Approach to patient with GI bleed

What are some things that can cause a black, tarry stool (often mistakened as false positive for melena)

- IRON - Bismuth - Spinach - Licorice - Charcoal - BLUEBERRIES

RECALL: PPIs all end in the word _____

-PRAZOLE

RECALL: H2 antagonists all end in the word _______

-TIDINE

List 3 clinical clues that will help you identify a duodenal ulcer

1) BURNING epigastric pain 2) Pain decreases WITH FOOD 3) Pain is usually worse at night (when food is gone)

List the three main complications of duodenal ulcers

1) Bleeding 2) Perforation 3) Pancreatitis

TEST: List at least 5 most common DDx for a lower GI bleed (hematochezia)

1) Diverticulosis 2) Angiodysplasia 3) HEMORRHOIDS, anal polyps/fissures 4) Irritable Bowel Disease 5) Ischemic colitis 6) Colorectal carcinoma/adenomatous polyps

List three areas where portal HTN can back up to

1) Gut (L. gastric --> esophageal v) 2) Butt (Superior rectal --> mid/inf rectal) 3) Abdomen (paraumbilical)

List the two most common causes of peptic ulcers

1) H. pylori infections 2) NSAID/aspirin use

What are the two types of hemorrhoids? Which one usually causes bleeding?

1) Internal (In general cause BLEEDING, no pain) 2) External (below the dentate line) - Usually PAINFUL

TEST/TEST: What are the two complications of diverticulosis?

1) Massive bleeding 2) Diverticulitis

TEST: List four complications associated with H. pylori infection

1) Peptic ulcer disease 2) Gastritis B 3) Gastric adenocarcinoma 4) B cell lymphoma

TEST: What are the 5 most common causes of upper GI bleeding?

1) Peptic ulcer disease (50%) 2) Varices 3) Gastritis (acute/chronic) 4) Esophagitis (covered w/ epigastric pain) 5) Mallory-Weiss Tear (tear of lower esophagus)

TEST: What are four tests for diagnosing H. pylori infections? Which one is the gold standard?

1) Urea breath test (for active disease) 2) Serology 3) Stool antigen test 4) Gastric biopsy (GOLD STANDARD)

The pH of the stomach is typically around ____, and the use of PPIs will (increase/decrease) this pH

1-3 With PPIs, pH will INCREASE (4-5)

Colonoscopy screening usually starts at age ___

50

Card number 69

69 69 69 69 69

AGAIN: Long term H. pylori infections can lead to what type of cancer?

ADENOCARCINOMA

TEST: Angiodysplasia usually causes (upper/lower) GI bleeding, occurs in the (young/elderly), and can be detected with either a ______ or an _________

Angiodysplasia usually causes LOWER GI bleeding, occurs in the ELDERLY, and can be detected with either a COLONOSCOPY or an ANGIOGRAM

BAORDS: Angiodysplasia is usually associated with heart condition?

Aortic stenosis

What is the standard quadruple therapy for an H. pylori infection?

BMTP - Bismuth - Metronidazole - Tetracycline - PPI

AGAIN: Hematochezia usually presents as (dark/bright red) blood coming from the rectum

BRIGHT RED

What is the preferred method of diagnosing diverticulosis?

Barium enema/colonoscopy

Serology testing for H. pylori (can/cannot) distinguish between active vs chronic disease

CANNOT

What is the standard triple therapy for H. pylori infection?

CAP - Clarithromycin - Amoxicillin - PPI

Thumb-printing on a barium enema of the colon is indicative of _____

COLITIS (can be any type)

Curling's ulcers are due to ____, while Cushing's ulcers are due to ____ injury

Curling's: BURNS Cushing's: CNS

TEST: The majority of all ulcers are (gastric/duodenal) ulcers

DUODENAL

RECAP: What is the gold standard in diagnosing a duodenal ulcer?

EGD

TEST/TEST: If a patient presents with hematemesis and melena, what is the NEXT BEST test?

EGD

The official term for sticking an endoscopy into the upper GI tract is called what?

EGD (EsophagoGastroDuodenoscopy) Can also called it an Upper endoscopy (but you cannot call it an UPPER GI, because that is when you do a barium swallow)

AGAIN: An upper endoscopy is also called a _____

EGD (Esophagogastroduodenoscopy)

RECAP: What is the gold standard in diagnosing a gastric ulcer?

EGD + biopsy

Ischemic colitis usually presents in the (young/elderly)

ELDERLY

TRUE or FALSE: Colonoscopy is a lower GI

FALSE Lower GI series = Barium ENEMA

TRUE or FALSE: Stool is well-formed by the time it enters the cecum

FALSE!

TRUE or FALSE: Diverticulosis is also known as diverticulitis

FALSE! Diverticulosis = Massive bleeding Diverticulitis = Just like appendicitis, except on the L side (no bleeding, elevated WBC, painful)

TRUE or FALSE: Stress is one of the most common cause of peptic ulcer disease

FALSE!!

TRUE or FALSE: H. pylori both colonizes and invades the mucus layer lining of the GI tract

FALSE, it only colonizes and it does NOT invade

TRUE or FALSE: Peptic ulcer disease is the same thing as gastric ulcers

FALSE, peptic ulcer disease (PUD) encompasses both GASTRIC and DUODENAL ulcers (as well as ESOPHAGEAL ulcers)

TRUE or FALSE: Diverticula bleeds are commonly seen in the office

FALSE, there is usually massive bleeding so they will usually be in an ER setting

What does FOBT stand for?

Furry orange bunny tails Fecal-Occult Blood Testing

RECALL: G cells secrete ______, which goes to the _____ cells to stimulate ____ secretion, which (increases/decreases) the pH

G cells secrete GASTRIN, which goes to the PARIETAL cells to stimulate HCl secretion, which DECREASES the pH

80% of gastric ulcers are caused by __.____ infections, while 20% are caused by ______

GASTRIC ulcers: - 80% = H. pylori - 20% = NSAIDs

TEST: If a patient is taking ibuprofen for weeks to months, they are more likely to develop a (gastric/duodenal) ulcer

GASTRIC!!!!!!!!!!!!! - More % of NSAID causing gastric ulcer vs duodenal ulcer

TEST/TEST: 95% of all duodenal ulcers are caused by what? What is the clinical implication of this?

H. PYLORI Clinical implication: If a patient comes in and you find a duodenal ulcer but H. pylori testing is negative, you STILL treat them! (You don't want them coming back next week again with a duodenal bleed, because the prevalence of H. pylori causing duodenal ulcers is so high!!)

Acute gastritis is predominantly caused by what?

H. PYLORI infections!!!!!!!!!!

H. pylori colonization can cause intestinal ________ (specifically the _____ cells), which is a precursor for developing _________ (type of cancer)

H. pylori colonization can cause intestinal METAPLASIA (specifically the GOBLET cells), which is a precursor for developing ADENOCARCINOMA

TEST: H. pylori is a _____ shaped gram (positive/negative) bacteria that produces ______ which is measured on breath test

H. pylori is a SPIRAL shaped gram NEGATIVE bacteria that produces UREASE (measured on breath test) It also produces PROTEASE and CYTOTOXINS

Upper GI bleeding common causes (hematemesis/hemoptysis)

HEMATEMESIS

AGAIN: (Melena/hematochezia) is usually associated with a lower GI bleed

HEMATOCHEZIA

What is the most likely cause of bleeding in a 38 year old obese female who presents to the CLINIC (not ER) and has a long standing history of constipation with no abdominal pain and no meds?

Hemorrhoids/polyps

Internal hemorrhoids are usually a cause of (upper/lower) GI bleed

LOWER GI bleed

GI bleeding is split into upper and lower based on what anatomical landmark? What is the function of this landmark?

Ligament of TREITZ Function: Suspends the fourth part of the duodenum to the R crus

RECALL: What is the main cause behind esophageal varices?

Liver cirrhosis backs up the PORTAL system through the portacaval anastomoses, which will dilate the gastric v which drains the esophagus (via the esophageal v)

What are some risk factors for an H. pylori infection?

Low socioeconomic status Household crowing Developing countries (vs industrialized)

Ulcers are defects in the mucosa of the stomach or small intestine that extend through the ________ _______

MUSCULARIS MUCOSAE

TEST: What is the difference between melena and hematochezia?

Melena: OLD blood, BLACK tarry stools - Usually UPPER GI bleed Hematochezia: NEW blood, RED bloody stools - Usually LOWER GI bleed (however could be upper GI bleed if it happens quick enough)

Most of the bleeding from diverticulosis comes from the ____ colon, which is usually why there is (bright red/dark) bleeding

Most of the bleeding from diverticulosis comes from the SIGMOID colon, which is usually why there is BRIGHT RED bleeding

AGAIN/TEST: What is a Mallory-weiss tear? What is the typical patient presentation?

Mucosal TEAR at the DISTAL ESOPHAGUS Patient presentation: Alcohol/food poisoning causing RETCHING, which causes the actual tear in the lower esophagus --> HEMATEMESIS "Nausea and vomiting preceding hematemesis"

GI bleeding is blood loss anywhere from the ______ to the ____

OROPHARYNX to ANUS

AGAIN: Diverticulosis presents with (painful/painless) bleeding

PAINLESS

Esophageal varices produces (painful/painless) hematemesis

PAINLESS

RECALL: What cells in the stomach produce HCl?

PARIETAL cells

Which cells actually contain the proton-pumps that are commonly inhibited with PPIs?

PARIETAL cells!

Explain why you would give PPIs to treat pancreatitis

PPIs elevate the pH to 4-5, so that when the contents get into the duodenum, it WON'T stimulate SECRETIN (which is normally stimulated by acid) - No secretin stimulation means no stimulation of the pancreas!

TEST: What is the most common cause of elevated gastrin levels?

PPIs!!! PPIs raise the pH to 4-5, which will stimulate G cells to secrete gastrin, which will stimulate HCl secretion

TEST: What is the number one cause of gastric polyps?

PPIs!!!!! Continuous use of PPIs will cause the parietal cells to ENLARGE because it will be constantly required to secrete more HCl, and over time it will become HYPERPLASTIC and develop into a POLYP!

Capsule endoscopy are for (small/large) intestines

SMALL

Meckel's Diverticulum usually causes bleeding in the (small/large) intestine

SMALL

BOARDS: What is the best screening test for ZE syndrome?

Serum GASTRIN levels

Besides H. pylori infections, 5% of duodenal ulcers are caused by what?

Slide says: Zollinger-Ellison Syndrome First Aid says: Zollinger-Ellison Syndrome He says: NSAIDS (said slide was typo)

H. pylori infections are usually treated with _____ or ______ therapy. Briefly describe what this is.

TRIPLE or QUADRUPLE therapy: - Usually involves 2 antibiotics and a PPI - Can substitute 2nd PPI for bismuth salicylate

TRUE or FALSE: You can't have an anal fissure without pain

TRUE, anal fissures are PAINFUL

TRUE or FALSE: H. pylori infection prevalence increases with age. Why or why not?

TRUE, simply because there is MORE years of EXPOSURE

What are you actually measuring for in a urea breath test?

The CO2 levels, which is produced by UREA breakdown into ammonia and CO2 by UREASE (which is produced by H. pylori!)

What is angiodysplasia? Does this usually occur in the young or the elderly?

Tortuous veins in the colonic submucosa Usually occurs in the ELDERLY

TEST/TEST: (Acute/chronic) gastritis has two main types. What is each type predominantly caused by?

Type A - Autoimmune (Pernicious Anemia), body-dominant Type B - H. pylori infections, antrum-dominant (type B for Bacterial)

AGAIN: 90% of the time, melena is representative of a(n) (upper/lower) GI bleed

UPPER

Ischemic colitis will present (with/without) pain

WITH pain (can't have ischemia without pain)

AGAIN: Diverticulosis presents (with/without) pain and (with/without) bleeding

WITHOUT pain, WITH bleeding DiverticuLITIS is WITH pain, NO bleeding

Gastric ulcers get (better/worse) with eating, so typically the patient will (gain/lose) weight

WORSE, so typically the patient will LOSE weight

What is Zollinger-Ellison syndrome? What is the pathophysiology behind it, and what is the number one clinical presentation?

ZE syndrome refers to MALIGNANT PANCREATIC islet cell tumors Pathophys: Excess GASTRIN --> hyperacidity Number one clinical presentation: MULTIPLE RECURRENT ULCERS