|
