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3 GI, U/L Tracts
Step Up to Medicine, Chap 3: Bleeding, Upper and Lower GI Tracts
| Question | Answer |
|---|---|
| Definition of upper GI bleed. | Bleeding from above the ligament of Treitz in the duodenum. |
| Pt with a past h/o aortic graft surgery for an aortic aneurysm who comes to the hospital with a small GI duodenal bleed and goes into massive hemorrhage hours (to weeks) later. Dx? Management? | Dx: Aortoenteric fistula. Management: emergent endoscopy or surgery |
| Which test do you order little intern?: hematemesis | Upper GI endoscopy |
| Which test do you order little intern?: hematochezia | R/o anorectal causes first (e.g., hemorrhoids). Colonoscopy is initial test of choice. |
| Which test do you order little intern?: melena | Upper endoscopy. Order colonoscopy if no bleeding site ID'd on endoscopy. |
| Which test do you order little intern?: occult blood | Colonoscopy. Order upper endoscopy if no bleeding site ID'd on colonoscopy. |
| Submucosal dilated arterial lesions that can cause massive GI bleeding | Dieulafoy's vascular malformation |
| MC source of GI bleeding in pts under 60yo; usually painless | Diverticulosis |
| MC source of GI bleeding in pts over 60yo | Angiodysplasia |
| Most upper GI bleed episodes req' which tx? | Supportive. 80% of episodes stop spontaneously. |
| What is "coffee ground" emesis suggestive of? | Upper GI bleed with slow rate of bleeding (extra time for vomitous to turn dark and grainy) |
| What causes the black color of melena? | Colonic bacteria metabolizing Hgb |
| False positives for melena? Name 5. | Bismuth, iron, spinach, charcoal, and licorice. |
| What question should always be asked when taking a history for a GI bleed? | NSAID/aspirin or anticoagulant use |
| What does an elevated PT indicate? | Liver dysfunction, vit K deficiency, consumptive coagulopathy, or warfarin therapy |
| What should the Hgb level be in elderly? | >10 (7-8 is ok in younger pts without active bleeding) |
| What happens to the BUN:Cr ratio in upper GI bleeding | Elevated (suggests upper GI bleed if pt doesn't have renal insufficiency) |
| Interpret: nasogastric tube aspiration with bile but no blood | upper GI bleed unlikely; site is prob distal to ligament of Treitz |
| Interpret: BRB or "coffee grounds" | upper GI bleed |
| Interpert: clear gastric fluid | cannot r/o GI bleed, but upper GI bleed unlikely |
| Treatment for pt with GI bleed? | 1. Supplemental oxygen, 2. Place 2 large bore IV lines; give fluids if hypovolemic, 3. Draw blood (Hgb/Hct, PT, PTT, platelet ct), 4. Type and crossmatch PBRCs (tranfuse as necessary) |
| 2 major risk factors for SCC of esophagus? | Alcohol and tobacco use (also nitrosamines, betel nuts, hot foods/beverages), Plummer Vinson syndrome |
| Major risk factors for adenocarcinoma (more common) of the esophagus? | GERD and Barrett's esophagus |
| MC symptom of esophageal carcinoma? | Dysphagia (first to solids, then to liquids); weight loss is 2nd MC symptom |
| What does odynophagia (painful swallowing) suggest in a pt with s/s esophageal carcinoma? | Extraesophageal involvement (mediastinal invasion) |
| Definitive diagnostic test for esophageal adenocarcinoma? | Upper endoscopy with biopsy and brush cytology. Also want to do full metastatic workup (CT scan chest/abd, CXR, bone scan) |
| Tx for esophageal adenocarcinoma? | Palliative (usually advanced at presentation). |
| Acquired motor disorder in which LES fails to completely relax with swallowing and abnormal peristalsis occurs | Achalasia |
| Worldwide important cause of achalasia? | Chagas disease |
| How does the clinical presentation of achalasia differ from that of esophageal carcinoma? | Achalasia presents with dysphagia to solids AND liquids, whereas carcinoma presents with dysphagia initially only to solids and finally also to liquids |
| Dx for achalasia? | Barium swallow (bird's beak appearance) |
| Risk of which malignancy is increased with achalasia? How should these pts be managed? | SCC esophageal cancer; perform surveillance esophagoscopy to detect tumor at early stage |
| How is diffuse esophageal spasm (DES) different from achalasia in terms of pathophys? | DES has normal sphincter f'n whereas achalasia has inability of LES to fully relax during swallowing |
| Dx test for DES? | Esophageal manometry (usually do ACS rule-out first to make sure chest pain is non-cardiac) |
| Tx for DES? | Nitrates, CCB (decreases amplitude of contractions), TCAs |
| MC complication of sliding hiatal hernia? | GERD. Other complications include reflux esophagitis and aspiration. |
| Difference in treatment between sliding hiatal hernias (type 1) and paraesophageal hiatal hernias (type 2)? | Type 1: medically (antacids, small meals, elevation of head after meals). Type 2: elective surgery (b/c risk of complications include obstruction, hemorrhage, incarceration, and strangulation) |
| Diagnostic test for Mallory Weiss tears? | Upper endoscopy |
| Difference in pathophys between Mallory Weiss and Boerhaave's syndrome? | Mallory Weiss tear is mucosal and at GE j'n. Boerhaave's tear is transmural (perforation). |
| Tx for Mallory Weiss | Usually resolve on own. May need surgery, but rare. Acid suppression to promote healing. |
| Upper esophageal web (dysphagia), iron deficiency anemia, koilonychia, and atrophic oral mucosa. Dx? | Plummer-Vinson syndrome |
| Is Plummer Vinson considered a premalignant lesion? | YES! 10% develop SCC of oral cavity, hypopharynx, or esophagus |
| Circumferential ring in lower esophagus always accompanied by sliding hiatal hernia. | Schatzki's ring |
| Which is more dangerous- alkali or acid ingestion? Why? | Alkali is more dangerous b/c it causes liquefactive necrosis of the esophagus with full-thickness perforation. Acid only causes necrosis of mucosa. |
| Tx for caustic injury to esophagus? | Esophagectomy if full-thickness necrosis. Steroids, abx. Bougienage for strictures. No vomiting, gastric lavage, or oral intake. |
| Failure of cricopharyngeal m to relax during swallowing->increased intraluminal pressure-> outpouching of mucosa in pharyngeal constrictors | Zenker's diverticulum (upper third of esophagus) |
| Which type of diverticula is seen in pulmonary TB? Where is it located? | Traction diverticula; located in midpoint of esophagus. Caused by contiguous mediastinal inflammation and adenopathy--> traction. |
| Which type of diverticula is associated with spastic esophageal dysmotility or achalasia? Where is it located? | Epiphrenic diverticula. Lower third of esophagus. |
| Diagnostic test for esophageal diverticula? | Barium swallow |
| Tx for Zenker's diverticulum? | Surgery (cricopharyngeal myotomy) |
| What is the most important factor in determining survival in a pt with esophageal perforation? | Time btwn perf and operation. >24h increases mortality rate and likelihood of fistulization. |
| Pt with severe retrosternal pain radiating to shoulder, tachycardia, hyoptension, tachypnea, dyspnea, fever, mediastinal crunch (Hamman's sign), pneumothorax/pleural effusion. Dx? | Esophageal perforation |
| Dx study of choice in esophageal perforation? | Contrast esophagram w/soluble gstrografin swallow |
| Managment of esophageal perforation? | Small perf w/stable pt: medical (IV fluids, NPO, abx, H2 blockers). Large perf w/unstable pt: surgery in 24 hours |
| Nature of pain in PUD? | Nocturnal symptoms with aching/gnawing epigastric pain. Also early satiety, weight loss, n/v. |
| Which type of ulcers do not require biopsy: peptic or duodenal? | Duodenal (low malignant potential) |
| Which ulcer: eating relieves pain | Duodenal |
| Which ulcer: nocturnal symptoms more common | Duodenal |
| Which ulcer: smoking=risk factor | Gastric |
| What is triple therapy? | Bismuth subsalicylate + clarithromycin + amoxicillin or metronidazole |
| What is quadruple therapy? | PPI + bismuth subsalicylate + 2 abx |
| MCC of chronic gastritis? | H pylori infection |
| Most sensitive test for gastric perforations? | CT scan |
| MCC of upper GI bleeding? | PUD |
| Where does it met to?: Krukenberg's tumor | Ovaries |
| Where does it met to?: Blumer's shelf | Rectum (pelvic cul-de-sac; can palpate on rectal exam) |
| Where does it met to?: Sister Mary Joseph's node | Periumbilical lymph node |
| Where does it met to?: Irish's node | Left axillary adenopathy |
| Difference between distal and proximal SBO? | DIStal: less frequent vomiting and significant abdominal DIStention. Proximal: frequent vomiting, extreme pain, minimal distention. |
| What are the metabolic effects of SBO? | Dehydration--> hypokalemia, hypochloremia, and metabolic alkalosis |
| MCC SBO in adults? | Adhesions from prior abdominal surgeries (incarcerated hernia=2nd MCC) |
| MCC large bowel obstruction? | Colon cancer |
| Metabolic effects of a strangulated bowel in SBO? | Acidosis (increased lactic acid) |
| Which metabolic disorder can cause paralytic ileus of gut? | Hypokalemia |
| Surgery for paralytic ileus? | Nope! Medical managment. |
| Hallmark location for Crohn's disease? | Terminal ileum |
| Which IBD: noncaseating granulomas | Crohn's |
| Location of abdominal pain in Crohn's? | RLQ |
| Which IBD: aphthous ulcers | Crohn's |
| MC indication for surgery in Crohn's? | SBO |
| Name 2 types of malabsorption seen with Crohn's. | 1. B12, 2. bile acids (both occur in terminal ileum) |
| Which IBD eye lesion parallels the course of disease in the bowels? | Episcleritis (anterior uveitis occurs independently) |
| Which IBD: erythema nodosum | Crohn's |
| Which IBD: increased risk of ankylosing spondylitis | UC |
| MC extraintestinal manifestation of IBD? | Arthritis |
| Which type of arthritis parallels bowel disease activity in IBD? | Migratory monoarticular arthritis |
| What is the mechanism of sulfasalazine (5-ASA /mesalamine= active compound) in UC? | Blocks prostaglandin |
| Name 4 indications for surgery in IBD. | 1. SBO, 2. Fistula, 3. Disabling disease, 4. Perforation/abscess |
| Which IBD: ALWAYS involves the rectum | UC |
| Which IBD: inflammation limited to mucosa and submucosa | UC |
| Which IBD: crypt abscesses | UC |
| Which IBD: hematochezia (bloody diarrhea), abdominal pain, and tenesmus | UC |
| Workup for UC? | Stool cultures (r/o infectious diarrhea), fecal leukocytes, WBC, and colonoscopy |
| Which IBD: colectomy is curative | Colectomy |
| Which IBD: increased risk for sclerosing cholangitis and colorectal cancer | UC |
| Leading cause of death in UC? | toxic megacolon (increased risk of perforation) |
| Mainstay of treatment for UC? | Sulfasalazine |
Created by:
sarah3148
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