gi emergencies

• 6.7% of all visits
• 8.04 million patient encounters annually
• Admission rates: 18-42%
• Admission rate as high as 63% in those >65YO

• (stomach duodenum, biliary tract)
• - supplied by Celiac Trunk
• - Produces epigastric pain

• (most of the small bowel, appendix, cecum)
• - supplied by SMA
• - produces periumbilical pain

• - supplied by IMA
• - Produces suprapubic pain

Sharp, well characterized and precisely localized by patient

• Vague, dull diffuse in character
• Steady or cramp-like/intermittent pain resulting from peristalic contractions

palor, jaundice, diaphoretic, rashes, scars

• General, skin, heart & lung
• Abdominal, pelvic and rectal

• Elderly
• Dementia patients
• Psychiatric patients
• Spinal Cord Injuries
• Immunocompromised
• Pt’s with significant Ascites

• Beta Hcg on all women of childbearing age
• CBC
• BMP
• Coagulation Studies
• Hepatic Panel/Liver function tests
• Lipase
• Lactate
• Urinalysis
• Heme occult blood

• Ultrasound
• Abdominal x-ray – determine views needed
• CT +/- contrast

• IV Fluid Resuscitation
• Analgesics
• Anti-emetics
• +/- Antibiotics

• – Analgesic and anti-inflammatory agent
• - NO antiplatelet effect
• - Safe in all age groups
• - Hepatotoxicity can occur at doses 140mg/kg/d

• Nonsteroidal Anti-inflammatory drugs (NSAIDS)
• - analgesic and anti-inflammatory agent
• - May cause platelet dysfunction, impaired coagulopathy, gastro-intestinal irritation and bleeding
• * Ex: Aspirin, Naproxen, Indomethacin, Ibuprofen, Ketorolac

• - IV NSAID
• - Indicated for moderate to severe pain
• - Similar risks to other NSAIDs
• - CI in those with severe renal disease

• Analgesic and sedative effects
• Side effects
• - Respiratory depression
• - Nausea and vomiting
• - Constipation
• - Urinary retention
• - Pruritus
• - Confusion
• - Muscle rigidity

• - Onset 5-20min
• - 10-30min peak effect
• - Duration 2-6hrs
• * May cause hypotension from histamine release

0.1-0.2mg/kg IV or IM

• - Onset 5-20 min
• - Duration 3-4hrs
• - Less sedation and nausea

• Dilaudid Dosing
• 1-2mg IV

• Toxic Appearance
• Unclear diagnosis in special populations
• Inability to reasonably exclude serious etiology
• Intractable pain, N/V
• Altered mental status
• Inability to follow up or follow discharge instructions

Controlled in Brainstem

through dopamine and serotonin

causes thru histamine & acetylcholine

• Primary gastrointestinal disorders
• Systemic disease
• CNS disorders
• Side effects from medications

• Onset and duration of symptoms
• Frequency and timing of episodes
• Content of emesis
• Associated symptoms (fever, chills, abdominal pain, diarrhea/constipation)
• Recent food ingestion, out to dinner, something new?
• Recent sick contacts/travel
• Previous abdominal surgeries or GI medical history
• Medications

• Sick vs Not Sick – general appearance
• Assess for signs of dehydration: hypotension, tachycardia, lethargy, poor skin turgor, dry mucous membranes, delayed capillary refill
• Skin
• Heart
• Lungs
• Abdominal Exam
• +/- DRE or vaginal exam

• Labs and imaging will be based on history and PE findings and may include:
• CMP, CBC, Hepatic Panel, Amylase, Lipase, Lactate, Coagulation Panel, Tox screen and Pregnancy Test
• CXR, Obstruction Series, US, CT +/- IV/PO contrast , MRI

• Correction of fluid and electrolyte imbalances
• PO intake should be limited or kept to CLD
• ? Nasogastric tube placement
• ? Foley catheter placement
• +/- pain control
• Anti-emetics

Phenothiazines

• Anti-emetics
• Quick onset of action
• Crosses blood brain barrier and placenta

• Most frequent side effects drowsiness, loss of muscular coordination, tone
• Tardive dyskinesia

Act on chemoreceptors in the brain by blocking D1 and D2, alpha-1, cholinergic, adrenegric and histamine receptors

• Primarily hepatic metabolism
• Half is excreted by kidneys and half through enterohepatic circulation

Tardive Dyskinesia: potentially irreversible, involuntary muscle movements that usually involve the tongue, lips, jaw, torso and extremities

• Antiemetics
• Prochlorperazine (Compazine)
• Promethazine (phenegran)
• Trimethobenzamide (tigan)

• 5-10mg PO TID or QID
• 10mg IV or IM q6H
• 25mg PR Bid

12.5-25mg PO, IM or PR q4-6H

• 250mg PO TID or QID
• 200mg IM TID or QID

• Selectively block serotonin 3 receptors located in the vagal nerve terminals and CNS chemoreceptor trigger zones
• Anti emetic

• Serotonin antagonist
• most commonly used
• - has 100% absorption rate if IV or IM, 50% if SL
• - Category B
• - Metabolized by the liver
• - 95% excreted by the kidneys
• - less side effects than phenothiazines
• - 4-8mg SL or IV up to q8h

• Reglan
• Haldol

• Dopamine antagonists
• Quick onset
• Prokinetic agent that also has central anti-emetic effects by minimizing the effects of dopamine at the D-receptor in the chemoreceptor trigger zone
• Not antiemetic @ 10mg is at 20mg

• Metabolized by the liver
• Excreted mostly by the kidneys, dose adjustment if renal insufficiency present

• Extensive side effects: sedation, orthostatic hypotension and extrapyramidal symptoms (tardive dyskinesia)
• Do not give to patients with bowel obstruction, Parkison’s disease, depression

• Anti-emetic
• Dopamine antagonist
• utilized in hospice setting mostly

• Anti-emetic
• Inhibit the action of H-receptors
• limits stimulation of the vomiting center from the vestibular system
• Best utilized for nausea and vomiting related to motion sickness or vertigo

• Diphenhydramine
• Dimenhydrinate
• MECLIZINE

• 25-50mg PO q6-8h
• 10-50mg IV q2h

50-100mg PO or IV q4-6h

12.5-25mg 1h before travel

confusion, sedation, dizziness, tinnitus, insomnia, fatigue, tremors

• anticholinergic
• Primary antimuscarinic agent with prominent CNS activity
• Inhibits the action of acetylcholine at the muscarinic receptor
• Limits stimulation of vomiting center through the vestibular system, therefore also good for motion sickness, vertigo

dry mouth, urinary retention, blurred vision, exacerbation of narrow angle glaucoma

• Pt’s with severe dehydration, electrolyte abnormalities,
• renal impairment,
• and inability to tolerate PO despite anti-emetics
• (Special attention to peds and elderly)

• improved symptoms after re-hydration and anti-emetics
• PO anti-emetics
• Recommendation for BRAT diet
• Education on importance of adequate hydration
• Follow up plan with PCP
• Return to ER if signs and symptoms…

• Defined as 3 or more watery stools per day
• Acute = <3 weeks, abrupt onset, increased frequency and fluidity
• Chronic = >3 weeks, loose stools with or without increased frequency

• Increased intestinal secretions
• Decreased intestinal absorption
• Increased osmotic load
• Abnormal intestinal motility

• Most common cause is viral or bacterial infections
• Other pathogens: Non-shiga E coli, C-difficile, Campylobacter, shigella, Salmonella, Shiga E coli, Protozoa
• Pseudomembranous Colitis – usually in the setting of prior antimicrobial treatment (Fluoroquinolones, PCN, Clindamycin and Cephalosporins)
• IBD – Crohn’s or Ulcerative colitis
• Giardiasis – history of drinking or swimming in lake or stream water
• Amebiasis – history of recent travel to areas with poor sanitation
• Medications – laxatives, antacids, cardiac medications (digitalis, quinidine), antimicrobials

(Novorvirus causes 50-80% of infectious diarrhea in US)

• Sick vs Not Sick – general appearance
• Assess for signs of dehydration: hypotension, tachycardia, lethargy, poor skin turgor, dry mucous membranes, delayed capillary refill
• Skin
• Heart
• Lungs
• Abdominal Exam
• +/- DRE or vaginal exam

• Routine labs CBC and BMP likely warranted
• Stool cultures should be limited to severely dehydrated or toxic patients or those with blood and/or pus in stool, symptoms >3 days
• >7 days duration, travel abroad or consumed untreated water add Ova and Parasite study
• Sigmoidoscopy if warranted would be completed on an outpatient basis

• Adequate fluid resuscitation (20ml/kg in peds, 500ml bolus adults)
• Bowel rest, or minimum clear liquids with advancement to BRAT diet
• +/- Antibiotics
• +/- Anti-diarrheal agents

• Only recommended for pts with moderate to severe disease with associated systemic symptoms
• Antimicrobial of choice depends on offending pathogen

should NOT be used in patients with bloody diarrhea or in those with suspected inflammatory diarrhea due to the potential for prolonged fever or development of toxic megacolon

should NOT be used in patient’s with Shiga toxin producing E-coli O157:H7 due to risk of Hemolytic uremic syndrome

• Ciprofloxacin 500mg x 1 day or 500mg BID x 3 days
• Trimethoprim/sulfamethoxazole 10-50mg/kg/day x 3 days (children and nursing mothers)

• - Metronidazole (Flagyl) - 500mg PO q6h for 10-14 days
• - Vancomycin 125 to 250 mg PO q6h for 10-14 days (reserved for resistant cases)
• - Hospital admission depends on severity of disease

• - Metronidazole 750mg PO TID or 500mg IV q8h for 5-10days
• - Paromomycin 500mg PO TID x 7 days or
• Iodoquinol 650 mg TID x 20 days

• - Metronidazole 250mg PO TID for 5-7 days or
• - Tinidazole 2g x 1 dose or
• - Quinacrine 100mg PO TID for 7 days

• Use with caution in the elderly
• None are approved for <2yrs of age
• Pepto
• Lomotil
• Imodium

• antidiarrheal
• - absorbent preparations that bind toxins
• - some antimicrobial effect against bacterial and viral pathogens
• - 2 tabs or 30ml q 30min – 1h, repeat prn
• - Can turn the tongue and stools gray-black

• - “anti-motility agent”
• - opiate (no analgesic effects) + atropine (anticholinergic)
• - 15-20mg PO per day, initial dose is 5mg
• - Side effects: dry mouth, dry mucous membranes, flushing,
• tachycardia, and urinary retention
• - Contraindicated in patients with narrow angle glaucoma

Pt w/ narrow angle glaucoma

• - “anti-motility agent”
• - inhibits peristalsis by a direct effect on the circular and
• longitudinal muscles of the intestinal wall
• - reduces fecal volume, increases viscosity and bulk and
• diminishes the loss of fluid and electrolytes
• - Initial dose 4mg, followed by 2mg after each unformed stool
• Not to exceed 16mg per day

• Mucosal tear most often at the GE junction
• Usually caused by vomiting or retching
• More common in alcoholics
• Account for 5-10% of UGI bleeds
• Most tears will heal spontaneously within 48hrs with conservative treatment

• History of retching, vomiting or straining
• - Tachycardic
• - Hypotensive
• - Hematemesis
• - +/- Melena
• - Abdominal or thoracic pain

• Diagnosis is initially made clinically from history and PE
• Obtain CBC, BMP, Coagulation studies

• - Fluid resuscitation with either NS or PRBCs
• - NPO
• - +/- Foley
• - Broad spectrum parenteral antibiotics
• a. Piperacillin-tazobactam (Zosyn) 3.375gm IV
• b. Cefotaxime 2gms IV + Clindamycin 600mg IV
• Ceftriaxone 2gm IV + Metronidazole 1gm IV

• Spontaneous rupture of the esophagus
• Transmural, full thickness tear of the esophageal wall
• Caused by sudden use in intra-esophageal pressure during forceful vomiting
• Tear is usually in the lower 1/3 of the esophagus, 2-3cm proximal to the GE junction

• Hypotensive
• Tachycardic
• Lower thoracic pain
• Subcutaneous emphysema
• +/- pleural effusions (particularly left sided)
• Abdominal rigidity

• BMP, CBC, Lactate, Cardiac Enzymes, Coagulation studies, Type and Screen vs Cross
• CXR
• - mediastinal widening
• - unilateral pleural effusion (left side)
• - hydropneumothorax
• - pneumomediastinum
• CT with PO contrast typically demonstrates air in the abdomen

• - mediastinal widening
• - unilateral pleural effusion (left side)
• - hydropneumothorax
• - pneumomediastinum

• EARLY recognition is key
• ABC’s, IV, O2, Monitor
• IVF Resuscitation
• Broad spectrum antibiotics
• Pain control
• Anti-emetics
• Foley
• Call Surgery!!!
• Mortality is almost 100% without treatment

gallstones without inflammation

gallstones with gallbladder inflammation

gallbladder inflammation without stones

gallstones in the common bile duct

inflammation, infection of the common bile duct

impaired function of gallbladder emptying

• Age (peaks in 60-70’s)
• Female > Male (2-3:1)
• Pregnancy, multiparity
• Obesity
• Rapid weight loss, prolonged fasting or TPN use
• Hereditary
• Hemolytic disorders (ex sickle cell)
• Medications (OCPs, Estrogen replacement therapy, corticosteroids)

• RUQ, Epigastric Pain coming in distinct attacks that last 30 min to several hours
• Pain is initially colicky and becomes continuous
• Post prandial, following fatty food ingestion
• +/- Fever
• +/- Radiation to the back
• +/- Nausea and vomiting
• +/- Clay colored stool
• +/- Jaundice or icterus

• PE may be relatively benign
• General appearance/Skin - jaundice
• HEENT: sclera and under tongue for jaundice
• Heart
• Lungs
• Abdominal exam: Mild to severe RUQ, epigastric pain, + Murphy’s sign
• +/- DRE

• Elevated Bilirubin, Aspartate Aminotransferase, Alkaline Phosphatase
• Each 70% sensitive and 42% specific

• Gold standard, 91% sensitivity
• - Distended gallbladder
• - Thickened wall >5mm
• - Peri-cholecystic fluid
• - gallstones/sludge
• - dilated CBD
• - sonographic Murphy’s sign

• US
• CT
• HIDA

can demonstrate distention, wall thickening, stones and surrounding fluid but less sensitive than US

• 97% sensitive, 90% specific
• - enables visualization of the biliary system by the injection of radionuclide
• - Radionuclide is secreted by the liver and should fill gallbladder ducts within 30 min
• - Non-filling of the gallbladder after 4hrs is considered evidence of disease
• - Test is inaccurate after Morphine administration

• Criteria for discharge to home with follow up
• - Symptoms are controlled
• - No “itis”

• - PO pain medications and anti-emetic
• - Educate on Low fat diet
• - Follow up with PCP or General Surgery
• - Return to ER if develop fever, symptoms increase and
• cannot be controlled

• - Fever
• - “Itis” , blocked CBD
• - Uncontrolled N/V or abdominal pain

• NPO, IVF hydration
• - pain control, anti-emetics
• - IV antibiotics
• - Surgery consult, +/- GI consult

Gram Negative and Anaerobic coverage

• Piperacillin/tazobactam (Zosyn) 3.375 g IV q6H or 4.5 g IV q 8hr
• Ampicillin/sulbactam (Unasyn) 3g IV q 6h
• Ceftriaxone or Cefotaxime 1gm IV + Metronidazole 500mg q6hr

Ciprofloxacin 400mg IV q12h + Metronidazole 500mg q6h

• Ranges from 5-30 cases per 100,000 people
• 250,000 hospital admissions annually
• Costing $4-6 billion in health care dollars

• Gallstones and Alcohol account for 70-80% of all cases
• 10% have unknown etiology

• - pass through the ampulla of Vater causing obstruction of the pancreatic duct
• 5% of patients with gallstones will develop pancreatitis

• - >5 years with an average of 5-8 drinks daily is usually required
• - Mechanism involves a mixture of direct toxicity, oxidative stress and alterations in pancreatic enzymes

• example offenders: azathioprine, valproic acid,
• furosemide, sulfonamides, aminosalicylates
• Elevated triglycerides

• - Post ERCP: risk ranges from 5-20%
• - Post op: ex. Ischemia following cardiopulmonary bypass
• - Blunt or penetrating trauma

- Ascaris lumbricoides, CMV, Coxsackie B virus, Mumps virus

• Fever
• Chills
• Fatigue
• Nausea
• Vomiting
• Abdominal pain – progressively worsening, steady epigastric pain, radiation to back, that lasts for days

• VS: Fever, tachycardia, hypotension, tachypnea
• General: +/- Confusion, altered mental status
• Skin: +/- Jaundice
• Heart
• Lung
• Abdomen: distended, diminished BS, tenderness to epigastric region
• * Findings will depend and indicate the severity of disease.

• CBC
• BMP
• Hepatic Panel – ALT >3 times normal would indicate gallstone etiology
• Lipase
• +/- Amylase
• Enzymes are cleared by the kidney and therefore can be falsely elevated in the setting of renal insufficiency

• - 90% sensitivity
• - start to increase within the first few hours of onset
• - remains elevated longer than amylase
• - More specific to the pancreas than amylase

• - starts to increase within the first few hours of onset
• - can be elevated from a variety of extra abdominal conditions

• US
• Abd/pelvic CT

• - Can confirm the presence
• Findings include: pancreatic enlargement, edema, peri-pancreatic fluid
• - Will ID gallstones or dilated CBD well
• - Visualization of the pancreas may be limited due to body habitus or overlying intestinal gas

• – 78% sensitive, 86% specificity
• - More accurate than US for confirming diagnosis and presence of pancreatic necrosis
• - Particularly helpful in excluding other intra-abdominal conditions that mimic pancreatitis
• - Less accurate on gallbladder evaluation

• IV contrast enhances viable tissue. Tissue that does not enhance is necrotic.
• Necrosis is seen best 3 days after presentation and can be missed on early CT

• Characteristic Abdominal Pain
• Elevation (typically 3x) Amylase and Lipase
• CT or US findings

• General Supportive Care
• Bowel rest (NPO)
• IVF resuscitation – replete within the first 24hrs
• IV pain control
• Anti-emetics
• +/- foley, NGT
• +/- Consult GI or Surgery
• Admission – ICU vs General floor (Ranson’s Criteria)
• IV antibiotics are NOT indicated unless a specific source of infection is suspected

• If the score ≥ 3, severe pancreatitis likely.
• If the score < 3, severe pancreatitis is unlikely
• Or
• Score 0 to 2 : 2% mortality
• Score 3 to 4 : 15% mortality
• Score 5 to 6 : 40% mortality
• Score 7 to 8 : 100% mortality

• Lifetime incidence is 7-9%
• Prevalence 10-30yrs old
• Males > Females (3:2)
• Most common cause of the acute surgical abdomen

• Thought to be obstruction of the appendiceal lumen
• Distention  Ischemia  Bacterial overgrowth  perforation  abscess formation

• - Fecalith
• - Lymphoid tissue (peds)
• - Vegetable, fruit seeds, foreign body
• - Intestinal worms (Ascarid)
• - Strictures, fibrosis, neoplasms

• The “classic” story
• - vague abdominal periumbilical abdominal pain that migrates to RLQ
• Associated symptoms: Anorexia, Nausea, vomiting, obstipation
• 50% of patients will present with the “classic” story

more often present with high fever, more vomiting and diarrhea

• difficult to diagnose as normal response to infection and inflammation is reduced, appendix is pushed out of the pelvis
• Geriatrics: More likely to present atypically

• VS: Fever (late finding), tachycardia
• Abdominal Exam:
• RLQ abdominal pain, greatest at McBurney’s point
• Rovsing’s Sign = RLQ pain with palpation of LLQ
• Psoas Sign = RLQ pain with right thigh extension

• CBC – leukocytosis with left shift
• Pregnancy screen in all woman of childbearing age
• UA

• Us abd
• Ct abd/pelvis w/ contrast
• Mri

• - more likely to start here with females and children
• - can rule in the diagnosis but not exclude

• 985 sensitive, 95% specificity
• - concern about radiation
• - will confirm or rule out diagnosis

- growing in popularity due to lack of radiation

• Acute Appendicitis – Treatment
• NPO, IV fluid hydration, pain control, anti-emetics
• IV antibiotics u
• Call sx ( if just abc reccurence 14-20% w/in 1 yr)

Ampicillin/sulbactam (Unasyn) or Cefoxitin

• – Piperacillin/tazobactam (Zosyn) or
• Ticarcillan/clauvanate (Timentin)

• Small bowel obstruction is more common than large bowel obstruction
• Can be Mechanical or Functional

• = adynamic or paralytic ileus
• Ileus is much more common
• Example of adynamic is Ogilvie Syndrome

• A = Adhesions
• B = Bulge (aka Hernia)
• C = Cancer (more common in large bowel)

• Inflammatory Bowel disease – Ulcerative Colitis, Crohn’s disease (stricture)
• Foreign body; Intra-abdominal abscess
• Intussusception; Fecal impaction
• Diverticulitis (stricture)

• Blockage prevents passage of intraluminal contents
• Proximal structures become dilated/distended due to accumulation of gastric/biliary/pancreatic secretions, food
• Distention increases the intraluminal pressure which decreases blood flow to the bowel wall
• When pressure exceeds capillary pressure absorption of nutrients ceases and leakage of fluids can occur (third-spacing)
• If continued compromised blood flow – bowel wall necrosis and perforation

• Previous abdominal surgeries
• History of inflammatory bowel disease
• History of a known hernia
• Colonoscopy?

• BELCHING
• Nausea
• Vomiting (emesis can be bilious or feculent)
• Abdominal pain – colicky = intermittent, cramp like
• Abdominal distention/bloating
• Decreased flatus
• Diarrhea (early) constipation (late)

• Vital Signs
• Skin
• CVS
• Pulmonary
• Abdomen: Inspect – bulges, abdominal incisions
• Auscultate – high pitched rushes (early), hypoactive (late)
• Percuss/Palpate – start furthest from area of pain
• DRE – impaction, carcinoma
• GYN – if deemed necessary

• Usually can be made with good history and PE
• Labs: CBC, BMP, +/- LFTs, Coagulation studies, Lactate, Type and Screen
• Imaging:
• CXR; AXR
• CT +/- contrast

• chest– looking for free air under the diaphragm
• abd– supine – dilated loops of bowel, upright – air fluid levels

• 1. Partial vs complete obstruction
• 2. Obstruction vs ileus
• 3. Cause of obstruction (mass vs hernia vs adhesions vs stricture…)

• ABC’s, IV, O2, Monitor, NPO
• Fluid resuscitation – crystalloid
• Pain Medication – IV dilaudid, morphine, ofirmev
• Anti-emetics – ondansetron
• +/- NGT placement for bowel decompression
• +/- Foley placement for accurate I&Os
• +/- Consult GI or Surgery

• results in colonic obstruction when the colon twists on it’s mesentery
• >90% involve the Sigmoid colon

• 1. Elderly
• 2. Hx/o Chronic constipation
• 3. Hx/o Laxative use
• 4. Hx/o Psychiatric illness

• Nausea
• Vomiting
• Acute abdominal distention
• Abdominal pain – will progress as blood flow is compromised leading to bowel wall ischemia, necrosis and perforation

• Labs: CBC, BMP, Lactate level, Coagulation studies, Type and screen
• Abdominal X-ray
• Sigmoid Volvulus – apex is located in the RUQ
• Cecal Volvulus – apex is located in the epigastrum/LUQ
• Water-soluble contrast enema – will confirm presence and site of obstruction, “bird’s beak” configuration

• ABC’s, IV, O2, Monitor
• NPO, Fluid resuscitation
• Pain medications
• Anti-emetics
• NGT for decompression
• Foley for accurate urine I&Os
• Consult Surgery urgently, +/- GI

“Area of weakness or frank disruption of the fibromuscular tissues of the body wall through which intra-cavity structures pass”

• Inguinal
• Direct or indirect or pantaloon
• Ventral; Incisional; Femoral; Umbilical
• Spigelian
• Reducible; Irreducible
• Strangulated; Richter; sliding

: herniation through defect in transversalis fascia of abdominal wall medial to the inferior epigastric vessels

herniation lateral to the inferior epigastric vessels through the internal inguinal ring in the inguinal canal

• combination of direct and indirect hernia.
• Protrusion of abdominal wall on both sides of the epigastric vessels.

herniation that descends through the femoral canal deep to the inguinal ligament

herniation through a defect at the site of a prior surgical incision

Herniation through abdominal wall

Herniation through a defect at the umbilical ring

hernia sac insinuates itself between the layers of the abdominal wall.

\ extruded sac and contents can be returned to it’s original intra-abdominal position

extruded sac and contents cannot be returned to it’s original intra-abdominal position

bloody supply to the hernia sac and contents is compromised

partial circumference of the bowel is incarcerated or strangulated.

wall of the viscus forms part of the wall of the hernia sac

• Affects 10% of the population
• 75-80% are Inguinal (Indirect most common)
• 10% are femoral but 40% of femoral hernias present as a surgical emergency

• Increased age
• Increased abdominal pressure
• Obesity
• Smoking
• Pregnancy
• Chronic Steroid use
• Prematurity

• pain, nausea, vomiting,
• bloating, decreased bowel function

• Examine supine and standing
• May observe and palpate a bulge

• Labs: +/- CBC, BMP, Coagulation studies, Type and Screen
• Imaging – US can be used to assess inguinal hernias,
• CT remains the BEST IMAGING source but may or may not be necessary

• ABC’s
• IV, O2, Monitor, NPO
• IV Fluid resuscitation
• Pain control
• Anti-emetics
• +/- NGT, Foley
• +/- Antibiotics
• Attempted Hernia reduction (allows for elective repair)
• Surgical Consult vs outpatient referral

• Account for > 1 million hospitalizations in the US annually
• More common in males and the elderly
• Upper originates proximal to the Ligament of Treitz (Esophagus, stomach and duodenum)
• lower originates usually from the colon or rectum
• Occult bleeding is detected by the presence of Iron Deficiency Anemia or + fecal occult blood test

• More common in males and the elderly
• ASA or NSAID use
• Known or suspected liver disease
• Heavy ETOH
• Vomiting
• Hx/o diverticulosis

• fatigue, dizziness, lightheadedness,
• hematemesis (coffee-ground appearance),
• melena (15-20% will have hematochezia due to brisk bleeding)

fatigue, dizziness, lightheadedness, hematochezia, BRBPR,

• will depend on if bleed is Acute vs Chronic
• Tachycardia
• Hypotension
• Orthostatic Hypotension

• GI Bleed Review – Etiology UGI
• Peptic Ulcer disease (most common)
• Esophageal or gastric Varices (portal HTN)
• Esophagitis/Gastritis (including erosive)
• Tumors
• Mallory-Weiss Tears
• GI Bleed Review – Etiology

• Diverticulosis ( most common)
• Hemorrhoids
• Tumors
• Ischemic Colitis

VS (orthostatics), General, Skin, CVS, Pulmonary, Abdominal, DRE

• Diagnostic Labs – CBC, BMP, Liver Function tests, Coagulation studies, Type and Screen
• Imaging – Endoscopy which can be both diagnostic and therapeutic
• (EGD, anoscopy, flexible sigmoidoscopy, colonoscopy)

• ABC’s – Airway, breathing and circulation
• IV, O2, Monitor
• Resuscitation with IV fluids or blood products
• Foley, +/- NGT
• +/- Antibiotics
• Consult GI for endoscopy
• +/- Surgery consult

• Initial Hematocrit <30%
• Initial systolic BP <100mmHg
• Red blood in NGT lavage/Hematemesis
• Comorbidities (liver disease)
• Coagulopathy
• Need for multiple transfusions

• Acute or Chronic
• Occlusive vs Non-occlusive

results from an embolic occlusion or primary thrombosis of at least 1 major mesenteric vessel

is seen in patients with low flow states (heart failure or from hypotension)

“Key is severe, steady epigastric or periumbilical pain with minimal to no findings on physical exam.”

• Fever
• Tachycardia
• Hypotension
• Nausea and vomiting
• Abdominal distention
• Diarrhea (may be bloody from sloughing of the inner wall)

• Labs: CBC (leukocytosis), BMP, Lactic Acid, +/- LFTs, amylase, lipase
• Imaging:
• - Contrast enhanced CT: highly accurate at determining the presence of ischemic intestine
• - CTA/MRA – can demonstrate narrowing of the proximal vessels GOLD STANDARD but not readily avb

• Bowel wall thickening
• Free fluid or free air
• Mesenteric arterial thromboembolism
• Pneumatosis intestinalis
• Mesenteric or portal venous gas
• Mesentery edema
• Infarction of other abdominal organs

• ABCs
• IV/O2/Monitor
• NPO, IVF hydration
• Pain control/anti-emetics
• IV antibiotics
• Foley
• Call surgery

has a better prognosis due to collateral circulation and usually improves with conservative treatment.

• Fever
• Hypotension
• Chills
• Nausea, vomiting
• Left lower quadrant abdominal pain
• Alteration of bowel habits (diarrhea/constipation, bloody vs non-bloody)
• Tenesmus

• Labs: CBC, BMP, UA, +/- Type and screen and coagulation panel
• Imaging: CT scan is most commonly used

• ABC’s, IV, O2, Monitor
• Bowel rest, IVF hydration
• IV antibiotics, pain control, anti-emetics
• +/- NGT or Foley
• Surgical consultation

• -Metronidazole 500mg q8h + Ciprofloxacin 500 mg q12h or Clindamycin 300mg q6h
• -Amoxicillin-clavulnate 875mg q12h
• -Moxifloxacin 400mg q24h

• -Metronidazole 500mg + Ciprofloxacin 400mg or Levofloxacin 750mg
• -Ampicillin-sulbacttam 3gm
• -Piperacillin-tazobactom 3.35gm
• -Severe disease: Imipenem 500mg, Meropenem 1gm or Doripenem 500mg