Title UPPER GI DISEASE | ACHALASIA | ABDOMINAL MASS ✅

TOPIC : UPPER GI LONG CASE UITM NOTES: UGIB 1. HISTORY TAKING 1. 4C a. Complain Variceal bleed secondary to portal hypertension due to cirrhosis ● Hematemesis(fresh red blood, active bleeding or coffee ground like material) ● Melena(black tarry stool) ● Anemic symptoms ● Hematochezia(Usually LGIB but can due to UGIB transits GIT quickly) Peptic ulcer disease(PUD) ● Abdominal pain/dyspepsia ● Hematemesis(coffee ground vomitus) ● Melena Acute gastritis ● Epigastric pain ● Hematemesis(in severe gastritis) ● Malena(in severe gastritis) Gastric cancer ● Dyspepsia ● Constitutional symptoms ● Hematemesis ● Melena ● Vomiting due to gastric outlet obstruction ● Dysphagia Mallory weiss tear ● Hematemesis(small amount) b. Course (Natural History - If cannot found in book, write based on common case seen) Variceal bleed secondary to portal hypertension due to cirrhosis ● Associated with lethargy, nausea/vomiting, pruritus, weight gain, shortness of breath an early satiety. Peptic ulcer disease(PUD) ● Related to meal, poor appetite-> (loss of weight=gastric ulcer relieves by meal), (good appetite=duodenal ulcer) Acute gastritis ● Transient acute mucosal inflammatory process Gastric cancer ● Severe vomiting due to gastric outlet obstruction ● Chronic blood loss Mallory weiss tear ● Secondary to violent retching following alcoholic binge->lead to longitudinal tear below the gastresophageal junction leading to haematemesis
c. Cause Variceal bleed secondary to portal hypertension due to cirrhosis ● Viral hepatitis ● Alcohol intake ● Hepatotoxic drug ● Malignancy Peptic ulcer disease(PUD) ● H.pylori infection ● NSAIDs ● Smoking ● Alcohol Acute gastritis ● Bile reflux ● NSAIDS ● H.Pylori infection ● Crohn disease Gastric cancer ● H.pylori ● Smoking ● Family history of gastric cancer Mallory weiss tear ● Tear in the mucosa due to sudden increase in intra abdominal pressure ● After large amount of alcohol d. Complications Variceal bleed secondary to portal hypertension due to cirrhosis ● Coagulopathy ● Jaundice ● Encephalopathy ● Ascites Peptic ulcer disease(PUD) ● Bleeding ● Perforation Acute gastritis ● Bleeding ● Perforation Gastric cancer ● Gastric outlet obstruction ● Biliary obstruction ● Dysphagia
● Iron deficiency anemia ● Fistula formation Mallory weiss tear ● Bleeding 2. Systemic Review a. Exclude complications ● Exclude based on listed complaint above b. Exclude other diagnosis ● Exclude based on listed complaint above 3. Past Medical History ● Any history of chronic liver disease(variceal bleed) ● Ask about risk factor for chronic liver disease(viral hepatitis, alcohol intake, hepatotoxic drug, malignancy(variceal bleed) ● Any NSAID prescribed for a long duration(PUD) ● History of gastric polyps(gastric ca) ● History of Barrett esophagus(gastric ca) 4. Past Surgical History ● History of partial gastrectomy done(gastric ca) 5. Social History a. Acute i. Distance from home ii. Who take care of the patient iii. Knowledge of the disease b. Chronic i. Distance from home for multiple visit ii. Who take care of the patient and ensure compliance iii. How the disease affects patient lifestyle iv. Bantuan kewangan dari mana mana jabatan 6. PHYSICAL EXAMINATION 1. Growth a. Physical b. Mental c. Developmental 2. Nutritional Status 3. Sign of acute illness 4. Sign of chronic illness 5. Skin Colour 6. Peripheral attachment 7. Focus examination anticipated findings specific for the case a. https://www.youtube.com/watch?v=PYAnF6GJY2I
Vital Signs (most important) ● Assess hemodynamic stability and postural BP ● Any resting tachycardia Confirm UBGIT ● DRE for melenic stool (differentiate from Fe-laden stools) Determine Etiology ● Variceal Bleed: stigmata of chronic liver disease, jaundice ● Non-variceal bleed o H&N: Bleeding source in nose or mouth, cervical lymph nodes, o Abd: Tenderness, guarding, rebound, epigastric mass, arterial bruit of AAA o Rectal: PR bleed, anal, perianal or rectal pathology Look for complications ● Signs of Anemia ○ Face – (i) conjunctival pallor (ii) pallor of mucous membrane ○ Cardiac Auscultation – short systolic flow murmur at aortic area ○ Pulse – (i) tachycardia (ii) bounding (iii) collapsing pulse ○ Hands – pallor of palmar creases ● Lungs examine for aspiration pneumonia ● Exclude Peritonism 8. GENERAL INVESTIGATION AND MANAGEMENT CHRONOLOGICALLY (FROM GP/KK TO GENERAL HOSPITAL) Whatever the cause, the patient should first be resuscitated and then investigated urgently to determine the cause of bleeding inform GS registrar on call of the patient’s admission 1. Resuscitation ABC 2. Blood for investigation ● GXM: order in active bleed 4 pints PCT ● FBC (Hb will not drop in first 24hrs, thrombocytopenia secondary to hypersplenism in portal hypertension – can exacerbate bleeding, MCV and MCHC determine cause of anemia) ● U/E/Cr (dehydration raised Ur more than Cr (isolated uraemia suggestive of bleeding GIT), Metabolic Disturbances hypokalemic, hypochloremic, metabolic alkalosis with paradoxical aciduria* ● PT/PTT (r/o coagulopathy which can exacerbate bleeding) ● LFT (Child's score - ind etiology and outcome) – do in alcoholic hx or liver disease