gi emergencies

Card Set Information

Author:
alyspins
ID:
307286
Filename:
gi emergencies
Updated:
2015-09-03 01:50:58
Tags:
emergency medicine
Folders:

Description:
gi emergencies
Show Answers:

Home > Flashcards > Print Preview

The flashcards below were created by user alyspins on FreezingBlue Flashcards. What would you like to do?


  1. Abd pain Epidemiology
    • 6.7% of all visits
    • 8.04 million patient encounters annually
    • Admission rates: 18-42%
    • Admission rate as high as 63% in those >65YO
  2. Foregut
    • (stomach duodenum, biliary tract)
    • - supplied by Celiac Trunk
    • - Produces epigastric pain
  3. Midgut
    • (most of the small bowel, appendix, cecum)
    • - supplied by SMA
    • - produces periumbilical pain
  4. Hindgut (transverse and left colon, rectum, intraperitoneal portions of GU tract)
    • - supplied by IMA
    • - Produces suprapubic pain
  5. Parietal Pain
    Sharp, well characterized and precisely localized by patient
  6. Visceral pain
    • Vague, dull diffuse in character
    • Steady or cramp-like/intermittent pain resulting from peristalic contractions
  7. Skin
    palor, jaundice, diaphoretic, rashes, scars
  8. Physical exam
    • General, skin, heart & lung
    • Abdominal, pelvic and rectal
  9. Special Populations
    • Elderly
    • Dementia patients
    • Psychiatric patients
    • Spinal Cord Injuries
    • Immunocompromised
    • Pt’s with significant Ascites
  10. Diagnostic Testing - Labs
    • Beta Hcg on all women of childbearing age
    • CBC
    • BMP
    • Coagulation Studies
    • Hepatic Panel/Liver function tests
    • Lipase
    • Lactate
    • Urinalysis
    • Heme occult blood
  11. Diagnostic Testing - Imaging
    • Ultrasound
    • Abdominal x-ray – determine views needed
    • CT +/- contrast
  12. ER Care
    • IV Fluid Resuscitation
    • Analgesics
    • Anti-emetics
    • +/- Antibiotics
  13. Acetaminophen (Tylenol)/ofrimev(IV)
    • – Analgesic and anti-inflammatory agent
    • - NO antiplatelet effect
    • - Safe in all age groups
    • - Hepatotoxicity can occur at doses 140mg/kg/d
  14. 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
  15. Toradol (Ketorolac Tromethamine)
    • - IV NSAID
    • - Indicated for moderate to severe pain
    • - Similar risks to other NSAIDs
    • - CI in those with severe renal disease
  16. ER Care: Opioid Analgesics
    • Analgesic and sedative effects
    • Side effects
    • - Respiratory depression
    • - Nausea and vomiting
    • - Constipation
    • - Urinary retention
    • - Pruritus
    • - Confusion
    • - Muscle rigidity
  17. Morphine
    • - Onset 5-20min
    • - 10-30min peak effect
    • - Duration 2-6hrs
    • * May cause hypotension from histamine release
  18. Morphine Dose
    0.1-0.2mg/kg IV or IM
  19. Hydromorphone (Dilaudid)
    • - Onset 5-20 min
    • - Duration 3-4hrs
    • - Less sedation and nausea
  20. Dilaudid Dosing
    1-2mg IV
  21. Indications for admission gi
    • 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
  22. Nausea/vomiting
    Controlled in Brainstem
  23. Visceral Stimulation and chemorecptor n/v
    through dopamine and serotonin
  24. Vestibular &CNS n/v
    causes thru histamine & acetylcholine
  25. N/V causes
    • Primary gastrointestinal disorders
    • Systemic disease
    • CNS disorders
    • Side effects from medications
  26. N/V hx pt
    • 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
  27. N/V PE
    • 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
  28. N/V dx
    • 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
  29. N/V tx
    • 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
  30. Anti-emetics
    Phenothiazines
  31. Phenothiazines
    • Anti-emetics
    • Quick onset of action
    • Crosses blood brain barrier and placenta
  32. Phenothiazine side effects
    • Most frequent side effects drowsiness, loss of muscular coordination, tone
    • Tardive dyskinesia
  33. Phenothiazine function
    Act on chemoreceptors in the brain by blocking D1 and D2, alpha-1, cholinergic, adrenegric and histamine receptors
  34. Phenothiazine metab/excrete
    • Primarily hepatic metabolism
    • Half is excreted by kidneys and half through enterohepatic circulation
  35. Phenothiazine CAUTION
    Tardive Dyskinesia: potentially irreversible, involuntary muscle movements that usually involve the tongue, lips, jaw, torso and extremities
  36. Phenothiazine meds
    • Antiemetics
    • Prochlorperazine (Compazine)
    • Promethazine (phenegran)
    • Trimethobenzamide (tigan)
  37. Prochlorperazine (Compazine)
    • 5-10mg PO TID or QID
    • 10mg IV or IM q6H
    • 25mg PR Bid
  38. Promethazine (Phenergan)
    12.5-25mg PO, IM or PR q4-6H
  39. trimethobenzamide (Tigan)
    • 250mg PO TID or QID
    • 200mg IM TID or QID
  40. Serotonin 5 HT3 Receptor Antagonists
    • Selectively block serotonin 3 receptors located in the vagal nerve terminals and CNS chemoreceptor trigger zones
    • Anti emetic
  41. Ondansetron (Zofran)
    • 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
  42. Dopamine antagonistis
    • Reglan
    • Haldol
  43. Metoclopramide (Reglan)
    • 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
  44. Reglan metab
    • Metabolized by the liver
    • Excreted mostly by the kidneys, dose adjustment if renal insufficiency present
  45. Reglan side effects
    • Extensive side effects: sedation, orthostatic hypotension and extrapyramidal symptoms (tardive dyskinesia)
    • Do not give to patients with bowel obstruction, Parkison’s disease, depression
  46. Haldol
    • Anti-emetic
    • Dopamine antagonist
    • utilized in hospice setting mostly
  47. Antihistamine Agents
    • 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
  48. ANTIHISTAMINE anti-emetic drugs
    • Diphenhydramine
    • Dimenhydrinate
    • MECLIZINE
  49. Diphenhydramine (Benadryl)
    • 25-50mg PO q6-8h
    • 10-50mg IV q2h
  50. Dimenhydrinate (Dramamine)
    50-100mg PO or IV q4-6h
  51. Meclizine (Antivert)
    12.5-25mg 1h before travel
  52. Antihistamine side effects
    confusion, sedation, dizziness, tinnitus, insomnia, fatigue, tremors
  53. Scopolamine patch
    • 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
  54. Anticholinergics side effects
    dry mouth, urinary retention, blurred vision, exacerbation of narrow angle glaucoma
  55. N/V admit
    • Pt’s with severe dehydration, electrolyte abnormalities,
    • renal impairment,
    • and inability to tolerate PO despite anti-emetics
    • (Special attention to peds and elderly)
  56. n/v d/c
    • 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…
  57. Diarrhea
    • 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
  58. Diarrhea – Pathophysiology
    • Increased intestinal secretions
    • Decreased intestinal absorption
    • Increased osmotic load
    • Abnormal intestinal motility
  59. Diarrhea causes
    • 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
  60. Diarrhea novirus
    (Novorvirus causes 50-80% of infectious diarrhea in US)
  61. Diarrhea – Physical assessment
    • 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
  62. Diarrhea – Diagnostics
    • 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
  63. Diarrhea – Treatment
    • 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
  64. Diarrhea – Antibiotics
    • Only recommended for pts with moderate to severe disease with associated systemic symptoms
    • Antimicrobial of choice depends on offending pathogen
  65. Anti-motility agents and diarrhea
    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
  66. Antibiotics and anti-motility agents use
    should NOT be used in patient’s with Shiga toxin producing E-coli O157:H7 due to risk of Hemolytic uremic syndrome
  67. Antibiotic Examples: Infectious Diarrhea
    • Ciprofloxacin 500mg x 1 day or 500mg BID x 3 days
    • Trimethoprim/sulfamethoxazole 10-50mg/kg/day x 3 days (children and nursing mothers)
  68. Antibiotic Treatment: C-difficile
    • - 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
  69. Diarrhea Amebiasis abx tx
    • - 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
  70. Giardiasis diarrhea tx
    • - Metronidazole 250mg PO TID for 5-7 days or
    • - Tinidazole 2g x 1 dose or
    • - Quinacrine 100mg PO TID for 7 days
  71. Anti-diarrheals Agents
    • Use with caution in the elderly
    • None are approved for <2yrs of age
    • Pepto
    • Lomotil
    • Imodium
  72. Bismuth Subslicylate (Pepto-Bismol or Kaopectate)
    • 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
  73. Diphenoxylate with Atropine (Lomotil)
    • - “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
  74. Lomotil contraindication
    Pt w/ narrow angle glaucoma
  75. Loperamide Hydrochloride (Imodium)
    • - “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
  76. Mallory-Weiss Tear
    • 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
  77. Mallory-Weiss Tear Symptoms:
    • History of retching, vomiting or straining
    • - Tachycardic
    • - Hypotensive
    • - Hematemesis
    • - +/- Melena
    • - Abdominal or thoracic pain
  78. Mallory-Weiss Tear dx
    • Diagnosis is initially made clinically from history and PE
    • Obtain CBC, BMP, Coagulation studies
  79. Mallory-weiss Initiate treatment
    • - 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
  80. Boerhaave’s Syndrome
    • 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
  81. Boerhaave’s Syndrome Symptoms:
    • Hypotensive
    • Tachycardic
    • Lower thoracic pain
    • Subcutaneous emphysema
    • +/- pleural effusions (particularly left sided)
    • Abdominal rigidity
  82. Boerhaave’s Syndrome Diagnostics
    • 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
  83. Boehaaves syndrome cxr
    • - mediastinal widening
    • - unilateral pleural effusion (left side)
    • - hydropneumothorax
    • - pneumomediastinum
  84. Boerhaave’s Syndrome – Treatment
    • 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
  85. Cholelithiasis
    gallstones without inflammation
  86. Acute Cholecystitis
    gallstones with gallbladder inflammation
  87. Acalculous Cholecystitis
    gallbladder inflammation without stones
  88. Choledocholithiasis
    gallstones in the common bile duct
  89. Cholangitis
    inflammation, infection of the common bile duct
  90. Biliary dyskinesia
    impaired function of gallbladder emptying
  91. Gallbladder Disease Risk Factors
    • 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)
  92. Gallbladder Disease Signs and Symptoms
    • 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
  93. Gallbladder Disease – Physical Exam
    • 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
  94. Gallbladder Disease: Labs
    • Elevated Bilirubin, Aspartate Aminotransferase, Alkaline Phosphatase
    • Each 70% sensitive and 42% specific
  95. Gallbladder Disease ultrasound
    • Gold standard, 91% sensitivity
    • - Distended gallbladder
    • - Thickened wall >5mm
    • - Peri-cholecystic fluid
    • - gallstones/sludge
    • - dilated CBD
    • - sonographic Murphy’s sign
  96. Gallbladder Imaging
    • US
    • CT
    • HIDA
  97. CT Scan Abdomen gall bladder
    can demonstrate distention, wall thickening, stones and surrounding fluid but less sensitive than US
  98. HIDA:
    • 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
  99. Gallbladder Disease Treatment
    • Criteria for discharge to home with follow up
    • - Symptoms are controlled
    • - No “itis”
  100. Gall bladder Discharge home
    • - 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
  101. Gallbladder Disease Admission Criteria
    • - Fever
    • - “Itis” , blocked CBD
    • - Uncontrolled N/V or abdominal pain
  102. Gall bladder Initial ER treatment
    • NPO, IVF hydration
    • - pain control, anti-emetics
    • - IV antibiotics
    • - Surgery consult, +/- GI consult
  103. Gallbladder Disease – Antibiotics
    Gram Negative and Anaerobic coverage
  104. Example regimens gall bladder
    • 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
  105. PCN allergy gall bladder
    Ciprofloxacin 400mg IV q12h + Metronidazole 500mg q6h
  106. Acute Pancreatitis – Epidemiology
    • Ranges from 5-30 cases per 100,000 people
    • 250,000 hospital admissions annually
    • Costing $4-6 billion in health care dollars
  107. Acute Pancreatitis – Etiology
    • Gallstones and Alcohol account for 70-80% of all cases
    • 10% have unknown etiology
  108. Gallstones:
    • - pass through the ampulla of Vater causing obstruction of the pancreatic duct
    • 5% of patients with gallstones will develop pancreatitis
  109. Alcohol and 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
  110. pancreatitis Drugs, Toxins and Metabolic Factors:
    • example offenders: azathioprine, valproic acid,
    • furosemide, sulfonamides, aminosalicylates
    • Elevated triglycerides
  111. Acute Pancreatitis Trauma:
    • - Post ERCP: risk ranges from 5-20%
    • - Post op: ex. Ischemia following cardiopulmonary bypass
    • - Blunt or penetrating trauma
  112. Pancreatitis Infections:
    - Ascaris lumbricoides, CMV, Coxsackie B virus, Mumps virus
  113. Acute Pancreatitis – Symptoms
    • Fever
    • Chills
    • Fatigue
    • Nausea
    • Vomiting
    • Abdominal pain – progressively worsening, steady epigastric pain, radiation to back, that lasts for days
  114. Acute Pancreatitis – Physical Exam
    • 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.
  115. Acute Pancreatitis – Diagnostic Labs
    • 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
  116. Lipase acute pancreatitis
    • - 90% sensitivity
    • - start to increase within the first few hours of onset
    • - remains elevated longer than amylase
    • - More specific to the pancreas than amylase
  117. Amylase
    • - starts to increase within the first few hours of onset
    • - can be elevated from a variety of extra abdominal conditions
  118. Pancreatitis – Imaging
    • US
    • Abd/pelvic CT
  119. Pancreatitis Ultrasound
    • - 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
  120. Acute Pancreatitis CT Abdomen and Pelvis
    • – 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
  121. Ct pancreatic nectrosis
    • 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
  122. Acute Pancreatitis – 3 Criteria for Dx’s
    • Characteristic Abdominal Pain
    • Elevation (typically 3x) Amylase and Lipase
    • CT or US findings
  123. Acute Pancreatitis – Treatment
    • 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
  124. Ranson’s Criteria Mortality Prediction
    • 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
  125. Acute Appendicitis – Epidemiology
    • Lifetime incidence is 7-9%
    • Prevalence 10-30yrs old
    • Males > Females (3:2)
    • Most common cause of the acute surgical abdomen
  126. Acute Appendicitis – Pathophysiology
    • Thought to be obstruction of the appendiceal lumen
    • Distention  Ischemia  Bacterial overgrowth  perforation  abscess formation
  127. Appendicitis Causes of Obstruction
    • - Fecalith
    • - Lymphoid tissue (peds)
    • - Vegetable, fruit seeds, foreign body
    • - Intestinal worms (Ascarid)
    • - Strictures, fibrosis, neoplasms
  128. Acute Appendicitis – History
    • 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
  129. Appendicitis Pediatrics
    more often present with high fever, more vomiting and diarrhea
  130. Pregnancy appendicitis
    • 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
  131. Acute Appendicitis – Physical exam
    • 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
  132. Acute Appendicitis – Diagnostic Labs
    • CBC – leukocytosis with left shift
    • Pregnancy screen in all woman of childbearing age
    • UA
  133. Acute Appendicitis – Diagnostic Imaging
    • Us abd
    • Ct abd/pelvis w/ contrast
    • Mri
  134. Ultrasound Abdomen appendicitis
    • - more likely to start here with females and children
    • - can rule in the diagnosis but not exclude
  135. Appendicitis CT abdomen and pelvis with contrast
    • 985 sensitive, 95% specificity
    • - concern about radiation
    • - will confirm or rule out diagnosis
  136. MRI a ppendicits
    - growing in popularity due to lack of radiation
  137. 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)
  138. Uncomplicated appendicitis
    Ampicillin/sulbactam (Unasyn) or Cefoxitin
  139. Complicated appendicitis
    • – Piperacillin/tazobactam (Zosyn) or
    • Ticarcillan/clauvanate (Timentin)
  140. Bowel Obstruction
    • Small bowel obstruction is more common than large bowel obstruction
    • Can be Mechanical or Functional
  141. Functional bowel obstruction
    • = adynamic or paralytic ileus
    • Ileus is much more common
    • Example of adynamic is Ogilvie Syndrome
  142. Bowel obstructionMechanical Obstructions
    • A = Adhesions
    • B = Bulge (aka Hernia)
    • C = Cancer (more common in large bowel)
  143. Bowel obstrucitons Additional Etiologies:
    • Inflammatory Bowel disease – Ulcerative Colitis, Crohn’s disease (stricture)
    • Foreign body; Intra-abdominal abscess
    • Intussusception; Fecal impaction
    • Diverticulitis (stricture)
  144. Bowel Obstruction Pathophysiology:
    • 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
  145. Review Bowel Obstruction hx
    • Previous abdominal surgeries
    • History of inflammatory bowel disease
    • History of a known hernia
    • Colonoscopy?
  146. Bowel Obstruction Symptoms
    • BELCHING
    • Nausea
    • Vomiting (emesis can be bilious or feculent)
    • Abdominal pain – colicky = intermittent, cramp like
    • Abdominal distention/bloating
    • Decreased flatus
    • Diarrhea (early) constipation (late)
  147. Bowel Obstruction Physical Exam
    • 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
  148. Bowel Obstruction Diagnosis
    • Usually can be made with good history and PE
    • Labs: CBC, BMP, +/- LFTs, Coagulation studies, Lactate, Type and Screen
    • Imaging:
    • CXR; AXR
    • CT +/- contrast
  149. Bowel obstruction Xray
    • chest– looking for free air under the diaphragm
    • abd– supine – dilated loops of bowel, upright – air fluid levels
  150. bowel obstCT +/- Contrast – can identify:
    • 1. Partial vs complete obstruction
    • 2. Obstruction vs ileus
    • 3. Cause of obstruction (mass vs hernia vs adhesions vs stricture…)
  151. bowel obstructionTreatment
    • 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
  152. Colonic Volvulus
    • results in colonic obstruction when the colon twists on it’s mesentery
    • >90% involve the Sigmoid colon
  153. Colonic volvus risk
    • 1. Elderly
    • 2. Hx/o Chronic constipation
    • 3. Hx/o Laxative use
    • 4. Hx/o Psychiatric illness
  154. Colonic Volvulus Symptoms
    • Nausea
    • Vomiting
    • Acute abdominal distention
    • Abdominal pain – will progress as blood flow is compromised leading to bowel wall ischemia, necrosis and perforation
  155. Colonic Volvulus Diagnosis
    • 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
  156. Colonic Volvulus Treatment
    • 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
  157. Hernias
    “Area of weakness or frank disruption of the fibromuscular tissues of the body wall through which intra-cavity structures pass”
  158. Hernias – Types
    • Inguinal
    • Direct or indirect or pantaloon
    • Ventral; Incisional; Femoral; Umbilical
    • Spigelian
    • Reducible; Irreducible
    • Strangulated; Richter; sliding
  159. Direct inguinal
    : herniation through defect in transversalis fascia of abdominal wall medial to the inferior epigastric vessels
  160. Indirect inguinal
    herniation lateral to the inferior epigastric vessels through the internal inguinal ring in the inguinal canal
  161. Pantaloon
    • combination of direct and indirect hernia.
    • Protrusion of abdominal wall on both sides of the epigastric vessels.
  162. Femoral
    herniation that descends through the femoral canal deep to the inguinal ligament
  163. Incisional
    herniation through a defect at the site of a prior surgical incision
  164. Ventral
    Herniation through abdominal wall
  165. Umbilical
    Herniation through a defect at the umbilical ring
  166. Spigelian Hernia
    hernia sac insinuates itself between the layers of the abdominal wall.
  167. Reducible
    \ extruded sac and contents can be returned to it’s original intra-abdominal position
  168. Irreducible/Incarcerated
    extruded sac and contents cannot be returned to it’s original intra-abdominal position
  169. Strangulated
    bloody supply to the hernia sac and contents is compromised
  170. Richter
    partial circumference of the bowel is incarcerated or strangulated.
  171. Sliding
    wall of the viscus forms part of the wall of the hernia sac
  172. Hernias – Epidemiology
    • 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
  173. Hernia rf
    • Increased age
    • Increased abdominal pressure
    • Obesity
    • Smoking
    • Pregnancy
    • Chronic Steroid use
    • Prematurity
  174. Hernia S/Sx’s
    • pain, nausea, vomiting,
    • bloating, decreased bowel function
  175. hernia PE
    • Examine supine and standing
    • May observe and palpate a bulge
  176. Hernia Diagnostics
    • 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
  177. Hernias – Treatment
    • 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
  178. GI Bleed Review - Epidemiology
    • 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
  179. GI Bleed – Risk Factors
    • More common in males and the elderly
    • ASA or NSAID use
    • Known or suspected liver disease
    • Heavy ETOH
    • Vomiting
    • Hx/o diverticulosis
  180. UGI Bleed ssx
    • fatigue, dizziness, lightheadedness,
    • hematemesis (coffee-ground appearance),
    • melena (15-20% will have hematochezia due to brisk bleeding)
  181. LGI Bleed ssx
    fatigue, dizziness, lightheadedness, hematochezia, BRBPR,
  182. gi bleeds general Signs
    • will depend on if bleed is Acute vs Chronic
    • Tachycardia
    • Hypotension
    • Orthostatic Hypotension
  183. 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
  184. LGI
    • Diverticulosis ( most common)
    • Hemorrhoids
    • Tumors
    • Ischemic Colitis
  185. GI bleed PE
    VS (orthostatics), General, Skin, CVS, Pulmonary, Abdominal, DRE
  186. Gi bleed diagnostic
    • 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)
  187. GI Bleed – Treatment
    • 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
  188. GI Bleed Poor Prognostic Indicators
    • Initial Hematocrit <30%
    • Initial systolic BP <100mmHg
    • Red blood in NGT lavage/Hematemesis
    • Comorbidities (liver disease)
    • Coagulopathy
    • Need for multiple transfusions
  189. Visceral Artery Insufficiency
    • Acute or Chronic
    • Occlusive vs Non-occlusive
  190. Occlusive visceral artery insufficiency
    results from an embolic occlusion or primary thrombosis of at least 1 major mesenteric vessel
  191. Non-occlusive visteral artery insufficiency
    is seen in patients with low flow states (heart failure or from hypotension)
  192. Visceral Artery Insufficiency ssx key
    “Key is severe, steady epigastric or periumbilical pain with minimal to no findings on physical exam.”
  193. Visceral Artery Insufficiency ssx
    • Fever
    • Tachycardia
    • Hypotension
    • Nausea and vomiting
    • Abdominal distention
    • Diarrhea (may be bloody from sloughing of the inner wall)
  194. Visceral Artery Insufficiency diagnostics
    • 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
  195. Visceral Artery Insufficiency CT
    • 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
  196. Visceral Artery Insufficiency tx
    • ABCs
    • IV/O2/Monitor
    • NPO, IVF hydration
    • Pain control/anti-emetics
    • IV antibiotics
    • Foley
    • Call surgery
  197. Ischemic colitis prognosis
    has a better prognosis due to collateral circulation and usually improves with conservative treatment.
  198. Diverticulitis ssx
    • Fever
    • Hypotension
    • Chills
    • Nausea, vomiting
    • Left lower quadrant abdominal pain
    • Alteration of bowel habits (diarrhea/constipation, bloody vs non-bloody)
    • Tenesmus
  199. Diverticulitis Diagnostics:
    • Labs: CBC, BMP, UA, +/- Type and screen and coagulation panel
    • Imaging: CT scan is most commonly used
  200. Diverticulitis Treatment:
    • ABC’s, IV, O2, Monitor
    • Bowel rest, IVF hydration
    • IV antibiotics, pain control, anti-emetics
    • +/- NGT or Foley
    • Surgical consultation
  201. Diverticulitis abx PO regimens
    • -Metronidazole 500mg q8h + Ciprofloxacin 500 mg q12h or Clindamycin 300mg q6h
    • -Amoxicillin-clavulnate 875mg q12h
    • -Moxifloxacin 400mg q24h
  202. Diverticulitis abx IV regimens
    • -Metronidazole 500mg + Ciprofloxacin 400mg or Levofloxacin 750mg
    • -Ampicillin-sulbacttam 3gm
    • -Piperacillin-tazobactom 3.35gm
    • -Severe disease: Imipenem 500mg, Meropenem 1gm or Doripenem 500mg

What would you like to do?

Home > Flashcards > Print Preview