gi emergencies

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  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

    • 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
  14. Toradol (Ketorolac Tromethamine)
    • - IV NSAID
    • - Indicated for moderate to severe pain
    • - Similar risks to other NSAIDs
    • - CI in those with severe renal disease
  15. ER Care: Opioid Analgesics
    • Analgesic and sedative effects
    • Side effects
    • - Respiratory depression
    • - Nausea and vomiting
    • - Constipation
    • - Urinary retention
    • - Pruritus
    • - Confusion
    • - Muscle rigidity
  16. Morphine
    • - Onset 5-20min
    • - 10-30min peak effect
    • - Duration 2-6hrs
    • * May cause hypotension from histamine release
  17. Morphine Dose
    0.1-0.2mg/kg IV or IM
  18. Hydromorphone (Dilaudid)
    • - Onset 5-20 min
    • - Duration 3-4hrs
    • - Less sedation and nausea

    • Dilaudid Dosing
    • 1-2mg IV
  19. 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
  20. Nausea/vomiting
    Controlled in Brainstem
  21. Visceral Stimulation and chemorecptor n/v
    through dopamine and serotonin
  22. Vestibular &CNS n/v
    causes thru histamine & acetylcholine
  23. N/V causes
    • Primary gastrointestinal disorders
    • Systemic disease
    • CNS disorders
    • Side effects from medications
  24. 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
  25. 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
  26. 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
  27. 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
  28. Anti-emetics
    Phenothiazines
  29. Phenothiazines
    • Anti-emetics
    • Quick onset of action
    • Crosses blood brain barrier and placenta
  30. Phenothiazine side effects
    • Most frequent side effects drowsiness, loss of muscular coordination, tone
    • Tardive dyskinesia
  31. Phenothiazine function
    Act on chemoreceptors in the brain by blocking D1 and D2, alpha-1, cholinergic, adrenegric and histamine receptors
  32. Phenothiazine metab/excrete
    • Primarily hepatic metabolism
    • Half is excreted by kidneys and half through enterohepatic circulation
  33. Phenothiazine CAUTION
    Tardive Dyskinesia: potentially irreversible, involuntary muscle movements that usually involve the tongue, lips, jaw, torso and extremities
  34. Phenothiazine meds
    • Antiemetics
    • Prochlorperazine (Compazine)
    • Promethazine (phenegran)
    • Trimethobenzamide (tigan)
  35. Prochlorperazine (Compazine)
    • 5-10mg PO TID or QID
    • 10mg IV or IM q6H
    • 25mg PR Bid
  36. Promethazine (Phenergan)
    12.5-25mg PO, IM or PR q4-6H
  37. trimethobenzamide (Tigan)
    • 250mg PO TID or QID
    • 200mg IM TID or QID
  38. Serotonin 5 HT3 Receptor Antagonists
    • Selectively block serotonin 3 receptors located in the vagal nerve terminals and CNS chemoreceptor trigger zones
    • Anti emetic
  39. 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
  40. Dopamine antagonistis
    • Reglan
    • Haldol
  41. 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
  42. Reglan metab
    • Metabolized by the liver
    • Excreted mostly by the kidneys, dose adjustment if renal insufficiency present
  43. 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
  44. Haldol
    • Anti-emetic
    • Dopamine antagonist
    • utilized in hospice setting mostly
  45. 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
  46. ANTIHISTAMINE anti-emetic drugs
    • Diphenhydramine
    • Dimenhydrinate
    • MECLIZINE
  47. Diphenhydramine (Benadryl)
    • 25-50mg PO q6-8h
    • 10-50mg IV q2h
  48. Dimenhydrinate (Dramamine)
    50-100mg PO or IV q4-6h
  49. Meclizine (Antivert)
    12.5-25mg 1h before travel
  50. Antihistamine side effects
    confusion, sedation, dizziness, tinnitus, insomnia, fatigue, tremors
  51. 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
  52. Anticholinergics side effects
    dry mouth, urinary retention, blurred vision, exacerbation of narrow angle glaucoma
  53. 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)
  54. 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…
  55. 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
  56. Diarrhea – Pathophysiology
    • Increased intestinal secretions
    • Decreased intestinal absorption
    • Increased osmotic load
    • Abnormal intestinal motility
  57. 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
  58. Diarrhea novirus
    (Novorvirus causes 50-80% of infectious diarrhea in US)
  59. 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
  60. 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
  61. 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
  62. Diarrhea – Antibiotics
    • Only recommended for pts with moderate to severe disease with associated systemic symptoms
    • Antimicrobial of choice depends on offending pathogen
  63. 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
  64. 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
  65. 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)
  66. 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
  67. 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
  68. 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
  69. Anti-diarrheals Agents
    • Use with caution in the elderly
    • None are approved for <2yrs of age
    • Pepto
    • Lomotil
    • Imodium
  70. 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
  71. 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
  72. Lomotil contraindication
    Pt w/ narrow angle glaucoma
  73. 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
  74. 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
  75. Mallory-Weiss Tear Symptoms:
    • History of retching, vomiting or straining
    • - Tachycardic
    • - Hypotensive
    • - Hematemesis
    • - +/- Melena
    • - Abdominal or thoracic pain
  76. Mallory-Weiss Tear dx
    • Diagnosis is initially made clinically from history and PE
    • Obtain CBC, BMP, Coagulation studies
  77. 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
  78. 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
  79. Boerhaave’s Syndrome Symptoms:
    • Hypotensive
    • Tachycardic
    • Lower thoracic pain
    • Subcutaneous emphysema
    • +/- pleural effusions (particularly left sided)
    • Abdominal rigidity
  80. 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
  81. Boehaaves syndrome cxr
    • - mediastinal widening
    • - unilateral pleural effusion (left side)
    • - hydropneumothorax
    • - pneumomediastinum
  82. 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
  83. Cholelithiasis
    gallstones without inflammation
  84. Acute Cholecystitis
    gallstones with gallbladder inflammation
  85. Acalculous Cholecystitis
    gallbladder inflammation without stones
  86. Choledocholithiasis
    gallstones in the common bile duct
  87. Cholangitis
    inflammation, infection of the common bile duct
  88. Biliary dyskinesia
    impaired function of gallbladder emptying
  89. 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)
  90. 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
  91. 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
  92. Gallbladder Disease: Labs
    • Elevated Bilirubin, Aspartate Aminotransferase, Alkaline Phosphatase
    • Each 70% sensitive and 42% specific
  93. Gallbladder Disease ultrasound
    • Gold standard, 91% sensitivity
    • - Distended gallbladder
    • - Thickened wall >5mm
    • - Peri-cholecystic fluid
    • - gallstones/sludge
    • - dilated CBD
    • - sonographic Murphy’s sign
  94. Gallbladder Imaging
    • US
    • CT
    • HIDA
  95. CT Scan Abdomen gall bladder
    can demonstrate distention, wall thickening, stones and surrounding fluid but less sensitive than US
  96. 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
  97. Gallbladder Disease Treatment
    • Criteria for discharge to home with follow up
    • - Symptoms are controlled
    • - No “itis”
  98. 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
  99. Gallbladder Disease Admission Criteria
    • - Fever
    • - “Itis” , blocked CBD
    • - Uncontrolled N/V or abdominal pain
  100. Gall bladder Initial ER treatment
    • NPO, IVF hydration
    • - pain control, anti-emetics
    • - IV antibiotics
    • - Surgery consult, +/- GI consult
  101. Gallbladder Disease – Antibiotics
    Gram Negative and Anaerobic coverage
  102. 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
  103. PCN allergy gall bladder
    Ciprofloxacin 400mg IV q12h + Metronidazole 500mg q6h
  104. 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
  105. Acute Pancreatitis – Etiology
    • Gallstones and Alcohol account for 70-80% of all cases
    • 10% have unknown etiology
  106. Gallstones:
    • - pass through the ampulla of Vater causing obstruction of the pancreatic duct
    • 5% of patients with gallstones will develop pancreatitis
  107. 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
  108. pancreatitis Drugs, Toxins and Metabolic Factors:
    • example offenders: azathioprine, valproic acid,
    • furosemide, sulfonamides, aminosalicylates
    • Elevated triglycerides
  109. Acute Pancreatitis Trauma:
    • - Post ERCP: risk ranges from 5-20%
    • - Post op: ex. Ischemia following cardiopulmonary bypass
    • - Blunt or penetrating trauma
  110. Pancreatitis Infections:
    - Ascaris lumbricoides, CMV, Coxsackie B virus, Mumps virus
  111. Acute Pancreatitis – Symptoms
    • Fever
    • Chills
    • Fatigue
    • Nausea
    • Vomiting
    • Abdominal pain – progressively worsening, steady epigastric pain, radiation to back, that lasts for days
  112. 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.
  113. 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
  114. 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
  115. Amylase
    • - starts to increase within the first few hours of onset
    • - can be elevated from a variety of extra abdominal conditions
  116. Pancreatitis – Imaging
    • US
    • Abd/pelvic CT
  117. 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
  118. 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
  119. 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
  120. Acute Pancreatitis – 3 Criteria for Dx’s
    • Characteristic Abdominal Pain
    • Elevation (typically 3x) Amylase and Lipase
    • CT or US findings
  121. 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
  122. 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
  123. Acute Appendicitis – Epidemiology
    • Lifetime incidence is 7-9%
    • Prevalence 10-30yrs old
    • Males > Females (3:2)
    • Most common cause of the acute surgical abdomen
  124. Acute Appendicitis – Pathophysiology
    • Thought to be obstruction of the appendiceal lumen
    • Distention  Ischemia  Bacterial overgrowth  perforation  abscess formation
  125. Appendicitis Causes of Obstruction
    • - Fecalith
    • - Lymphoid tissue (peds)
    • - Vegetable, fruit seeds, foreign body
    • - Intestinal worms (Ascarid)
    • - Strictures, fibrosis, neoplasms
  126. 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
  127. Appendicitis Pediatrics
    more often present with high fever, more vomiting and diarrhea
  128. 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
  129. 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
  130. Acute Appendicitis – Diagnostic Labs
    • CBC – leukocytosis with left shift
    • Pregnancy screen in all woman of childbearing age
    • UA
  131. Acute Appendicitis – Diagnostic Imaging
    • Us abd
    • Ct abd/pelvis w/ contrast
    • Mri
  132. Ultrasound Abdomen appendicitis
    • - more likely to start here with females and children
    • - can rule in the diagnosis but not exclude
  133. Appendicitis CT abdomen and pelvis with contrast
    • 985 sensitive, 95% specificity
    • - concern about radiation
    • - will confirm or rule out diagnosis
  134. MRI a ppendicits
    - 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)
  135. Uncomplicated appendicitis
    Ampicillin/sulbactam (Unasyn) or Cefoxitin
  136. Complicated appendicitis
    • – Piperacillin/tazobactam (Zosyn) or
    • Ticarcillan/clauvanate (Timentin)
  137. Bowel Obstruction
    • Small bowel obstruction is more common than large bowel obstruction
    • Can be Mechanical or Functional
  138. Functional bowel obstruction
    • = adynamic or paralytic ileus
    • Ileus is much more common
    • Example of adynamic is Ogilvie Syndrome
  139. Bowel obstructionMechanical Obstructions
    • A = Adhesions
    • B = Bulge (aka Hernia)
    • C = Cancer (more common in large bowel)
  140. Bowel obstrucitons Additional Etiologies:
    • Inflammatory Bowel disease – Ulcerative Colitis, Crohn’s disease (stricture)
    • Foreign body; Intra-abdominal abscess
    • Intussusception; Fecal impaction
    • Diverticulitis (stricture)
  141. 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
  142. Review Bowel Obstruction hx
    • Previous abdominal surgeries
    • History of inflammatory bowel disease
    • History of a known hernia
    • Colonoscopy?
  143. 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)
  144. 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
  145. 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
  146. Bowel obstruction Xray
    • chest– looking for free air under the diaphragm
    • abd– supine – dilated loops of bowel, upright – air fluid levels
  147. 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…)
  148. 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
  149. Colonic Volvulus
    • results in colonic obstruction when the colon twists on it’s mesentery
    • >90% involve the Sigmoid colon
  150. Colonic volvus risk
    • 1. Elderly
    • 2. Hx/o Chronic constipation
    • 3. Hx/o Laxative use
    • 4. Hx/o Psychiatric illness
  151. 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
  152. 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
  153. 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
  154. Hernias
    “Area of weakness or frank disruption of the fibromuscular tissues of the body wall through which intra-cavity structures pass”
  155. Hernias – Types
    • Inguinal
    • Direct or indirect or pantaloon
    • Ventral; Incisional; Femoral; Umbilical
    • Spigelian
    • Reducible; Irreducible
    • Strangulated; Richter; sliding
  156. Direct inguinal
    : herniation through defect in transversalis fascia of abdominal wall medial to the inferior epigastric vessels
  157. Indirect inguinal
    herniation lateral to the inferior epigastric vessels through the internal inguinal ring in the inguinal canal
  158. Pantaloon
    • combination of direct and indirect hernia.
    • Protrusion of abdominal wall on both sides of the epigastric vessels.
  159. Femoral
    herniation that descends through the femoral canal deep to the inguinal ligament
  160. Incisional
    herniation through a defect at the site of a prior surgical incision
  161. Ventral
    Herniation through abdominal wall
  162. Umbilical
    Herniation through a defect at the umbilical ring
  163. Spigelian Hernia
    hernia sac insinuates itself between the layers of the abdominal wall.
  164. Reducible
    \ extruded sac and contents can be returned to it’s original intra-abdominal position
  165. Irreducible/Incarcerated
    extruded sac and contents cannot be returned to it’s original intra-abdominal position
  166. Strangulated
    bloody supply to the hernia sac and contents is compromised
  167. Richter
    partial circumference of the bowel is incarcerated or strangulated.
  168. Sliding
    wall of the viscus forms part of the wall of the hernia sac
  169. 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
  170. Hernia rf
    • Increased age
    • Increased abdominal pressure
    • Obesity
    • Smoking
    • Pregnancy
    • Chronic Steroid use
    • Prematurity
  171. Hernia S/Sx’s
    • pain, nausea, vomiting,
    • bloating, decreased bowel function
  172. hernia PE
    • Examine supine and standing
    • May observe and palpate a bulge
  173. 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
  174. 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
  175. 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
  176. 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
  177. UGI Bleed ssx
    • fatigue, dizziness, lightheadedness,
    • hematemesis (coffee-ground appearance),
    • melena (15-20% will have hematochezia due to brisk bleeding)
  178. LGI Bleed ssx
    fatigue, dizziness, lightheadedness, hematochezia, BRBPR,
  179. gi bleeds general Signs
    • 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
  180. LGI
    • Diverticulosis ( most common)
    • Hemorrhoids
    • Tumors
    • Ischemic Colitis
  181. GI bleed PE
    VS (orthostatics), General, Skin, CVS, Pulmonary, Abdominal, DRE
  182. 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)
  183. 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
  184. 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
  185. Visceral Artery Insufficiency
    • Acute or Chronic
    • Occlusive vs Non-occlusive
  186. Occlusive visceral artery insufficiency
    results from an embolic occlusion or primary thrombosis of at least 1 major mesenteric vessel
  187. Non-occlusive visteral artery insufficiency
    is seen in patients with low flow states (heart failure or from hypotension)
  188. Visceral Artery Insufficiency ssx key
    “Key is severe, steady epigastric or periumbilical pain with minimal to no findings on physical exam.”
  189. Visceral Artery Insufficiency ssx
    • Fever
    • Tachycardia
    • Hypotension
    • Nausea and vomiting
    • Abdominal distention
    • Diarrhea (may be bloody from sloughing of the inner wall)
  190. 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
  191. 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
  192. Visceral Artery Insufficiency tx
    • ABCs
    • IV/O2/Monitor
    • NPO, IVF hydration
    • Pain control/anti-emetics
    • IV antibiotics
    • Foley
    • Call surgery
  193. Ischemic colitis prognosis
    has a better prognosis due to collateral circulation and usually improves with conservative treatment.
  194. Diverticulitis ssx
    • Fever
    • Hypotension
    • Chills
    • Nausea, vomiting
    • Left lower quadrant abdominal pain
    • Alteration of bowel habits (diarrhea/constipation, bloody vs non-bloody)
    • Tenesmus
  195. Diverticulitis Diagnostics:
    • Labs: CBC, BMP, UA, +/- Type and screen and coagulation panel
    • Imaging: CT scan is most commonly used
  196. Diverticulitis Treatment:
    • ABC’s, IV, O2, Monitor
    • Bowel rest, IVF hydration
    • IV antibiotics, pain control, anti-emetics
    • +/- NGT or Foley
    • Surgical consultation
  197. Diverticulitis abx PO regimens
    • -Metronidazole 500mg q8h + Ciprofloxacin 500 mg q12h or Clindamycin 300mg q6h
    • -Amoxicillin-clavulnate 875mg q12h
    • -Moxifloxacin 400mg q24h
  198. 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
Author:
alyspins
ID:
307286
Card Set:
gi emergencies
Updated:
2015-09-03 05:50:58
Tags:
emergency medicine
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Description:
gi emergencies
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