UPPER GI TRACT DO

ACUTE EPIGASTRI PAIN #1

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