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%