Barium esophagram with fluoro
waht is the best test to perform when a person has achalasia(impairment of swallowing)
*Schatzki's ring is an extra fiberous tissue that has developed, this is an actual physical problem. This is different from acholasia which is a nervous system problem. W/Schatzkis ring, the treatment is to break up the tissue.*
***What is schatskys ring***
Proximal to the ligament of treitz
an upper GI bleed is described as a bleed that occurs____________
Melena-passage of tarry or maroon stool. It can mean an upper or lower gi bleed, but more commonly an upper GI bleed
What is melena? what does it usually mean?
Bright red blood per rectum
Usually characteristic of colonic hemorrhage
What is hematochezia? What does it signify?
PUD, gastritis, varicies from hypertension, mallory-weiss tears, esophagitis, malignancy, Boerhaave Syndrome, Nasopharyngeal bleed
What is in the Diff Dx for Upper GI bleed?
A superficial tear in the esophagus.
Wiki:bleeding from tears (a Mallory-Weiss tear) in the mucosa at the junction of the stomach and esophagus, usually caused by severe retching, coughing, or vomiting.
**What is a Mallory Weiss tear?*
"varicies are like hemmorrhoids in the esophagus"
Wiki:esophageal varices are extremely dilated sub-mucosal veins in the lower esophagus. They are most often a consequence of portal hypertension, commonly due to cirrhosis; patients with esophageal varices have a strong tendency to develop bleeding.
What are varicies?
A test to check for hepatic encephalopathy. Stand with arms outstretched with wrists extended. Should be able to do this w/out a "flapping tremor"
What is asterixes? What does it check for?
If anemic and symptomatic, give blood
Place NGT/lavage (helps for endoscopy)
GI Consult for Upper endoscopy (EGD)
If visible clot, visible vessel, or active bleeding, should cauterize/coagulate or inject sclerosing agent
For acute variceal bleeding: endoscopic band ligation & sclerotherapy or somatostatin. For prophylaxis of variceal bleeding: beta-block
Start proton pump inhibitor (PPI) infusion
What is the management for an Upper GI bleed?
BUN would go up due to recycling of RBC, but creatinine should stay the same
If you have a GI bleed, what will you find in a Basic Metabolic Panel/chem 7?
Bun,creatine,chloride, Co2,Glucose, Potassium, Sodium
What do you see on a basic metabolic panel/chem7
Always, perform ABC's first & resuscitate with IVF as needed
NGT/lavage to confirm active bleeding
Focused H&P looking for common causes: ulcers, varices, "-itis", Mallory-Weiss, AVM
Endoscopy is 1st line for acute UGI-Bleed
Don't forget to start intravenous PPI infusion
Endoscopy has associated complications-perfuration
Surgery if still bleeding
Take Home Points - Acute GI bleed
Histamine,Acetylcholine, and Gastrin
What are the 3 main components that help in acid production in the stomach?
mucus-bicarbonate layer ---- serves as a physiochemical barrier to multiple molecules.
It is made up of 95% water and bicarb.
what is the pre-epithelial defense system in the gut?
HCO3- ----neutralizing acid
metabolism - removal of toxic metabolic by-products
mucosal microvascular system plays a key role
providing HCO3- from circulation
providing micronutrients and O2 for removal of toxic metabolic by-products
what makes up the subepithelial defense system
A circumscribed ulceration of the gastrointestinal mucosa occurring in areas exposed to acid and pepsin and most often caused by Helicobacter pylori infection
A _______ is a mucosal break, 3 mm or greater, that can involve the stomach or duodenum
H pylori, NSAIDs, acid, and pepsin.
The most important contributing factors for Peptic ulcers are____________________
an oversecretion of acid; impairment of mucosal protection
In duodenal ulcers there is ________; while in gastric ulcers there is an ________
tachycardia + orthostasis
vomiting leading to dehydration
active GI bleeding
severe tender, board-like abdomen which usually means a perforation
PUD- physical examination. What might you see?
Endoscopy, Barium study, Serum gastrin and acid analysis, screen for NSAID use, H-pylori workup
How do you DX pud?
occurs 1-3 hours after a meal and may awaken patient from sleep. Pain is relieved by food, antacids, or vomiting
b/c they contain Urease for protection. Urease converts Urea+H2O to Co2+NH3(amonium) which can be picked up on breath test.
why can you do a breath test for H. Pylori.
PPI+ amoxicillin and clarithromycin. It comes in a "prep pack" This costs about $300-500. Take for 14 days.
What is normal H Pylori treatment?
Tetracycline, Metronidazole, Omeprazole, Bismuth. Take for 14 days
What is the "cheap" H pylori treament?
a syndrome characterized by delayed gastric emptying in the absence of mechanical obstruction of the stomach.
Anything that cause nerve problems...
surgery on the stomach or vagus nerve
anorexia nervosa or bulimia
medications—anticholinergics and narcotics—that slow contractions in the intestine
smooth muscle disorders, such as amyloidosis and scleroderma
nervous system diseases, including abdominal migraine and Parkinson's disease
metabolic disorders, including hypothyroidism
idiopathic gastroparesis, ie the cause is unknown
****Nondiabetic causes of gastroparesis**
***vomiting of undigested food—sometimes several hours after a meal,abdominal bloating
** good sign of gastropoesis?
This test involves eating a bland meal, a small amount of a radioisotope. When more than 10 percent of the meal is still in the stomach at 4 hours, the diagnosis of gastroparesis is confirmed.
What is Gastric emptying scintigraphy
Metoclopramide-caution w/tardive dyskinesia
Erythromycin-works by increasing the contractions that move food through the stomach.
Treatments for gastropoesis?
area in the brain by the vomitting center in post brain stem. It has "holes or finestrations" that form a weak blood brain barrier and is succeptible to infection.
what is the "area postrema"
Know these but there are more:
name some of the drugs that can cause Nausea and vommiting.
Ondansetron(used in chemo induced n/v) ,promethazine(phenergan)
what 2 drugs does Dr. Barron use for antiemetics?
1 dose 2 times a day. Give it on an empty stomach, then make them eat after 30-60 mins. The proton pumps have to be turned on in order for PPI's to work. Proton pumps only turned on w/food.
What is the maximum dose of PPI?
Vague symptoms- early satiety, abdominal (epigastric) pain, bloating, dyspepsia, wt loss, anorexia
GI bleeding, microcytic anemia, vomiting if GOO present
clinical features of gastric cancer?
"In individuals with ______ the opening of the esophageal hiatus is larger than normal, and a portion of the upper stomach slips up or passes through the hiatus and into the chest
a superficial leasion in the esophageal mucosa. Does not go deep, but there is a lot of bleeding. Usually from severe retching from alcohol abuse. This is usually self limiting
mallory weiss syndrome
this is a deep leasion/cut/tear throught the esophageal muscle. Most test ?'s have mallory weiss as the answer w/Boorhaves being the distractor. BUT, if the pt hemmorrhages and dies, they probably had Boerhaave's.