DISEASES: CRITERIA · DIAGNOSTICS · TREATMENT

1. PEPTIC ULCER DISEASE (PUD)

  • Definition/Criteria: Mucosal break ≥5mm in stomach or duodenum extending through muscularis mucosae; caused by H. pylori (most common), NSAIDs, or acid hypersecretion; duodenal ulcers almost never malignant — gastric ulcers MUST be biopsied

  • Diagnostics: EGD (gold standard); urea breath test or stool antigen for H. pylori (4 weeks after PPI); BUN:Cr >20 suggests upper GI source; Forrest classification on EGD (Ia = spurting → highest rebleed risk)

  • Treatment: PPI 40 mg PO BID x4–8 weeks (duodenal), 8–12 weeks (gastric); H. pylori eradication: bismuth quadruple (Omeprazole + Bismuth + Tetracycline + Metronidazole x14 days) or clarithromycin triple if local resistance <15%; hold NSAIDs; EGD follow-up at 8–12 weeks for gastric ulcers

2. GASTRITIS / EROSIVE ESOPHAGITIS

  • Definition/Criteria: Gastritis = inflammatory mucosal injury of the stomach; erosive esophagitis = mucosal injury of the esophagus; Los Angeles grading A–D for esophagitis (Grade C/D needs BID PPI); H. pylori positive more specific to PUD; erosive esophagitis is endoscopic, GERD is clinical

  • Diagnostics: EGD; CBC, BMP; H. pylori testing; anti-parietal cell antibody if autoimmune gastritis suspected (+ B12/intrinsic factor Abs); Grade A/B → daily PPI; Grade C/D → BID PPI

  • Treatment: Gastritis: PPI BID x4–8 weeks; H. pylori eradication if positive; avoid NSAIDs/alcohol; Erosive esophagitis: Pantoprazole 40 mg BID x8 weeks (LA grade C/D), step down to daily PPI; Eosinophilic esophagitis (EoE): budesonide oral suspension 2 mg BID x12 weeks OR swallowed fluticasone; 6-food elimination diet

3. GERD / ESOPHAGEAL MOTILITY DISORDERS

  • Definition/Criteria: GERD = chronic acid reflux causing symptoms or mucosal injury; diagnosed clinically or pH monitoring; EGD may be normal; Achalasia = aperistalsis + incomplete LES relaxation (barium "bird's beak"); distinguish from cancer by age, manometry, and EGD

  • Diagnostics: EGD first (exclude Barrett's, malignancy); manometry for achalasia (gold standard — aperistalsis + incomplete LES relaxation); pH monitoring for GERD without esophagitis; barium swallow for stricture/achalasia; biopsy ≥15 eos/hpf = EoE

  • Treatment: GERD: lifestyle modification + PPI daily; Achalasia: pneumatic dilation or POEM (preferred for younger); nifedipine 10–20 mg SL before meals as bridge; EoE: budesonide oral suspension + 6-food elimination diet, PPI trial first; Stricture: endoscopic dilation q4–6 weeks PRN; Malignancy: CT staging + multidisciplinary oncology referral

4. MALLORY-WEISS TEAR

  • Definition/Criteria: Longitudinal mucosal laceration at the GEJ from forceful vomiting or retching; NO precipitating retching = think Boerhaave; mucosal only (not full thickness); EGD shows mucosal tear at GEJ on retroflexion; usually self-limited (>90% stop spontaneously)

  • Diagnostics: EGD (retroflexion at GEJ — key view); CBC, BMP, coagulation; always scope to confirm source; distinguish from varices, PUD, Boerhaave; no free air on imaging (distinguishes from perforation)

  • Treatment: >90% spontaneous resolution; IV access + fluid resuscitation; NPO until EGD; PPI IV; endoscopic hemostasis (epinephrine injection/clips) if active bleeding; treat with antiemetics (ondansetron 4 mg IV q6h, promethazine 12.5 mg IV q6h PRN); alcohol cessation; discharge with PPI x4–8 weeks; follow-up 2–4 weeks

5. BOERHAAVE SYNDROME (ESOPHAGEAL PERFORATION)

  • Definition/Criteria: Full-thickness esophageal rupture from sudden forceful vomiting; sudden tearing chest/back pain + subcutaneous emphysema + mediastinal air = surgical emergency; distinguish from Mallory-Weiss (mucosal only, no free air, less severe)

  • Diagnostics: CXR (mediastinal widening, subcutaneous emphysema, pleural effusion — usually left); CT chest with oral contrast (confirms perforation, mediastinal air); avoid EGD initially; left pleural effusion with low pH = amylase-rich fluid (diagnostic)

  • Treatment: Surgical emergency — immediate surgical consult; NPO, broad-spectrum antibiotics (pip-tazo), IV PPI; early surgical repair (<24h = best outcomes); late presentation: esophageal stenting + drainage; never delay for further workup if clinically suspected

6. VARICEAL BLEEDING (ESOPHAGEAL/GASTRIC)

  • Definition/Criteria: Hemorrhage from portal hypertension-driven esophageal or gastric varices; stigmata of liver disease + large-volume hematemesis; HR >100 + SBP <90 = ICU; gastric varices bleed more, are harder to treat than esophageal; cirrhosis history or signs (spider angiomata, splenomegaly, ascites)

  • Diagnostics: EGD within 12h (EVL = endoscopic variceal ligation is first-line); CBC q6h, BMP, LFTs, coags, type & screen; trend ammonia + fever; restrictive transfusion (Hgb 7–8, platelets <50k = airway protection before EGD); INR unreliable in cirrhosis (use TEG)

  • Treatment: Octreotide 50 mcg IV bolus → 50 mcg/hr x3–5 days; ceftriaxone 1g IV daily x7 days (SBP prophylaxis — reduces mortality); EVL at EGD; early TIPS (<72h) if Child B active bleed or Child C <14 pts; balloon tamponade only as bridge; restrictive transfusion (Hgb 7–8); non-selective BB (propranolol or carvedilol) after acute bleed; avoid beta-blockers acutely (blunts compensatory tachycardia)

7. NON-VARICEAL UPPER GI BLEEDING (NVUGIB)

  • Definition/Criteria: Upper GI bleed from non-variceal source (PUD most common, also Mallory-Weiss, GAVE, Dieulafoy); Forrest classification drives management: Ia (spurting) → highest rebleed risk → IV PPI infusion; BUN:Cr >20 suggests upper GI source; melena = upper GI until proven otherwise

  • Diagnostics: EGD within 24h (hemoclip or epinephrine if active bleed/visible vessel); CBC, BMP, coags, type & screen; BUN:Cr ratio; H. pylori testing; NG lavage not routinely required

  • Treatment: IV PPI bolus 80 mg → 8 mg/hr infusion x72h (high-risk lesion); EGD hemostasis (epinephrine + clip or thermal); IV access x2, resuscitate; NPO; antiemetics; failed endoscopic hemostasis x2 → IR embolization → surgery; discharge: PPI daily x4–8 weeks; hold NSAIDs; H. pylori eradicate if positive

8. GASTRIC ANTRAL VASCULAR ECTASIA (GAVE) / PORTAL HYPERTENSIVE GASTROPATHY (PHG)

  • Definition/Criteria: GAVE = "watermelon stomach" — discrete vascular ectasias in antrum (not portal HTN driven); PHG = diffuse mucosal congestion in cirrhosis ("snake skin"/"mosaic" pattern) from portal HTN; both cause chronic occult/overt bleeding and iron deficiency anemia; treated differently — GAVE uses APC, NOT banding

  • Diagnostics: EGD (GAVE: discrete red spots in antrum in watermelon pattern; PHG: proximal stomach diffuse congestion); CBC (iron deficiency anemia); iron studies; liver disease workup (if PHG suspected); multiple EGDs often needed for GAVE

  • Treatment: GAVE: argon plasma coagulation (APC) at EGD; iron supplementation; transfusion if anemic; thalidomide or hormonal therapy for refractory; PHG: non-selective BB (propranolol/carvedilol) to reduce portal pressure; TIPS for refractory PHG; iron supplementation

9. DIEULAFOY LESION

  • Definition/Criteria: Large submucosal artery eroding through mucosa without ulceration; recurrent large-volume GI bleeds with no ulcer found; most common in proximal stomach (within 6 cm of GEJ); EGD may miss it — requires multiple endoscopies; NO prior retching, NO liver disease, NO ulcer = think Dieulafoy

  • Diagnostics: EGD (may need multiple scopes — can be very small, easily missed); tagged RBC scan or CT angiography if EGD negative; push enteroscopy if suspected small bowel; lesion appears as pulsatile artery or visible vessel without surrounding ulcer

  • Treatment: Endoscopic hemostasis (hemoclip preferred — best long-term results); epinephrine injection + clip or thermal; IR embolization if endoscopy fails; surgery (wedge resection) for refractory; PPI after; consider recurrent bleeds = always biopsy at EGD, always scope for source

10. AORTOENTERIC FISTULA

  • Definition/Criteria: Communication between aorta (or aortic graft) and GI tract (usually duodenum); prior aortic surgery/graft = must rule out; herald bleed (small bleed followed by exsanguinating hemorrhage) is classic; massive hemorrhage after any prior aortic graft surgery = aortoenteric fistula until proven otherwise

  • Diagnostics: CT angiography (imaging of choice — shows graft, perigraft air, fistula tract); EGD if stable (shows blood in distal duodenum, may see graft); DO NOT delay CT for EGD if prior aortic graft + massive bleed

  • Treatment: Surgical emergency — immediate vascular surgery consult; IV access, resuscitate, crossmatch; broad-spectrum antibiotics; endovascular stenting as bridge to surgery; high mortality even with surgery; never manage conservatively

11. FOOD BOLUS IMPACTION / ESOPHAGEAL FOREIGN BODY

  • Definition/Criteria: Difficulty swallowing or complete obstruction by food bolus requiring urgent endoscopic removal; EoE is #1 cause in young adults (always biopsy even if esophagus looks normal); esophageal malignancy in elderly (weight loss, progressive dysphagia); impacted >6h = risk of pressure necrosis

  • Diagnostics: CXR (exclude free air or mediastinal widening — if present = perforation → surgery first); CT if perforation suspected; EGD = diagnostic and therapeutic; glucagon 1 mg IV can relax LES and allow passage; always biopsy after removal

  • Treatment: Urgent EGD within 6h (drooling/inability to manage secretions) or 24h (partial); push or pull technique; NPO; post-removal inspection + biopsy for underlying lesion; treat EoE if found; PPI ongoing for stricture; Zenker's diverticulum: alert endoscopist before EGD (perforation risk with blind intubation); Surgery if endoscopy fails or perforation

12. ANEMIA OF GI ETIOLOGY (IRON DEFICIENCY / HEMORRHAGIC)

  • Definition/Criteria: Anemia from acute hemorrhage (normocytic, hemodilution takes 24–48h) or chronic GI blood loss (microcytic, low ferritin, low MCV); iron deficiency anemia in adults = GI malignancy until proven otherwise; distinguish from anemia of chronic disease (normal/high ferritin, low TIBC) and hemolytic (elevated LDH, indirect bili, low haptoglobin)

  • Diagnostics: CBC, reticulocyte count, iron studies (serum iron, ferritin, TIBC, transferrin sat); peripheral smear; BMP; hemolysis panel (LDH, haptoglobin, indirect bili, Coombs) if hemolytic suspected; EGD ± colonoscopy for source identification; serial CBC q6h if acute

  • Treatment: Transfusion thresholds: Hgb <7 (stable, non-cardiac); Hgb <8 (ACS, hemodynamic instability, elderly with cardiovascular disease); 1 unit pRBCs raises Hgb ~1 g/dL; IV iron (ferric carboxymaltose 500–1000 mg) if deficient and PO not tolerated; ferrous sulfate 325 mg PO TID with vitamin C; correct coagulopathy (FFP if INR >1.5 + bleeding); identify and treat source

PART 2 — DDX QUICK REVIEW

HEMATEMESIS / UPPER GI BLEED

PUD (Bleeding)

  • Epigastric pain, NSAID use, H. pylori history, melena, BUN:Cr >20

  • Dx: EGD (Forrest classification), H. pylori testing

  • Tx: IV PPI (80 mg bolus → 8 mg/hr infusion), endoscopic hemostasis, eradicate H. pylori

Variceal Bleed

  • Cirrhosis, portal HTN, splenomegaly, large-volume hematemesis

  • Dx: EGD within 12 hr

  • Tx: Octreotide + Ceftriaxone + EVL ± TIPS

Mallory-Weiss Tear

  • Hematemesis after forceful retching/vomiting

  • No mediastinal air

  • Dx: EGD (retroflexion)

  • Tx: Antiemetics, PPI, endoscopic therapy if active bleeding

Boerhaave Syndrome

  • Vomiting → sudden chest/back pain + subcutaneous emphysema

  • Mediastinal air present

  • Dx: CT chest with oral contrast

  • Tx: Surgical emergency, broad-spectrum antibiotics, repair <24 hr

Dieulafoy Lesion

  • Massive recurrent bleeding

  • No ulcer, no cirrhosis

  • Often multiple negative EGDs

  • Dx: Repeat EGD ± CTA

  • Tx: Hemoclip, IR embolization if needed

Aortoenteric Fistula

  • Prior aortic graft + herald bleed

  • Dx: CT angiography FIRST

  • Tx: Emergent vascular surgery

GAVE

  • Chronic iron deficiency anemia

  • "Watermelon stomach"

  • Dx: EGD

  • Tx: APC (NOT banding)

Upper GI Malignancy

  • Weight loss, dysphagia, age >50

  • Irregular ulcer margins

  • Dx: EGD + biopsy, CT staging

  • Tx: Oncology referral

DYSPHAGIA

Eosinophilic Esophagitis (EoE)

  • Young male, atopy, food impaction

  • Dx: EGD + biopsy (≥15 eos/hpf)

  • Tx: Budesonide + 6-food elimination diet + PPI trial

Esophageal Stricture

  • Progressive solids > liquids

  • Long-standing GERD

  • Dx: EGD or barium swallow

  • Tx: Endoscopic dilation + PPI

Achalasia

  • Progressive solids AND liquids

  • Regurgitation of undigested food

  • Bird's-beak appearance

  • Dx: Manometry (gold standard)

  • Tx: POEM or pneumatic dilation

Esophageal Cancer

  • Progressive dysphagia

  • Weight loss

  • Smoker/alcohol history

  • Dx: EGD + biopsy

  • Tx: Oncology, surgery ± chemo/XRT

Zenker Diverticulum

  • Halitosis

  • Regurgitation of undigested food

  • Coughing/choking

  • Dx: Barium swallow

  • Tx: Surgical/endoscopic repair

Oropharyngeal Dysphagia

  • Choking immediately upon swallowing

  • Nasal regurgitation

  • Neurologic disease

  • Dx: Video swallow study

  • Tx: SLP therapy + treat underlying cause

Schatzki Ring

  • Intermittent solid-food dysphagia

  • Normal between episodes

  • Dx: EGD or barium swallow

  • Tx: Endoscopic dilation

EPIGASTRIC PAIN

PUD

  • Duodenal ulcer: relieved by food

  • Gastric ulcer: worsened by food

  • Melena, NSAIDs, H. pylori

  • Dx: EGD + H. pylori testing

  • Tx: PPI + eradicate H. pylori

GERD / Esophagitis

  • Burning substernal pain

  • Worse lying down

  • Improved with antacids

  • Dx: Clinical ± EGD

  • Tx: PPI + lifestyle modification

Acute Pancreatitis

  • Epigastric pain radiating to back

  • Lipase >3× ULN

  • Dx: Lipase

  • Tx: IVF, analgesia, early enteral feeding

Biliary Colic

  • Post-fatty meal RUQ/epigastric pain

  • Dx: RUQ ultrasound

  • Tx: Analgesics, elective cholecystectomy

Acute Cholecystitis

  • Fever + RUQ pain + Murphy sign

  • Dx: RUQ ultrasound

  • Tx: Antibiotics + cholecystectomy

Functional Dyspepsia

  • Chronic symptoms

  • Normal EGD

  • Dx: Diagnosis of exclusion

  • Tx: PPI ± low-dose TCA

Gastric Cancer

  • Weight loss

  • Early satiety

  • Age >50

  • Dx: EGD + biopsy

  • Tx: Oncology referral

Perforated Viscus

  • Sudden severe pain

  • Rigid abdomen

  • Free air

  • Dx: CXR/CT

  • Tx: Emergent surgery

ANEMIA (GI CONTEXT)

Iron Deficiency Anemia

  • Microcytic anemia

  • Low ferritin

  • Chronic occult GI blood loss

  • Dx: Iron studies + GI workup

  • Tx: Iron replacement + identify source

Anemia of Chronic Disease

  • Normocytic anemia

  • High ferritin, low TIBC

  • Dx: Iron studies

  • Tx: Treat underlying disease

B12/Folate Deficiency

  • Macrocytic anemia

  • Hypersegmented neutrophils

  • Neurologic symptoms (B12)

  • Dx: B12/Folate levels

  • Tx: Vitamin replacement

Hemolytic Anemia

  • ↑ LDH, ↑ indirect bilirubin, ↓ haptoglobin

  • Dx: Hemolysis labs

  • Tx: Treat underlying cause

Acute Hemorrhagic Anemia

  • Acute GI bleed

  • Tachycardia, hypotension

  • Hgb may initially be normal

  • Dx: Serial CBCs

  • Tx: Resuscitation + transfusion

Aplastic Anemia

  • Pancytopenia

  • Hypocellular marrow

  • Dx: Bone marrow biopsy

  • Tx: Hematology referral

ACUTE GI BLEED — RAPID TRIAGE

  • Hematemesis + Cirrhosis + Unstable → Variceal bleed → ICU + EGD ≤12 hr

  • Melena + NSAIDs + Epigastric pain → PUD → PPI drip + EGD ≤24 hr

  • Retching → Hematemesis → Mallory-Weiss tear

  • Vomiting → Chest pain + Crepitus → Boerhaave → CT chest → Surgery NOW

  • Prior Aortic Graft + GI Bleed → Aortoenteric fistula → CTA → Vascular surgery NOW

  • Recurrent Massive Bleed + Negative EGD → Dieulafoy lesion

  • Iron Deficiency + Watermelon Stomach → GAVE → APC

  • Young Male + Food Impaction + Atopy → EoE → EGD + biopsy + budesonide

This format reads much faster during rounds and call nights than the original table.