A patient presents with abrupt onset of epigastric pain 4 hours ago. CBC, amylase, lipase, bili and alk phos are all WNL. Abdominal u/s reveals a normal gallbladder and CXR is unremarkable. What is appropriate treatment for this patient?
PPI or H2 blocker to empirically treat for GERD, gastritis or ulcer. This is appropriate because you have effectively ruled out perforation, pancreatitis, cholelithiasis and infection.
What lifestyle modifications can be made for patients w/GERD?
Decrease ingestion of foods that decrease LES tone (chocolate, tea, coffee, alcohol), weight loss and elevation of the bed can improve 60-70% of patients.
What is the next step in a patient with persistent epigastric pain despite tx with PPIs and lifestyle modifications?
EGD to r/o malignancy and detect H. pylori w/sampling and subsequent urease test (CLO test), histology (Warthin-Starry silver staining) or culture. Note however, that H. pylori can also be detected with fecal antigen testing, urea breath test or serum antibody testing.
How do you treat a patient with PUD due to H. pylori?
Quadruple therapy: PPI (omeprazole), metronidazole, tetracycline and bismuth subcitrate potassium
Preop evaluation in a patient with GERD refractory to medical therapy
EGD w/biopsy and esophageal manometry to demonstrate intact esophageal peristalsis before surgery. If manometry shows normal LES tone, 24-hour pH monitoring should be done to confirm GERD.
Next step in a patient with GERD sx and esophagitis on EGD
24 hour pH monitor to confirm GERD. Lifestyle modifications + PPI resolve esophagitis in 8-12 weeks in 85% of patients. Once esophagitis becomes erosive a Nissen fundoplication is warranted.
A patient presents with GERD sx, manometry shows normal esophageal peristalsis and EGD biopsy shows Barrett esophagus. What is your next step?
If dysplasia is mild-moderate, surveillance EGD and biopsy every 18-24 months + lifestyle modifications and PPIs. If dysplasia is severe, confirm dx with another pathologist and then send for esophagectomy.
Treatment for the different types of hiatal hernias
Type I: "sliding hiatal hernia", GEJ migrates above diaphragm, tx w/lifestyle modification and PPI. Type II: "pure paraesophageal hiatal hernia", managed surgically to prevent strangulation, ischemia and necrosis of stomach, surgical emergency if present with hypotension and acidosis. Type III: combination of types I and II, managed surgically. Type IV: herniation of structure other than the stomach, managed surgically.
Possible causes of refractory PUD in patients being treated with quadruple therapy?
NSAIds and steroids are ulcerogenic
When is surgery appropriate for a patient with PUD? What are the surgical options?
1st r/o ulcerogenic causes like NSAIDs, steroid use and ZE syndrome (measure serum gastrin levels). After lifestyle modification and medical therapy for 4-6 weeks or 8-12 weeks for severe PUD fails. Highly selective vagotomy (HSV: low mortality rate and low rate of dumping syndrome, but high rate of ulcer recurrence), truncal vagotomy and pyloroplasty (V&P), vagotomy and antrectomy (V&A: low rate of ulcer recurrence, but high rate of anastomotic leak and dumping syndrome) are the most common procedures.
What are the different types of gastric ulcers? Which ones put out lots of acid?
Type I: incisura angularis on lesser curvature. Type II: incisura angularis + duodenal. Type III: prepyloric. Type IV: gastric cardia. Types I and IV are associated with low acid output and types II and III are associated with high acid output and thus merit some type of vagotomy if surgical intervention is appropriate.
When do you decide to do surgery on a patient with PUD?
Since gastric ulcers are strongly correlated with gastric cancer, you should get 8-12 biopsy samples at the border of each ulcer bed on endoscopy. If the ulcer is non-cancerous, medical therapy with antacids, PPIs and possible quadruple tx may be warranted for 12-18 weeks. If sx do not resolve, repeat endoscopy and biopsy and patient can try another round of medical management or go for surgery. Surgery can be sped along if the ulcer is > 5cm. Standard surgical procedures depend on the location of the ulcer: type I = antrectomy w/o vagotomy, type IV = distal gastric resection w/extension up lesser curvature to include the ulcer w/o vagotomy, type II: ulcer removal by antrectomy w/truncal vagotomy, type III: V&P.
What do you do if you perform biopsy via EGD on a patient with PUD and you find early gastric cancer?
Stage the cancer with CT looking for mets and LN involvement. Endoscopic u/s can also assess LN involvement. Next perform distal subtotal gastrectomy of 80% of stomach w/regional lymphadenectomy for staging. If tumor is confined to mucosa and LNs are negative 5 year survival is 90%.
What are the three types of gastric cancer and what is their prognosis?
Intestinal (gland forming) has a better prognosis than diffuse (extends widely into submucosa) adenocarcinoma. Diffusely infiltrating gastric carcinoma (linitis plastica) involves all layers of the stomach wall and cure rate is rare.
What types of surgery are indicated for treatment of gastric cancer?
In general the stomach w/6cm margins, omentum and perigastric LNs are resected. With linitus plastica, the spleen is also resected. If the GEJ is involved, the esophagus will need to be resected up to 6cm away from the tumor site.
What are the different regions of lymph node drainage in the stomach?
I) Inferior gastric II) Splenic III) Superior gastric IV) Hepatic
Next step in a patient with acute onset of epigastric pain and air underneath the diaphragm on upright CXR w/fresh perforation and no hx of PUD? Fresh w/hx of PUD? Fresh w/sepsis?
Operating room due to gastric perforation. If the perforation is only several hours old (fresh gastric content in abdomen) and the patient has no hx of PUD you can close with Graham patch (omentum over the perforation sutured in place). If the perforation is only several hours old and the patient has hx of PUD, close the perforation with Graham patch and consider HSV or V&P to prevent recurrence (usually not performed emergently though). If the patient is septic and the perforation is several hours old, close w/Graham patch, debride peritoneum and send to ICU for resuscitation w/IVFs, abx and omeprazole for ulcer prophylaxis...plan for definitve surgery at a later date.
Next step if your ICU patient develops coffee-ground material w/occasional blood streaks out of NG tube?
PPI (inhibits ATPase proton pump in parietal cell), H2 antagonist (inhibits histamine receptor on parietal cell), sucralfate (binds proteins in ulcer to protect mucosa) or antacids (neutralizes acid) w/pH monitoring. If pt is on NSAIDs, add misoprostal (synthetic PGE1 w/gastric mucosa protective properties)...EGD is not necessary at this time.
Your ICU patient has bright red blood coming out of her NG tube and has had coffee-ground material coming out previously to this. What do you do?
Type and cross, 2 large bore IVs and lavage the NG tube until blood stops coming out. Monitor for hypotension, start PPIs and monitor gastric pH (try to maintain > 5). Once the patient is stabilized to EGD to find source of bleeding.
What is the difference in management of a duodenal ulcer with a clean white base and no active bleeding, an ulcer w/fresh adherent clot, an ulcer w/fresh adherent clot and visible artery at its base and an ulcer with fresh bleeding and patient is hypotensive.
Clean white base and no active bleeding = has not bled recently, risk of rebleeding is low, observation is appropriate. Fresh adherent clot = 10-15% rebleed, endoscopic hemostatic therapy (epi, sclerosing agents, coagulation, laser and suturing). Fresh clot w/visible artery at base = 40% risk of rebleeding, most often in posterior duodenum at gastroduodenal artery, inject epi to attain local control and surgery within 1-2 days. Fresh bleeding and hypotensive = immediate resuscitation w/NS and/or blood then to the OR for vessel oversewing
What considerations do you need to make when treating a patient for a bleeding peptic ulcer when they have chronic renal failure? Liver failure?
With renal failure, uremia can inhibit platelet activation and make hemorrhage control difficult, make sure to have patient dialized before or give ddAVP. With liver failure, you may have decreased levels of clotting factors II, VII, IX and X...make sure you give FFP or have it on hand. Patients with liver failure may also have splenomegaly that causes thrombocytopenia and may need platelet transfusion.
How does management of a bleeding gastric ulcer differ from management of a bleeding duodenal ulcer?
All gastric ulcers need biopsy once bleeding is stable (~2 weeks after). Also surgical tx is excision, not oversewing.
What factors predispose someone to gastritis?
Trauma, sepsis and severe burns (Curling's ulcer from decreased plasma volume) due to mucosa damage and loss of protection from H+ due to tissue hypoxia. Renal failure and vent dependence also put patients at risk.
How should you manage a patient with bleeding due to gastritis?
PPI/H2 antagonists, sucralfate and antacids to keep pH > 5. This will control most cases, however, if it doesn't subtotal gastrectomy is warranted and moratlity is high.
A 66 year old alcoholic with a history of cirrhosis presents with hematemesis. What is the most likely cause of his hematemesis and how do you treat him?
Alcoholics with cirrhosis can have both esophageal and gastric varices. Note that bleeding in these patients is more often due to gastritis and not the varices, however, gastric varices are more difficult to manage than esophageal because they do not respond to banding or sclerotherapy. Patients should first be treated for gastritis. If the patient has ruptured varices and they are small, try cyanoacrylate glue. If that doesn't work you have to resort to transjugular intrahepatic portosystemic shunting (TIPS) or surgical portosystemic shunting or splenectomy.
What condition do you need to consider in a patient with gastritis and gastic varices with a history of pancreatitis?
Splenic vein thrombosis that resulted in left-sided portal hypertension. You need to treat this with splenectomy.
A patient presents with bleeding esophageal varices secondary to cirrhosis. What do you do to manage this patient?
1st attempt to band the bleeding varices then address clotting disorder with FFP, platelets and/or vitamin K. Next IV octreotide (or vasopressin) and a beta-blocker can be used to decrease the portal pressure (octreotide contraindicated in elderly and patients w/CAD due to coronary vasoconstriction, beta-blocker contraindicated in profound bradycardia or hypotension). Endoscopic variceal banding or sclerotherapy will control 80-95% of bleeding. Rebleeding rates are high so repeat endoscopy is necessary after 48 hours. If bleeding does not resolve you can do balloon tamponade (risk of esophageal, necrosis, perforation and aspiration...only done if patient is intubated), TIPS or other portosystemic shunting surgery (50% mortality rate!).
How do you treat an alcoholic that presents with sudden onset hematemesis due to Mallory-Weis tears?
Tears through the mucosa and submucosa at the GE junction often occur in alcoholics due to forceful vomiting. These bleeds can be managed with injection or electrocaudery if it does not resolve on its own. Rarely will you have to oversew the tear through an anterior longitudinal gastrotomy.
Long-term care for a patient with a hx of esophageal varices bleed
Oral beta-blockers can reduce portal HTN and reduce incidence of rebleeding. If pt is Child's class A, you can consider portosystemic shunting, which will delay the need for liver transplant 5-10 years.
How do you work up a patient with newly diagnosed gastric lymphoma?
Chest/abdominal CT, bone marrow biopsy, enlarger peripheral LN biopsy and examination of Waldeyer ring in oropharynx for staging.