34yo acute sharp epigastric pain that developed in 4hrs Previously healthy P/E: mild distress; moderate epigastric tenderness; no palpable masses DDx: Pancreatitis Peptic ulcer dz Gastric ulcer Gastroenteritis GERD Cholelithiasis H&P + initial lab studies that point to particular Dx: Pancreatitis hx gallstones/alcohol abuse -confirm w/serum amylase + lipase PUD h/o NSAID/steroids Routine screening: CBC UA Amylase + lipase LFT CXR + AXR If CBC, amylase, lipase, bilirubin, ALP, CXR/AXR nl, next step: Abdominal US r/o gallstones (-) H2 blocker/PPI for GERD/ulcers/gastritis GERD lifestyle change, wt loss, avoid meal before sleep If pain Sx continue: Upper GI endoscopy to establish Dx + biopsy to r/o malignancy EGD unremarkable; management: Nonulcer dyspepsia Sx treatment w/H2 blocker/PPI + Tx H. pylori if needed ACUTE EPIGASTRIC PAIN #2 45yo w/epigastric pain that doesnt respond w/medicine. EGD reqd Management of the following EGD findings: Symptomatic GERD w/maximal therapy: EGD w/biopsy + esophageal manometry before surgery -manometry demonstrates esophageal peristalsis imp to know if pt can swallow postop -manometry shows nl LES/atypical Sx (cough, asthma) 24hr pH probe (show reflux) Distal esophagitis Complication of GERD; from incompetent LES, insufficient esophageal clearance of acid, gastric dysfunx -common to have hiatal hernia -medical Tx resolves GERD usually -responds w/8-12wks PPI -severe esophagitis Tx w/antireflux surgery Biopsy of distal esophagus shows Barret esophagus -replaced w/columnar epiT increased risk for esoph adenoCa -req biopsy determine degree of dysplasia -minimal<->mild H2 blockers, bed elevation,etc intractable Sx, severe esophagitis, esophageal stricture surgery -surveillance endoscopy + biopsy/18-24mo monitoring Biopsy of distal esophagus showing Barret esophagus w/severe dysplasia -esophageal resection ACUTE EPIGASTRIC PAIN #3 -45yo w/epigastric pain that doesnt respond w/medicine. EGD reqd; pt has hiatal hernia Management for following types of hiatal hernia: Type 1 hiatal hernia -aka sliding hiatal hernia may affect pt w/reflux symptoms -GERD Tx w/o surgery Mixed type hiatal hernia -a)pure paraesophageal hiatal hernia no other organs involved -b) mixed sliding + paraesophageal hiatal hernia -repair reqd both have risk for strangulation + necrosis of gastric segment trapped in chest Type II Hiatal hernia -paraesophageal hiatal hernia contains stomach + other organs -portion of stomach herniates into chest, but GE junction stays in normal location -very dangerous, entire stomach can necrose if it gets involved in hernia sac + gets strangulated (gastric volvulus) -surgical repair -may present as serious illness w/acidosis + hTN surgical emergency ACUTE EPIGASTRIC PAIN #4 45yo w/epigastric pain that doesnt respond w/medicine. EGD reqd Manage the following findings on EGD Pyloric channel ulcer: Pyloric ulcers assd w/increased acid production -most peptic ulcers H. pylori serum Ab test/gastric biopsy for Cx/ bacterial stain (Warthin-Starry silver stain)/urease testing (CLO test)/urea breath test -Tx: PPI + metro + clarithromycin/amoxicillin PPI + metro + tetracycline + bismuth - bismuthinhibit adhesion to gastric epiT & inhibits urease, phospholipase, + protease activity Duodenal ulcer -similar management as above If pt remains symptomatic after treatment for H.pylori: Extend duration of Tx to 8-12wks -still symptomatic EGD + reeval. for H.pylori *imp Hx: NSAID/steroid use ulcerogenic Rx If pt completes Tx + Sx still persist, you repeat EGD + reveals enlargement of ulcer; next step: -surgery b/c medical Tx has failed -Highly selective vagotomy ToC @ uncomplicated PUD -measure serum gastrin lvl to r/o ZE syndrome ACUTE GASTRIC PAIN #5 45yo w/epigastric pain that doesnt respond w/medicine. EGD reqd. Evident gastric ulcer. How does location of ulcer relate to gastric acid production: Types I , IV low acid output Types II, III high acid output Management of gastric ulcer @ lesser curvature of stomach (type I) -ask pt about use of NSAIDS/steroids -gastric ulcers are assd with increased risk of gastric cancer -Endoscopy + biopsy -benign antacids, H2 blockers, H.pylori Tx If Sx resolve + biopsy is benign; next step: Follow pt as long as he is Sx free If Sx dont resolve + biopsy is benign; next step: -repeat endoscopy @ pt w/nonhealed gastric ulcers -if after 18wks + still not healed surgical resection (partial gastrectomy) How would management change for gastric ulcer @ GE junction (type IV) -all gastric ulcers should be biopsied to r/o Ca -if ulcer doesnt heal 8-16wks after medical Tx, repeat endoscopy -ulcer persists but is still benign @ biopsy cont. medical Tx or surgery Management of type II ulcer of stomach body assd with duodenal ulcer: -excess acid production surgery Management of prepyloric gastric ulcer (type III): -excess acid production surgery + make sure the ulcer isnt cancer ACUTE EPIGASTRIC PAIN #6 -45yo w/epigastric pain that doesnt respond w/medicine. EGD reqd Manage the following EGD findings: Distal gastric ulcer, w/biopsy indicating early gastric cancer -CT to assess distal mets/LN spread -Endoscopic US can help eval. Depth of spread/lymphatic involvement -Tx: gastrectomy + lymphadenectomy Biopsy indicating infiltrating gastric Ca: Intestinal type better Px Diffuse form extends widely into submucosa + poor Px Tx: resection of stomach, omentum, perigastric LN Biopsy indicating infiltrating gastric Ca and the wall of the stomach that appears fixed & rigid in its entirety -Linitis plastica diffusely infiltrating gastric Ca -poor Px -involves all layers of the stomach wall w/marked desmoplastic rxn Tx: gastrectomy + splenectomy -cure is rare A biopsy indicating gastric Ca @ the GE junction Gastric resection/esophagogastrectomy ACUTE GASTRIC PAIN #7 40yo 4hr h/o epigastric pain that has worsened over past hour low grade fevere + nl BP P/E: abdomen: tenderness + invol guarding/rigid abdomen + rebound tenderness WBC 18k w/leftward shift What study would you perform first -obstructive series + upright CXR to examine free air under diagram that might indicate perforated GIT -rigid abdomen is typical for chemical peritonitis (i.e. perforated ulcer) If CXR showed free air in peritoneal cavity, how would it affect management: Sx of perforation resuscitation then OR In OR they find 1cm perforation in ant. portion of the duodenum: If there are fresh gastric contents in the peritoneal cavity, and the perforation is several hours old: Close the perforation There are fresh gastric contents in the peritoneal cavity, perforation is several hours old, and ulcer Sx were present for 6mo while on H2 blockers -pt had prior ulcer + is at risk for future complications w/o definitive procedure -close perforation + vagotomy/gastrectomy/antrectomy There are fresh gastric contents in the peritoneal cavity, the perforation is several hrs old, and the pt has h/o RA requiring daily NSAIDs + steroids -NSAIDs + steroids cause ulceration due to breakdown of mucosal barrier -close ulcer + d/c Rx -cant d/c Rx vagotomy There are fresh gastric contents in the peritoneal cavity; the perforation is several hrs old; pt is hypotensive during the operation; presumably secondary to sepsis. Complete operation ASAP + stabilize pt @ ICU -close perforation, IV ABX, PPIs Perforation 24hr old, w/fibrinous exudate + evidence for infex throughout the peritoneal cavity -close ulcer ICU, vol resuscitation, IV ABX, PPI UPPER GI BLEEDING #1 20yo w/pneumonia @ ICU; ileus + NG tube drainage NG tube contains coffee-ground-type material + occasional blood streaks Pt management: H2 block/ sucralafate/antacids + gastric pH monitoring Agent Effect Pro/Con Antacids Neutralize gastric acid; may increase mucosal resistance Inexpensive H2 blocker Inhibits @ parietal cell Mainstay therapy; once daily evening dose PPI Inhibit ATPase proton pump Quicker healing More expensive Sucralfate Binds to proteins @ ulcer to form protective mucosal barrier
ABX Kill H.pylori inexpensive
-it pt is taking NSAIDs give pt misoprostol (PGE1 analog w/gastric mucosal protective properties; inhibits gastric acid secretion w/coffee-ground bleeding) Pts you would manage with ulcer PPx -pts @ ICU w/increased risk upper GI bleeding due to ulceration + gastritis If you give Tx but dont perform Dx procedures, and later in the day pt develops bright red blood in NG tube: -first step resuscitation w/large bore IV -blood draw for type + cross-match + Hct -lavage NG tube until blood no longer returns -IVF + monitor for hTN -give H2 blockers + monitor gastric pH -pt stabilizes upper endoscopy to find source Manage the following: Duodenal ulcer w/clean, white base + no active bleed White base= no recent bleeding; observe w/o endoscopy -in all gastric ulcers maintain gastric pH >5 -give H2 blocker/PPI to maintain gastric pH Duodenal ulcer w/fresh clot adherent to the ulcer Ulcer shows evidence of recent bleeding -endoscopic hemostatic therapy Epi injection, sclerosing Rx, thermal contact methods, laser therapy, suturing -indicated @ evidence of active/recent bleeds large initial blood loss high risk of rebleeding/death w/the bleed Duodenal ulcer w/fresh clot and a visible artery at its base Highest risk of rebleed; rebleeding may be massive -usually occurs @ post. duodenum + involves gastroduodenal a -inject the area around artery + attempt local control -operate w/in next 24-48hrs if significant bleed occurred before endoscopy Duodenal ulcer with fresh bleeding in a pt w/onset of hTN -pt gets hTN during endoscopy NS + packed RBC immediately -go to OR + sew vessel before exsanguinating hemorrhage Duodenal ulcer in pt w/ARF + Cr 6mg/dL Uremia platelet dysfunction increase risk bleeding -give dialysis + desmospressin -Tx ulcer as with any other upper GI bleed Duodenal ulcer in a pt w/chronic alcoholic cirrhosis -pt may have elevated PT from deficiency of factors 2,7,9,10 -correct w/FFP -congested splenomegaly thrombocytopenia --correct w/platelet transfusion -Tx upper GI as per usual Gastric ulcer All gastric ulcers warrant biopsy -management is otherwise similar to duodenal ulcers -malignant gastric ulcers exophytic masses w/heaped up margins -necrotic ulcer craters w/bleeding from the edge of craters -if bleeding controlled plan to reeval w/endoscopy in 2 wks -if surgery warranted excision Gastritis -multiple, nonulcerating erosions in the stomach -assd w/ventilator dependence, major trauma, severe burns, sepsis, renal failure -keep gastric pH above 5 w/antacid/H2B/PPI/sucralfate -most pt stop bleeding with Rx -if surgery reqd subtotal gastrectomy -poor Px regardless of Tx Gastritis + gastric varices in a pt w/Hx of cirrhosis Gastritis + gastric/esophageal varices occur w/alcoholic cirrhosis -bleeding is usually from gastritis, not varices-> Tx the gastritis -Tx gastric varices cyanoacrylate glue -still uncontrollable TIPS or splenectomy Gastritis + gastric varices w/ Hx of chronic pancreatitis -gastric varices may be due to splenic v thrombosis left-sided portal HTNsplenectomy Esophageal varices + h/o cirrhosis -Tx coagulation abnormalities FFP + vit K + vasopressin/octreotide -endoscopic sclerotherapy/variceal banding control bleed -repeat endoscopy in 48hr to ligate remaining bvs Multiple linear erosions in the gastric mucosa @ GE junction Mallory Weisstear through mucosa + submucosa due to forceful vomiting -bleeding gen. stops spontaneous -if it doesnt injection/electrocautery UPPER GI BLEEDING #2 35yo cirrhotic pt w/profuse upper GI bleed. Resuscitated, get upper GI endoscopy actively bleeding esophageal varices. Control the bleeding: -band varices -FFP + platelet transfusion -IV octreotide/vasopressin + Beta blocker(contra @ profound bradycardia/hTN) -repeat endoscopy -a) TIPS -b) balloon tamponade hemostasis when inflated; recurrence when not If pt stops bleeding and recovers after banding; next step: Management is based on overall medical condition -severity of liver failure; is it reversible? -psychosocial status Beta blockers decreases chance of rebleed -plan liver transplant ACUTE EPIGASTRIC PAIN #8 -48yo fever, chills, sweats, weight loss, epigastric upset Endoscopy: gastric lymphoma Management: -determine the degree of spread -chest CT -abd CT -biopsy peripheral LN -BM biopsy -survival depends on stage of dz, extent of penetration of gastric wall, histological grade of tumor Tx: MALT H.pylori Tx Stage I surgery +/- radiation Stage II total gastrectomy + regional LN resection + RTX + CTX Stage III IV CTX + RTX