Upper Gastrointestinal Disease Bradley J. Phillips, MD Burn-Trauma-ICU Adults & Pediatrics

CASE 1 A 46 year old businessman is brought to the Emergency Room with the sudden onset of severe generalized abdominal pain occurring one hour previously.

CASE 1 List your tentative differential diagnosis and how you would proceed to arrive at the correct diagnosis.

CASE 1 A 46 year old businessman is brought to the Emergence Room with the sudden onset of severe generalized abdominal pain occurring one hour previously. Vital signs are: BP 100/60, P 120, RR 28.

CASE 1 List your tentative differential diagnosis and how you would proceed to arrive at the correct diagnosis.

CASE 1 A 46 year old businessman is brought to the Emergence Room with the sudden onset of severe generalized abdominal pain occurring one hour previously. Vital signs are: BP 100/60, P 120, RR 28. He is pale and sweaty with a rigid tender abdomen and no bowel sounds.

CASE 1 List your tentative differential diagnosis and how you would proceed to arrive at the correct diagnosis.

CASE 1 Discuss your initial resuscitative treatment of this patient. What are you trying to accomplish, and how can you measure the effectiveness of your efforts?

CASE 1

Assuming that X-ray shows free air and initial resuscitation has been successful, what further treatment would you recommend? Are there alternatives? Describe them.

CASE 1 Definitions or Semantics? Fuzzy Thinking? –Treat conservatively –Treat Medically –Treat Surgically –Treat radically –Treat Operatively –Treat Non-operatively

CASE 1 What are common and uncommon causes of free air in the abdomen?

CASE 1 Assuming that free air was not present, what other “surgical” and “non-surgical” conditions could cause this clinical picture?

CASE 2 A 75 year old patient presents with a ten-day history of vomiting almost everything that he has eaten or drunk.

CASE 2 A 75 year old patient presents with a ten-day history of vomiting almost everything that he has eaten or drunk. He appears weak, dehydrated and moderately ill.

CASE 2 A 75 year old patient presents with a ten-day history of vomiting almost everything that he has eaten or drunk. He appears weak, dehydrated and moderately ill. The abdomen is soft and scaphoid with normal bowel sounds and no palpable masses.

CASE 2 A 75 year old patient presents with a ten-day history of vomiting almost everything that he has eaten or drunk. He appears weak, dehydrated and moderately ill. The abdomen is soft and scaphoid with normal bowel sounds and no palpable masses. Rectal exam is negative with no stool in the ampulla.

CASE 2 (cont.) An upper GI series shows a dilated stomach with only a trickle of barium passing through a deformed duodenal bulb.

CASE 2 (cont.) An upper GI series shows a dilated stomach with only a trickle of barium passing through a deformed duodenal bulb. Labs show: –Hct 56%, WBC 7500

CASE 2 (cont.) An upper GI series shows a dilated stomach with only a trickle of barium passing through a deformed duodenal bulb. Labs show: –Hct 56%, WBC 7500 –Na 130, K 2.0, Cl 79, HCO3 35

CASE 2 (cont.) An upper GI series shows a dilated stomach with only a trickle of barium passing through a deformed duodenal bulb. Labs show: –Hct 56%, WBC 7500 –Na 130, K 2.0, Cl 79, HCO3 35 –ABG: 7.50, 44, 98

CASE 2 (cont.) An upper GI series shows a dilated stomach with only a trickle of barium passing through a deformed duodenal bulb. Labs show: –Hct 56%, WBC 7500 –Na 130, K 2.0, Cl 79, HCO3 35 –ABG: 7.50, 44, 98 –BUN: 42

CASE 2 What is your tentative diagnosis?

CASE 2

What is your tentative diagnosis? Explain the abnormal lab data. –Hct 56% –Na 130, K 2.0 Cl 79, HCO3 35 –7.50, 44, 98 –BUN 42

CASE 2 What is your tentative diagnosis? Explain the abnormal lab data. –Hct 56% –Na 130, K 2.0 Cl 79, HCO3 35 –7.50, 44, 98 –BUN 42 Discuss your initial treatment.

CASE 2 What is your tentative diagnosis? Explain the abnormal lab data. –Hct 56% –Na 130, K 2.0 Cl 79, HCO3 35 –7.50, 44, 98 –BUN 42 Discuss your initial treatment. Discuss the definitive treatment of this condition.

CASE 3 A 70 year old woman presents to your office with a history of weight loss,...

CASE 3 A 70 year old woman presents to your office with a history of weight loss, decreased appetite, and epigastric discomfort.

CASE 3 A 70 year old woman presents to your office with a history of weight loss, decreased appetite, and epigastric discomfort. Examination reveals her to be thin but not cachectic and the stools to be positive for occult blood.

CASE 3 A 70 year old woman presents to your office with a history of weight loss, decreased appetite, and epigastric discomfort. Examination reveals her to be thin but not cachectic and the stools to be positive for occult blood. An upper GI series reveals a gastric cancer on the greater curvature.

CASE 3

What further workup is indicated for this patient?

CASE 3 What further workup is indicated for this patient? How do pathophysiology and symptoms of gastric ulcer differ from those of a duodenal ulcer?

CASE 3 What further workup is indicated for this patient? How do pathophysiology and symptoms of gastric ulcer differ from those of a duodenal ulcer? What is the relative risk of malignancy from a duodenal versus a gastric ulceration?

CASE 3 Does the exact location of the gastric ulcer have any significance?

CASE 3 Does the exact location of the gastric ulcer have any significance? What are the possible histologic types of gastric malignancy, and how do they differ in terms of epidemiology, risk factors, diagnosis, treatment and prognosis?