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3 GI, U/L Tracts

Step Up to Medicine, Chap 3: Bleeding, Upper and Lower GI Tracts

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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