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124 Cards in this Set
- Front
- Back
what is upper GI bleeding?
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bleeding into the lumen of the proximal GI tract, proximal to the ligament of treitz
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what are the signs/sx of upper GI bleeding?
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hematemesis, melena, syncope, shock, fatigue, coffee-ground emesis, hematochezia, epigastric discomfort, epigastric tenderness, signs of hypovolemia, guiac-positive stools
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why is it possible to have hematochezia?
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blood is a cathartic and hematochezia usually indicates a vigorous fate of bleeding from the UGI source
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are stools melenic or melanotic?
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melenic (melanotic is incorrect)
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how much blood do you need to have melena?
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>50 cc of blood
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what are the risk factors for upper GI bleeding?
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alcohol, cigarettes, liver disease, burn/trauma, aspirin/NSAIDs, vomiting, sepsis, steroids, previous UGI bleeding, history of PUD, esophageal varices, portal HTN, splenic vein thrombosis, abdominal aortic aneurysm repair (aortoenteric fistula), burn injury, trauma
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what is the most common cause of significant UGI bleeding?
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PUD -- duodenal and gastric ulcers (50%)
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what is the common DDx of UGI bleeding?
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acute gastritis, duodenal ulcer, esophageal varices, gastric ulcer, esophageal, mallory-weiss tear
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what is the UNCOMMON DDx of UGI bleeding?
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gastric cancer, hemobilia, duodenal diverticular, gastric volvulus, boerhaave's syndrome, aortoenteric fistula, paraesophageal hiatal hernia, epistaxis, NGT irritation, dieulafoy's ulcer, angiodysplasia
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what diagnostic tests are useful?
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history, NGT aspirate, abdominal x-ray, endoscopy (EGD)
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what are the treatment options w/the endoscope during an EGD?
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coagulation, injection of epinephrine (for vasoconstriction), injection of sclerosing agents (varices), variceal ligation (banding)
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what is the diagnostic test of choice w/UGI bleeding?
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EGD (>95% diagnosis rate)
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which lab tests should be performed?
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chem-7, bilirubin, LFTs, CBC, TYPE & CROSS, PT/PTT, amylase
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why is BUN elevated?
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b/c of absorption of blood by the GI tract
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what is the initial treatment?
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1. IVFs (16 G or larger peripheral IVs x2), Foley cath (monitor fluid status). 2. NGT suction (determie rate and amt of blood) 3. water lavage (use warm H2O -- will remove clots) 4. EGD: endoscopy (determine etiology/location of bleeding and possible tx - coagulate bleeders)
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why irrigate an upper GI bleed?
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to remove the blood clot so you can see the mucosa
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what test may help identify the site of massive UGI bleeding when EGD fails to dx cause and blood continues per NGT?
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selective mesenteric angiography
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what are the indications for surgical intervention in UGI bleeding?
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refractory or recurrent bleeding and site known, >3 u PRBCs to stabilize or >6 u PRBCs overall
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what % of patients require surgery? what % spontaneously stop bleeding?
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10% require surgery. 80-85% stop spontaneously
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what is the mortality of acute UGI bleeding?
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overall 10%, 60-80yo 15%, >80yo 25%
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what are the risk factors for death following UGI bleed?
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age older than 60yo, shock, >5 units of PRBC transfusion, concomitant health problems
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what is peptic ulcer disease? what are the possible consequences of PUD?
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gastric and duodenal ulcers. consequences: pain, hemorrhage, perforation, obstruction
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what is the incidence of PUD in the US? what % of patients w/PUD develops bleeding from the ulcer?
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~10% of the population will suffer from PUD in their lifetime. ~20% develop bleeding
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what bacteria are assoc w/PUD?
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helicobacter pylori
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what is the tx of PUD
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treat h. pylori w/MOC or ACO. 2-wk antibiotic regiments: metronidazole, omeprazole, clarithromycin (MOC) or ampicillin, clarithromycin, omeprazole (ACO)
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what is the name of the sign w/RLQ pain/peritonitis as a result of succus collecting from a perforated peptic ulcer?
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valentino's sign
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in which age group are duodenal ulcers most common? what is the ratio of male to female patients?
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40-65 yrs of age (younger than patients w/gastric ulcer). men>women (3:1)
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what is the classic pain response to food intake w/duodenal ulcer?
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food classically relieves duodenal ulcer
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what is the most common location of duodenal ulcers?
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most are w/in 2cm of the pylorus in the duodenal bulb
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what syndrome must you always think of w/a duodenal ulcer?
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zollinger-ellison syndrome
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what are the assoc risk factors for duodenal ulcer?
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male gender, smoking, aspirin and other NSAIDs, uremia, Z-E syndrome, h. pylori, trauma, burn injury
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what are the sx of duodenal ulcer?
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epigastric pain - burning or aching, usually several hours after a meal (food, milk, or antacids initially relieve pain); bleeding; back pain; nausea, vomiting, and anorexia; decreased appetite
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what are the signs of duodenal ulcer?
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tenderness in epigastric area (possibly), guiac-positve stool, elena, hematochezie, hematemesis
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what is the DDx of duodenal ulcer?
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acute abdomen, pancreatitis, cholecystitis, all causes of UGI bleeding, Z-E syndrome, gastritis, MI, gastric ulcer, reflux
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how is the dx of duodenal ulcer made?
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history, PE, EGD, UGI series (if patient is not actively bleeding)
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when is surgery indicated w/a bleeding duodenal ulcer>
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most surgeons use: >6 u PRBC transfusions, >3 u PRBCs needed to stabilize, or significant rebleed
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what EGD finding is assoc w/rebleeding?
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visible vessel in the ulcer crater, recent clot, active oozing
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what is the medical tx for duodenal ulcers?
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PPIs or H2 receptor antagonists - heal ulcers in 4-6wks for most cases. treatment for h. pylori
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when is surgery indicated in duodenal ulcers?
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IHOP: intractability, hemorrhage (massive or relentless), obstruction (gastric outlet obstruction), perforation
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how is a bleeding duodenal ulcer surgically corrected?
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opening of the duodenum through the pylorus, oversewing of the bleeding vessel
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what artery is involved w/bleeding duodenal ulcers?
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gastroduodenal artery
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what are the common surgical options for truncal vagotomy?
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pyloroplasty
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what are the common surgical options for duodenal perforation?
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graham patch (poor candidates, shock, prolonged perforation), truncal vagotomy and pyloroplasty incorporating ulcer, graham patch and highly selective vagotomy, truncal vagotomy and antrectomy (higher mortality rate but lowest recurrence rate)
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what are the common surgical options for duodenal obstruction resulting from duodenal ulcer scarring (gastric outlet obstruction)?
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truncal vagotomy, antrectomy, and gastroduodenostomy (BI or BII), truncal vagotomy and drainage procedure (gastrojejunostomy)
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what are the common surgical options for duodenal ulcer intractability?
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PGV (highly selective vagotomy), vagotomy and pyloroplasty, vagotomy and antrectomy BI or BII (especially if there is a coexistent pyloric/prepyloric ulcer) but assoc w/a higher mortality
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which ulcer operation has the highest ulcer recurrence rate and the lowest dumping syndrome rate? which ulcer operation has the lowest ulcer recurrence rate and the highest dumping syndrome rate?
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highest recurrence: PGV (proximal gastric vagotomy). lowest: vagotomy and antrectomy
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which duodenal ulcer operation has the lowest mortality rate?
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PGV (1/200 mortality), truncal vagotomy and pyloroplasty (1-2/200), vagotomy and antrectomy (1%-2% mortality) --> PGV is the operation of choice for intractable duodenal ulcers w/the cost of increased risk of ulcer recurrence
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why must you perform a drainage procedure (pyloroplasty, antrectomy) after a truncal vagotomy?
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pylorus will not open after a truncal vagotomy
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what is a kissing ulcer?
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2 ulcers, each on opposite sides of the lumen so that they can kiss
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why may a duodenal rupture be initially painless? why may a perforated duodenal ulcer present as lower quadrant abdominal pain?
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painless: fluid can be sterile w/a nonirritating pH of 7.0 initially. lower quad abd pain: fluid from stomach/bile drains down paracolic gutters to lower quadrants and causes localized irritation
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in which age group are gastric ulcers most common? how does the incidence in men compare w/that of women?
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40-70 yrs old (older than the duodenal ulcer population), rare in patients younger than 40yrs. men>women
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which is more common overall: gastric or duodenal ulcers?
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duodenal ulcers are more than 2x as common as gastric ulcers
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what is the classic pain response to food w/gastric ulcers?
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food classically increases gastric ulcer pain
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what is the cause of gastric ulcers?
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decreased cytoprotection or gastric protection (i.e., decreased bicarbonate/mucous production)
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is gastric acid production high or low in gastric ulcers?
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gastric acid production is normal or low!
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which gastric ulcers are assoc w/increased gastric acid?
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prepyloric, pyloric, coexist w/duodenal ulcers
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what are the assoc risk factors for gastric ulcers?
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smoking, EtOH, burns, trauma, CNS tumor/trauma, NSAIDs, steroids, shock, severe illness, male gender, advanced age
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what are the sx of gastric ulcers?
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epigastric pain +/- vomiting, anorexia, and nausea
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how is the dx of gastric ulcers made? when and why should biopsy be performed?
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history, PE, EGD w/multiple biopsy (looking for gastric cancer). biopsy should be performed with ALL gastric ulcers to rule out gastric cancer. if the ulcer does not heal in 6 wks after medical treatment, rebiopsy (always biopsy in OR also) must be performed
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what is the most common location for gastric ulcers?
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~70% are on the lesser curvature, 5% on the greater curvature
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what is the medical tx for gastric ulcers?
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similar to that of duodenal ulcer - PPIs or H2 blockers, h. pylori treatment
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when do patients w/gastric ulcers need to have an EGD?
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1. for dx w/biopsies 2. 6 wks postdx to confirm healing and r/o gastric cancer
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what are the indications for surgery w/gastric ulcers?
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ICHOP: intractability, cancer (rule out), hemorrhage (massive or relentless), obstruction (gastric outlet obstruction), perforation. note: surgery is indicated if gastric cancer cannot be ruled out
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what is the common operation for hemorrhage, obstruction, and perforation?
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distal gastrectomy w/excision of the ulcer w/o vagotomy unless there is duodenal disease (i.e., BI or BII)
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what are the options for concomitant duodenal and gastric ulcers?
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resect (BI, BII) and TRUNCAL VAGOTOMY
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what is a common option for surgical treatment of a pyloric gastric ulcer?
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truncal vagotomy and antrectomy (i.e., BI or BII)
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what is a common option for a poor operative candidate w/a perforated gastric ulcer?
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graham patch
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what must be performed in every operation for gastric ulcers?
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biopsy looking for gastric cancer
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cushing's ulcer
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PUD/gastritis assoc w/neurologic trauma or tumor
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curling's ulcer
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PUD/gastritis assoc w/major burn injury
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marginal ulcer
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ulcer at the margin of a GI anastomosis
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dieulafoy's ulcer
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pinpoint gastric mucosal defect bleeding from an underlying vascular malformation
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what are the sx of perforated peptic ulcer? what are the signs?
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acute onset of upper abdominal pain. signs: decreased bowel sounds, tympanic sound over the liver (air), peritoneal signs, tender abdomen
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what are the signs of posterior duodenal erosion/perforation? what sign indicates anterior duodenal perforation?
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posterior: bleeding from gastroduodenal artery (and possibly acute pancreatitis). anterior: free air (anterior perf is more common than posterior perf)
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what causes pain in the lower quadrants w/perforated peptic ulcer?
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passage of perforated fluid along colic gutters
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what is the DDx for perforated peptic ulcer?
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acute pancreatitis, acute cholecystitis, perforated acute appendicitis, colonic diverticulitis, MI, any perforated viscus
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which diagnostic tests are indicated for perforated peptic ulcer? what are the assoc lab findings?
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tests: x-ray (free air under diaphragm or in lesser sac in an upright CXR, or LL decub). labs: leukocytosis, high amylase serum (secondary to absorption into the blood stream from the peritoneum)
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what is the initial treatment of a perforated peptic ulcer?
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NPO: NGT (decreased contamination of the peritoneal cavity). IVF/foley catheter. antibiotics/PPIs. surgery.
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what is a graham patch?
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piece of omentum incorporated into the suture closure of perforation
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what are the surgical options for treatment of a duodenal perforation? for perforated gastric ulcer?
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duodenal perf: graham patch (open or laparoscopic), truncal vagotomy and pyloroplasty incorporating ulcer, graham patch and highly selective vagotomy. gastric perf: antrectomy incorporating perforated ulcer, graham patch or wedge resection in unstable/poor operative candidates
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what is the significance of hemorrhage and perforation w/duodenal ulcer?
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may indicated 2 ulcers (kissing); posterior is bleeding and anterior is perforated w/free air
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what type of perforated ulcer may present just like acute pancreatitis?
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posterior perforated duodenal ulcer into the pancreas (i.e., epigastric pain radiating to the back; high serum amylase)
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what is the classic difference b/w duodenal and gastric ulcer sx as related to food ingestion?
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duodenal=decreased pain, gastric=increased pain
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define graham patch
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for treatment of duodenal perforation in poor operative candidates/unstable patients, place viable omentum over perforation and tack into place w/sutures
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truncal vagotomy
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resection of a 1-2cm setment of each vagal trunk as it enters the abdomen on the distal esophagus, decreasing gastric acid secretion
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what other procedure must be performed along w/a truncal vagotomy
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drainage procedure (pyloroplasty, antrectomy, or gastrojejunostomy) b/c vagal fibers provide relaxation of the pylorus and if you cut them the pylorus will not open
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define: vagotomy and pyloroplasty, vagotomy and antrectomy
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v+p: pyloroplasty performed w/vagotomy to compensate for decreased gastric emptying. v+a: remove antrum and pylorus in addition to vagotomy, reconstruct as a billroth I or II
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what is the goal of duodenal ulcer surgery?
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decrease gastric acid secretion (and fix IHOP)
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what is the advantage of proximal gastric vagotomy (highly selective vagotomy)?
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no drainage procedure is needed; vagal fibers to the pylorus are preserved; rate of dumping syndrome is low
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what is a billroth I (BI)?
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truncal vagotomy, antrectomy, and gastroduodenostomy (think bI=1 limb off of the stomach remnant)
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what are the contraindications for a billroth I?
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gastric cancer or suspicion of gastric cancer
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what is a billroth II (BII)?
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truncal vagotomy, antrectomy, and gastrojejunostomy (BII=2 limbs off the stomach remnant)
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what is the kocher maneuver?
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dissect the L lateral peritoneal attachments to the duodenum to allow visualization of posterior duodenum
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what is stress gastritis? how is it diagnosed?
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superficial mucosal erosions in the stressed patient. diagnosed w/EGD if bleeding is significant
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what are the risk factors for stress gastritis?
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sepsis, intubation, trauma, shock, burn, brain injury
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what is the prophylactic treatment of stress gastritis? what is the treatment for gastritis?
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prophylaxis: H2 blockers, PPIs, antacids, sucralfate. treatment: LAVAGE out blood clots, give a max dose of PPI in a 24-hr IV drip
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what are the signs/sx of stress gastritis?
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NGT blood (usually), painless (usually)
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what is mallory-weiss syndrome?
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post-retching, postemesis longitudinal tear (submucosa and mucosa) of the stomach near the GE junction; approx 3/4 are in the stomach
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for what % of all upper GI bleeds does mallory-weiss syndrome account?
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~10%
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what are the causes of a tear? what are the risk factors for mallory-weiss syndrome?
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causes: increased gastric pressure, often aggravated by hiatal hernia. risk factors: retching, alcoholism (50%), >50% have hiatal hernia
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what are the sx of mallory-weiss syndrome? what % of patients will have hematemesis?
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sx: epigastric pain, thoracic substernal pain, emesis, hematemesis. 85% will have hematemesis
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how is the dx of mallory-weiss syndrome made?
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EGD
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what is the classic history for mallory-weiss syndrome?
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alcoholic patient after binge drinking - first vomit food and gastric contents, followed by forceful retching and bloody vomitus
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what is the tx for mallory-weiss syndrome? when is surgery indicated?
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tx: room temp water lavage (90% of patients stop bleeding), electrocautery, arterial embolization, or surgery for refractory bleeding. surgery indicated when medical/endoscopic tx fails (>6 u PRBCs infused)
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what is esophageal variceal bleeding?
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bleeding from formation of esophageal varices from back up of portal pressure via the coronary vein to the submucosal esophageal venous plexuses secondary to portal HTN from liver cirrhosis
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can the sengstaken-blakemore tamponade balloon be used for tx of mallory-weiss tear after bleeding?
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no, it makes bleeding worse. use the balloon only for bleeding from esophageal varices
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what is the rule of 2/3 of esophageal variceal hemorrhage?
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2/3 of patients w/portal HTN develop esophageal varices, 2/3 of patients w/esophageal varices bleed
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what are the signs/sx of esophageal varices?
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liver disease, portal HTN, hematemesis, caput medusa, ascitis
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how is the dx of UGI bleeding from esophageal varices made?
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EGD (very important b/c only 50% of UGI bleeding in patients w/known esophageal varices are bleeding from the varices, the other 50% have bleeding from ulcers etc.)
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what is the acute medical treatment of UGI bleeding from esophageal varices made?
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lower portal pressure w/somatostatin and vasopressin
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in the patient w/CAD, what must you give in addition to the vasopressin?
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nitroglycerin - to prevent coronary artery vasoconstriction that may result in an MI
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what are the tx options for esophageal varices? what is the sengstaken-blakemore balloon?
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tx: sclerotherapy or band ligation via endoscope, TIPS, liver transplant. sengstaken blakemore balloon: tamponades w/an esophageal balloon and a gastric balloon
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what is the problem w/shunts in esophageal varices?
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decreased portal pressure but increased encephalopathy
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what is boerhaave's syndrome? who was dr. boerhaave?
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postemetic esophageal rupture. dr. boerhaave was a dutch physician who 1st described the syndrome in the dutch grand admiral van wassenaer in 1724.
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why is the esophagus susceptible to perforation and more likely to break down an anastomosis?
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no serosa
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what is the most common location of boerhaave's syndrome?
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posterolateral aspect of the esophagus (on the L), 3-5cm above the GE jcn
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what is the cause of esophageal rupture? what is the assoc risk factor?
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increased intraluminal pressure, usually caused by violent retching and ovmiting. esophageal reflux dz is assoc risk factor (50%)
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what are the sx of boerhaave's syndrome? signs?
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pain postemesis (may radiate to the back, dysphagia). signs: left pneumothorax, hamman's sign, L pleural effusion, subcutaneous/mediastinal emphysema, fever, tachypnea, tachycardia, signs of infection by 24 hrs, neck crepitus, widened mediastinum on CXR
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what is mackler's triad? (boerhaave's syndrome)
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1. emesis 2. lower chest pain 3. cervical emphysema (subQ air)
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how is the dx of boerhaave's syndrome made?
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history, PE, CXR, esophagram w/water-soluble contrast
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what is hamman's sign? (boerhaave's syndrome)
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mediastinal crunch or clicking --> produced by heart beating against air-filled tissues
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what is the mortality rate if less than 24 hrs until surgery for perforated esophagus? if more than 24 hrs?
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<24 hrs: ~15%. >24 hrs: ~33%
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what is the tx for boerhaave's syndrome?
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surgery w/in 24 hrs to DRAIN the mediastinum and surgically close the perforation and placement of pleural patch; broad-spectrum antibiotics
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overall, what is the most common cause of esophageal perforation?
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iatrogenic (most commonly cervical esophagus)
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