Acute upper gastrointestinal haemorrhage

-This is the most common gastrointestinal emergency.
-The mortality of patients admitted to hospital is about 10%.
-Haematemesis is red with clots when bleeding is rapid and profuse, or black (‘coffee grounds’) when less severe.
-Syncope may occur and is caused by hypotension from intravascular volume depletion.
-Symptoms of anaemia suggest chronic bleeding.
-Melaena is the passage of black, tarry stools containing altered blood.
-It is usually caused by bleeding from the upper gastrointestinal tract,(about 60-100ml) although haemorrhage from the right side of the colon is occasionally responsible.
-The characteristic colour and smell of melena are the result of the action of digestive enzymes and of bacteria on haemoglobin.

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In case of Acute Upper GIT bleeding:

-Risk scoring systems have been developed to stratify the risk of needing endoscopic therapy or of having a poor outcome.

-The advantage of the Blatchford score is that it may be used before endoscopy to predict the need for intervention to treat bleeding.
-Low scores (2 or less) are associated with a very low risk of adverse outcome.

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•Mackler triad (esp. in Boerhaave syndrome) in Esophageal Perforation:

1-Vomiting and/or retching
2-Severe retrosternal pain that often radiates to the back
3-Subcutaneous or mediastinal emphysema:
crepitus in the suprasternal notch and neck region or crunching/crackling sound on chest auscultation (Hamman sign).

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•Extra-esophageal symptoms (respiratory )of GERD:

1-Reflux-induced Asthma.
2-Chronic Cough.
3-Aspiration pneumonia.
4-Recurrent laryngitis.
5-Pulmonary fibrosis.
6-Hiccups.
7-Pharyngeal & laryngeal irritation horsiness of voice.
8-Otitis media.

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•Complications of Barrett’s oesophagus:

1-Ulcerations and stricture
2-Dysphagia
3-Bleeding
4-Perforation
5-Adenocarcinoma of O-G junction (25 times more common).

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Note:

-Normal resting LOS pressure is 10–25 mmHg.
-During swallowing, pressure drops to 1–3 mmHg for few seconds (10 seconds).

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CONTRAST STUDY OF OESOPHAGUS:

Types
1.Barium swallow using barium sulphate (thick paste).

2.Using water-soluble contrast like ‘Gastrografin’.

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•Indications of Barium swallow:

1-Dysphagia due to motility disorder like achalasia, diffuse oesophageal spasm.
2-Dysphagia due to mechanical causes like carcinoma, benign strictures and neoplasms, external compression.
3-Pharyngeal pouch and other diverticula.
4-GORD.

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#Surgery

•Indications of Water-soluble contrast radiograph:

1-In suspected oesophageal perforation.
2-Leaking oesophageal anastomosis.

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•Important Findings in Barium Swallow


1-Achalasia cardia—‘Bird beak’ appearance, as the oesophagus is grossly dilated above an apparent narrowing at the cardia. In longstanding cases—‘sigmoid oesophagus’.
2-Diffuse oesophageal spasm—Corkscrew appearance.
3-GORD—shows reflux when done in Trendelen burg’s position.
4-Oesophageal carcinoma—irregular stenosing lesion with shouldering (‘Rat tail’ is a fluoroscopic finding).
5-Pharyngeal pouch—demonstration of the pouch.
6-External compression—indentation of barium column by superior or posterior mediastinal mass, enlarged left atria as in mitral stenosis.

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#Radiology

•In Esophageal Carcinoma:

-It is 6th most common cancer in the world.
-It is less than 1% of all cancers.
-It is 7% of all GI malignancies.
-Common in:
Middle third—50%.
Lower third—33%.
Upper third—17%.

-Recent onset of dysphagia is the commonest feature.

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#GIT

•Helicobacter pylori infection, which can cause stomach cancer, has not been associated with esophageal cancer.

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•24-hour pH recording is the ‘gold standard’ for diagnosis of GORD.

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Saphina varix :

-It is a dilatation of the termination of the long saphinous vein or one of its major tributaries.
-It shows as a blue tinged bulge in the groin that disappears on lying flat .

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#Vascular

•Gaiter region

The skin over the lower medial third of the leg ( skin just above the medial malleolus ) .

It's the most common site for venous ulcerations.

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#Vascular

Corona phlebectatcia " Ankle flare ",
When There's considerable dilatation of the intercutaneous veins BELOW the ankle in limbs with venous hypertension.

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#Vascular

Ogilvie syndrome .

is the acute dilatation of the colon in the absence of any mechanical obstruction in severely ill patients.

This is a CT-Scan showing a coronal section of the abdomen of an elderly woman with Ogilvie syndrome .

Acute colonic pseudo-obstruction is characterized by massive dilatation of the cecum (diameter > 10 cm) and right colon on abdominal X-ray.
It is a type of megacolon, sometimes referred to as "acute megacolon" to distinguish it from toxic megacolon.

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#GIT

Once you see the Earthy face of a Renal failure patient , you will never forget it.

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#UT

Remember:

-The best fluid replacement incase of hemorrhagic shock is Cross matched blood .

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-The most common cause of hypercalcemia in outpatients is hyperparathyroidism.

-The most common cause of Hypercalcemia in hospitalised patients is malignancy .

-The most common malignancy leading to hypercalcemic crisis is breast cancer.

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#Endocrine

•Whipple's triad

-Typical presentation of insulinomas.
Consists of :

1-Symptomatic fasting hypoglycemia.

2-Plasma glucose less than 50 mg/dl during the attack .

3-Dramatic improvement after administration of glucose.

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#Endocrine