Upper GI 2

Question 0

Mechanism of antacids? Mechanism of H2 antagonist? Mechanism of PPI’s?

Answer 0

Neutralize gastric acid

Inhibit histamine receptor on parietal cell, decreasing acid secretion

Inhibits ATPase proton pump, blocking acid secretion

Question 1

30 year old woman presents with pneumonia and is placed in ICU. Ileus requires NG tube drainage. NG tube contains coffee ground type material with occasional blood streaks. Management?

Answer 1

1. Initiation of H2 blockade, sucralfate, Or antacids with each gastric pH monitoring
2. If patient is taking NSAIDs, misoprostol (synthetic prostaglandin E1 analogue)
3. EGD not mandatory

Question 2

Patient undergoes EGD – finds ulcer that’s clean, with a white base no active bleeding. Interpretation? Management?

Answer 2

White base means ulcer has not bled recently. Risk of bleeding is low.

Endoscopic therapy is not needed. However necessary to maintain gastric pH at five to reduce risk of bleeding

Question 3

Patient undergoes EGD – finds duodenal ulcer with fresh clot. interpretation? Management?

Answer 3

Evidence of recent bleeding, has 10-15% chance of rebleeding.

Endoscopic hemostatic therapy is needed. (Injection of epinephrine and sclerosing agents, will contact methods, laser therapy, suturing)

Question 4

Patient has duodenal ulcer – indications for endoscopic therapy?

Answer 4

1. Active or recent bleeding
2. Large initial blood loss
3. high risk of rebleeding or death with bleed

Question 5

Patient undergoes EGD – finds duodenal ulcer with fresh clot and visible artery at base. Interpretation? Management?

Answer 5

Highest risk of rebleeding (40%). Usually in the posterior duodenum and involved Gasburg is hungry

Inject area around ulcer to attempt local control. Elective surgical repair in 24-48 hours if significant prior bleed.

Question 6

Patient undergoes EGD. Duodenal ulcer with fresh bleeding. Patient is hypotensive during endoscopy – management?

Answer 6

Immediate resuscitation with normal saline and packed RBCs. Most likely will need surgery.

Question 7

Patient with duodenal ulcer has acute renal failure and creatinine of 6 – concern? Management?

Answer 7

Platelet dysfunction caused by uremia increases likelihood of bleeding

Lesson dysfunction with dialysis or ddAVP

Question 8

Duodenal ulcer in the patient with chronic alcoholic cirrhosis – concern?

Answer 8

1. Elevated prothrombin time due to deficiency of factors (2, 7, 9, 10) – Temporarily correct with FFP
2. Thrombocytopenia due to congestive splenomegaly – partially corrected by platelet transfusion

Question 9

Gastritis – definition? Associated with? Goal of medical management? When is surgery needed? Type of surgery?

Answer 9

Multiple non-ulcerating erosions in the stomach

Ventilator, trauma, sepsis, burns, renal failure

Keep gastric pH over five

Surgery bleeding does not cease with medical therapy. Subtotal gastrectomy

Question 10

Patient history of cirrhosis with gastritis and gastric varices – Gastric varices do not respond to which therapies used for esophageal varices? Treatment options?

Answer 10

Banding or sclerotherapy

1. Cyanoacrylate glue
2. If bleeding is uncontrollable, Transjugular intrahepatic portosystemic shunt (TIPS) or splenectomy

Question 11

Patient with history of chronic pancreatitis presents with gastritis gastric varices – Varices may be the result of? Management bleeding is persistent?

Answer 11

Splenic vein thrombosis resulting in left-sided portal hypertension

Splenectomy

Question 12

Patient with history of cirrhosis presents with esophageal varices – management?

Answer 12

1. Treatment of underlying coagulation abnormalities with FFP and vitamin K
2. Vasopressin or octreotide to lower portal pressure
3. Endoscopic sclerotherapy or variceal banding controls bleeding in 90% of patients

Question 13

Patient with esophageal varices – choosing between sclerotherapy or band ligation?

Answer 13

Banding is preferred because it causes less injury to the esophagus

Question 14

Patient with multiple linear erosions in the gastric mucosa at the gastroesophageal junction – suspected diagnosis? Mechanism? Course of bleeding? Management?

Answer 14

Mallory-Weiss syndrome; forceful vomiting causes longitudinal tears in mucosa and submucosa of stomach near the gastroesophageal junction

Bleeding often stops spontaneously

If bleeding continues:

1. Injection or electrocautery
2. If severe, oversewing the laceration via anterior longitudinal gastrostomy

Question 15

35-year-old man with history of cirrhosis presents with profuse upper G.I. bleeding. EGD reveals esophageal varices. Steps to control the bleeding?

Answer 15

1. Attempt banding varices
2. Correct coagulopathy with FFP and thrombocytopenia with platelet transfusion
3. Octreotide or vasopressin to lower portal pressure
4. If continues to bleed, repeat endoscopy to reassess source and try to control again with banding
5. If still bleeding, portosystemic shunt or balloon tamponade

Question 16

Pt with esophageal varices– how to decide between octreotide and vasopressin?

Answer 16

Vasopressin can cause coronary constriction so do not give to:

1. Older patients
2. Patients with CAD
3. In conjunction with beta blocker (can cause bradycardia or hypertension)

Question 17

Balloon tamponade? Main Precaution?

Answer 17

Placing NG tube with attached esophageal gastric balloon to tamponade the bleeding

Only perform if intubated, because high-risk of aspirational pneumonia

Question 18

Patient with bleeding from esophageal varices. Bleeding is controlled. treatment that may lessen the chance of rebleeding?

Answer 18

Beta blocker

Question 19

40-year-old man presents with fever, chills, weight-loss, and gastric upset. Endoscopy shows gastric lymphoma – initial management?

Tx If determined to be:

1. mucosa-associated lymphoid-tissue lymphoma?
2. Stage 1?
3. Stage 2?
4. Stage 3?
5. Stage 4?

Answer 19

Determine degree of spread – chest and abdominal CT, peripheral node biopsy, bone marrow biopsy

1. Eradicate Helicobacter
2. Subtotal gastrectomy and regional node resection +/- radiation
3. Total gastrectomy and regional node resection followed by radiation and chemo
4. Chemoradiation
5. Chemoradiation