Endoscopic management of upper GI bleed

Forrest classification helps to predict who is at high-risk of re-bleed
1a: active, pulsatile bleeding. 50-90% rebleed
1b: active, non-pulsatile bleeding, 10-50% rebleed

2a: no active bleed, visible vessel. high risk rebleed (50-80%)
2b: adherent clot. low risk rebleed

3: no visible stigmata of bleeding. low risk rebleed

If you inject high risk lesions with 1:10,000 epinephrine risk of rebleed ~10-30%
other option is endoscopic coagulation or clips

Reasonable to repeat endoscopy in the case of rebleed

Consider OR if:
- large ulcer
- large bleeding vessel
- eldery >60
- active hemorrhage
- hypotension

angiography plays little role in controlling gastric ulcer bleeding as the vascular network is too rich

Perioperative Cardiac Risk Assessment

Assessment:
- History, physical
- Resting 12 lead ECG
- should be enough to stratify patients into low, intermediate and high cardiac risk

Risk of cardiac death and nonfatal MI also depends on procedure:
High risk >5%:
- Emergency operations (particularly in elderly)
- aortic, major vascular, peripheral vascular surgery
- Extensive operations with large volume shifts or blood loss

Intermediate risk <5%
- intraperitoneal or intrathoracic
- CEA
- H&N surgery
- Orthopedic
- Prostate

Low (<1%:
- endoscopic procedures
- superficial biopsy
- Cataract
- Breast surgery

Some merit has been shown in perioperative B-blockade to reduce perioperative cardiac risk.
The POISE study was reviewed in EBRS
- at adose of Metoprolol 100mg BID there is cardioprotective effect at this dose (lower doses do not afford same protective effects)
- however, patients need to be aware of the increased risk of hypotension, stroke and death

MAnagement of perioperative MI:
- STEMI: should be revascularized ASAP (within 12 hours). In post-op pt this likely means angiography as early post-op pts may not be eligible for throbolytics
- NSTEMI: stabilize medically and undergo risk stratification when stable
- Therapy with ASA, B-blocker and often ACEi (particularly in pts with low EF or anterior MI)
- Most post-MI pts should also be placed on a statin at discharge.

CHOP

Chemotherapeutic regimen for treatment of non-hodgkin's lymphoma

CHOP consists of:

• Cyclophosphamide, an alkylating agent which damages DNA by binding to it and causing cross-links
• Hydroxydaunorubicin (also called doxorubicin or Adriamycin), an intercalating agent which damages DNA by inserting itself between DNA bases
• Oncovin (which is the trade name for vincristine), which prevents cells from duplicating by binding to the protein tubulin
• Prednisone or prednisolone is a corticosteroid.

Normal cells are more able than cancer cells to repair damage from chemotherapy drugs.

This regimen can also be combined with the monoclonal antibody rituximab if the lymphoma is of B cell origin; this combination is called R-CHOP or CHOP-R. Typically, courses are administered at an interval of two or three weeks (CHOP-14 and CHOP-21 respectively). A staging CT scan is generally performed after three cycles to assess whether the disease is responding to treatment.

In patients with a history of cardiovascular disease, doxorubicin (which is cardiotoxic) is often deemed to be too great a risk and is omitted from the regimen. The combination is then referred to as COP (cyclophosphamide, Oncovin, and prednisone or prednisolone) or CVP (cyclophosphamide, vincristine, and prednisone or prednisolone).

Radiation Proctitis

Can result from external beam radiation or brachytherapy for cervical or prostate cancer.
Radiation oncologists can try and reduce incidence by using differential dosing during radiation or by using spacer techniques to increase distance between treated organ and rectum.

Complications of radiation proctitis include:
- bleeding
- tenesmus
- stricturing
- incontinence
- fistulas
- diarrhea

Mild radiation proctitis is usually self-limiting and decreases over time
proctitis can be acute or chronic and can present late even in the absence of immediate proctitis

Treatment options include:
- nothing
- enemas (cortisone, 5-ASA); evidence for these treatments is sparse and potentially can even cause more harm
- medium chain fatty acids
- Formalin/methanol topical application
- YAG laser
- thermal cautery
- if severe stricturing or fistulization then procetectomy or diverting colostomy maybe required

Hepatic Abscess

Potential routes for hepatic seeding are:
1) Biliary tree (currently most common)
2) Portal vein (usually GI source)
3) Hepatic artery (can be from any distant infection site/sepsis)
4) Direct extension (usually from abscess in vicinity of liver)
5) Trauma
Cryptogenic abscesses are very common and often a source is not identified

Microbiology:
most common organisms: E coli, Klebsiella pneumoniae

Antibiotic therapy and percutaneous drainage are currently the mainstays of treatment.
However, when this fails or the pt has a concomitant disease process that requires operative management, surgical drainage is indicated:
- use imaging to help guide site of drainage
- needle aspirate to confirm location and to get C&S sample (aerobic, anaerobic and gram stain - for ameobae too)
- abscess drained and finger dissection to break loculations
- biopsy wall of abscess cavity to rule out amebic trophozoites and presence of necrotic tumor
- biopsy normal liver --> presence of micro-abscesses will warrant a longer course of IV antibiotics
- closed suction drains in abscess cavity

Hypergastrinemia

Non-Ulcerogenic causes:
- Renal failure
- Atrophic gastritis
- Pernicious anemia
- Previous vagotomy
- Short-gut syndrome
- PPI

Ulcerogenic causes:
- ZES
- Retained or excluded antrum
- G-cell hyperplasia
- Gastric Outlet Obstruction

Gastrinoma

Most common site of gastrinoma:
- D2: 70%
- D1: 57%
- Pancreatic head: 27%, body: 23%, tail 50%

Gastric Ulcer Classification

Type I: Lesser curve at or proximal to incisura
Type II: 2 ulcers, Type I and an active or chronic duodenal ulcer
Type III: Located 2cm from pylorus
Type IV: Proximal stomach or gastric cardia
Type V: NSAID induced (diffuse)

Types II and III are associated with high-acid states.

Forrest Classification

1a: arterial, spurting hemorrhage

1b: Ozzing hemorrhage

2a: Visible vessel

2b: adherent clot

2c: Hematin-covered lesion

3: no signs of recent hemorrhage

Upper GI Bleed presentation:

http://fhs.mcmaster.ca/surgery/documents/gi_bleeding.pdf
Forrest class 2 lesions (Visible vessel or adherent clot will have) ~10% risk of rebleeding in first 24 hours
- risk of bleeding drops significantly in following 48-72 hours

Upper GI premalignant screening recommendations

American society of gastroenterologists recommendations:

http://www.guideline.gov/summary/summary.aspx?doc_id=9306


- Posted from iPhone

Gastric polyps

Gastric Polyps are encountered in ~3-4% of upper endoscopies

Hyperplastic polyps
- 80% of all types of polyps
- overgrowth of normal gastric epithelium
- atypic is rare and has no neoplasticism potential

Adenomatous polyps
- premalignant lesions
- risk of malignancy is 10-20% in polyps >2cm
- operative management for sessile polyps >2cm suggested.
- some centers are also using submucosal resection.

References:
- greenfield

Hashimoto's Thyroiditis

AKA: struma lymphomatosa

- transformation of thyroid tissue to lymphoid tissue

- most common inflammatory disorder of the thyroid

- most common cause of hypothyroidism

Etiology:

- autoimmune process caused by activation of CD4 T cells specific for thyroid antigens.  Innate and adaptive immune response against thyroid

Clinical Presentation

Hashimoto's thyroiditis is also more common in women (male:female ratio 1:10 to 20 ) between the ages of 30 and 50 years old. The most common presentation is that of a minimally or moderately enlarged firm granular gland discovered on routine physical examination or the awareness of a painless anterior neck mass, although 20% of patients present with hypothyroidism, and 5% present with hyperthyroidism (Hashitoxicosis). In classic goitrous Hashimoto's thyroiditis, physical examination reveals a diffusely enlarged, firm gland, which also is lobulated. An enlarged pyramidal lobe often is palpable.

Diagnostic Studies

- When suspected clinically, an elevated TSH and the presence of thyroid autoantibodies usually confirm the diagnosis.
- FNAB  indicated in patients who present with a solitary suspicious nodule or a rapidly enlarging goiter.
- Thyroid lymphoma is a rare but well-recognized, ominous complication of chronic autoimmune thyroiditis and has a prevalence 80 times higher than expected frequency in this population than in a control population without thyroiditis. Recent studies of clonal similarity indicate that lymphoma may, in fact, evolve from Hashimoto's thyroiditis.14
- Path: FNA sample will show Hurthle cells in conjunction with heterogeneous populations of lymphocytes

Treatment

Thyroid hormone replacement therapy is indicated in overtly hypothyroid patients, with a goal of maintaining normal TSH levels. The management of patients with subclinical hypothyroidism (normal T4 and elevated TSH) is controversial. Treatment is advised especially for middle-aged patients with cardiovascular risk factors such as hyperlipidemia or hypertension and in pregnant patients.15 Treatment also is indicated in euthyroid patients to shrink large goiters. Surgery may occasionally be indicated for suspicion of malignancy or for goiters causing compressive symptoms or cosmetic deformity.

Hypercalcemic Crisis

Presentation:
- severe dehydration
- hypotension,
- altered mental status
- dysrhythmias

Management:
- hydrate: normal saline at a rate of 300 ml/hr; rehydration promotes calcium excretion in proximal tubule which is associated with Na flux
- Loop diuretics: reduce fluid overload and inhibit calcium resorption in the loop of Henle, thus promoting increased renal calcium excretion. 
- Dialysis: Patients with renal failure should be dialyzed with low-calcium dialysate

Pharmacologic agents to be used after rehydration:
- Steroids: Glucocorticoids lower calcium by inhibiting effects of vitamin D, increasing renal calcium excretion, and inhibiting osteoclast-activating factor. 
- hydrocortisone is 200 to 400 mg IV per day for 3 to 5 days
- Bisphosphonates inhibit osteoclast activity, thus preventing bone resorption induced by PTH. 
- Pamidronate (90 mg IV) or zoledronic acid (4 mg IV initial treatment, 8 mg on retreatment) normalizes calcium levels in most patients
- Calcitonin acts quickly (within 24 to 48 hours) to lower serum calcium levels and is more effective when used in combination with glucocorticoids. It should not be used in patients with salmon allergies. 

After patients with PHPT and hypercalcemic crisis are stabilized and serum calcium levels have been reduced to acceptable levels, preoperative localization studies should be obtained expeditiously in anticipation of an urgent parathyroidectomy.

Cameron 9th ed

Parathyroid Hormone

Single most important regulator of calcium and phosphate homeostasis in the body.

Effects:
Direct effects on bone and kidneys
Indirect effects on intestines (mediated viaVitD)

Effects on Bone:
- complex interaction activating osteoblasts and osteoclasts
- act indrectly on osteoclasts but have direct ligands on osteoblasts
- acts first to mobilize minerals from areas of rapid equilibrium
- prolonged PTH exposure results in further bone mineralization as lysozomal and hydrolytic enzymes are synthesized

Effects on Kidney:
- PTH has 3 effects on kidneys
- increases production of alpha-hydroxolase, resulting in increased hydroxylation of cholecalciferol to calciferol.
- increases reabsorption of calcium in distal nephron (loop of henle and proximal tubule Ca reabsorption is linked to Na and not influenced by PTH)
- prevents reabsorption of both phosphate and bicarbonate

Effects on Intestine:
- indirect and results in increased calcium absorption by increased VitD hydroxylation in kidney

Feedback inhibition is regulated by calcium levels.
- increased calcium normally results in inhibition of PTH secretion
- decreased calcium levels result in increased PTH secretion

Merkel Cell Cancer

http://theghostofsnotboogie.blogspot.com/2009/12/skin-cancer-merkel-cell-carcinoma.html

Resection with 1-2 cm margins
- SLNB is bare minimum for all patients
- therapeutic LND in patients with positive SLN
- radiation to all primary tumor beds, radiation to LN basin ?depends on LN status
- chemotherapy not very effective and when to start is controversial

Adult Intussusception

Rare in adults

- risk of malignant lesion as lead point higher if colo-colonic intussusception

- If SB intussusception 60% chance of lead point being benign

Management is controversial:

- reduction of intussusception vs. en bloc resection

- if colonic intussusception then consider en bloc resection as more likely malignant lead point

- if SB intussusception then consider reduction and resection of lead point only

- id ischemia or necrosis then consider en bloc resection

- risk short-gut if extensive SB resection

Cubittal tunnel syndrome

Potential points of compression of the. Ulnar nerve.

1) Arcade of Struthers:
- thick fascism structure 8 cm proximal to the medial epicondyle between medial head if triceps and medial intermuscular septum.
- present in 70% of pts with ulnar nerve compression

2) medial intermuscular septum
- dense fascia that covers ulnar nerve as it travels in postcondylar groove

3) Osbornes's band
- leading edge of fascia that connects ulnar and humeral heads of flexor carpi ulnaris

4) aponeurosis of flexor-pronator mass
-

Examination:
- 2point discrimination, pinch and grip strength, motor strength for entire upper arm
- tinel's sign through course of ulnar nerve
- brachial plexus: arm raised to stress brachial plexus and observ for parasthesias
- nerve conduction studies. But normal study in the setting f painshould not preclude an operative repair.

Management:
- conduction greater than 40m/sec treat conservatively for 8 wks and or only if still symptomatic
- conduction < 40m/sec should be managed with release electively Conduction may not improve post procedure on basis of permanent axonal injury.
- <30m/sec release within 3 months
- <20m/sec release ASAP

Conservative treatment
- activity modification
- Ulnar nerve loose when arm extended. Therefore avoid elbow flexed positions
- elbowpads at night

Many options for surgical treatment.
- simple decompression
- medial epicondylectomy
- subcutaneous transposition
- intramuscular transposition
- trnasmuscular transposition

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Ulnar nerve compression points

brachial plexus

Brachial plexus video