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Upper GI Disease

Upper GI Disease. Lori F Gentile. Definitions. UGIH = proximal to ligament of Treitz Hematemesis = vomiting blood - bright red or coffee-ground (typically UGI source) Melena = black tarry stool (often UGI) Enzymatic breakdown Hematochezia = bloody stool (LGI > UGI)

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Upper GI Disease

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  1. Upper GI Disease Lori F Gentile

  2. Definitions • UGIH = proximal to ligament of Treitz • Hematemesis = vomiting blood - bright red or coffee-ground (typically UGI source) • Melena = black tarry stool (often UGI) • Enzymatic breakdown • Hematochezia = bloody stool (LGI > UGI) • Blood as cathartic agent • Occult blood = UGI or LGI source

  3. DDx- UGI Bleed • Peptic Ulcer Disease (PUD) >50% cases • Gastritis / Duodenitis (15-30%) • Subset due to NSAID use • Esophageal varices from portal hypertension (10-20%) • Gastric varices • Mallory-Weiss tears at GE junction (5%) • Esophagitis (3-5%) • Malignancy (3%) • Dieulafoy’s lesion (1-3%) • Nasopharyngeal bleed – swallowed blood

  4. Initial Evaluation • Evaluate ABCs/PE: • Can the pt protect his airway? • Is the pt hemodynamically unstable? • Does the pt have adequate IV access, Foley, NGT? • Resuscitate as appropriate • Orders: NPO, IVF, NGT to LCWS, Foley, HOB>30, continuous pulse oximetry & telemetry • Labs: type & cross, CBC, INR/PT/PTT, BMP, LFTs • Additional question to ask yourself: • Does the pt require a higher level of care?

  5. H&P • Risk factors: age, oral anticoagulant use, h/o prior GIB, PUD, NSAID use, alcohol/tobacco use, liver disease / portal HTN, burn/trauma, severe vomiting, h/o H. pylori, GI instrumentation, AAA repair • History: HPI, PMHx, PSHx, Meds, ALL, SHx. • Symptoms: none  postural hypotension, exertionaldyspnea • Coffee ground emesis (UGI) • PE: remember to examine for signs of cirrhosis & portal HTN (ascites, caput medusa, rectal varices) • Tests: T&C, CBC, coags, BMP, LFT, CXR/KUB

  6. Management • NGT/lavage -can identify UGI bleed • Start proton pump inhibitor (PPI) infusion • EGD-visualize bleeding source and treat • Tx- sclerotherapy, epinephrine, banding, cautery • For varices: octreotideinfusiom -Reduces portal pressure, vasoconstricts • Tagged pRBC scan if cannot localize source • More sensitive than angiography, Can detect bleeding rate > 3-10mL/hr • AngiographyAngiography (Diagnostic & Therapeutic) • Intra-arterial vasopressin • Embolization • Can detect bleeding rate > 30-50mL/hr • If pt unstable and continues to require blood->consider OR

  7. PUD • Most freq cause of UGI bleed • Usually in 1st part of duodenum • Anterior-perforate • Posterior-bleed from GDA • Spontaneous resolution in 80-90% • OR – perforation, refractory bleeding, obstruction, Inability to identify bleeding source • Surgery – • Duodenostomy, GDA ligation • Truncalvagotomy and pyloroplasty

  8. Long-Term Management • Test for H. pylori. Treatment = amoxicillin, clarithromycin, and PPI • Limit NSAID use • H2B, PPI

  9. Esophagus • Zenker’sDiverticulum– b/w cricophayngeas and pharyngeal constrictors • Sx- dysphagia, choking, halitosis, regurgitation of chewed food • Dx: barium swallow • Tx: cricopharyngealmyotomy +/- diverticulectomy • Achalasia- failure of peristalsis and LES relaxation • Sx- dysphagia, regurgitation, weight loss, respsx • Dx- manometry (inc LES pressure, incomplete LES relaxation, no peristalsis) • Tx- Medical- CCB, dialation, botox, Surgical-Heller myotomy • GERD – Surgery for failure of med mgt, stricture, Barrett’s esophagus • Dx- endoscopy, PH probe, manometry, UGI (make sure no motility d/o) • Tx- Nissenfundoplication 360 degree wrap

  10. Other Esophagus • Para-esophageal hernia – 4 types, must repair type 2. Repair with patch and Nissen • Esophageal Cancer – • Dx with endoscopy and biopsy followed by CT C/A • Adenocarcinoma – lower 1/3, most common • Squamous cell – upper 2/3, h/o etoh/tobacco use • Tx • T1- esophagectomy +/- adjuvent C/R • T2 – Gray area – If + Nodes then neoadjuvent C/R, esophagectomy • T3/T4 – Neoadjuvent C/R followed by esophagectomy +/- adjuvent therapy

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