Intern Survival Series GI EMERGENCIES

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Intern Survival SeriesGI EMERGENCIES

• Adib Chaaya MD, PGY5
• ACP, AGA, ASGE
• 7/9/9

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Case 1

• You are the team 1 short call intern. A nurse
  from 10 north pages you in a panic
• The patient in 1023w is vomiting blood!
• You arrive on the floor to find a middle-aged
  male in bed, well awake, vomiting bright red
  blood into a basin.
• What is your next step?

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• Always First thing ABC
• Vitals
• He is afebrile, blood pressure is 90/60, pulse
  is 120/min, sats 96 on room air
• Then review the chart or discuss with the patient
  the different medical problems

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• The nurse tells you that this is a 56-year old
  male with history of alcoholism and IV drug abuse
  admitted for pneumonia.

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• What else are you looking for on history?
• What are you looking for on physical exam?
• What is the differential diagnosis?
• What will you order?
• How will you initially manage the patient?

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What else are you looking for on history?

• History of liver disease/ portal hypertension
  (cirrhotic with variceal bleed)
• Anticoagulation (warfarin/heparin drip)
• Use of NSAIDs, Plavix, ASA, Steroids.
• Multiple episodes of vomiting (Mallory Weiss
  Tear)/ nausea
• Melena ,hematokezia.
• History of AAA repair
• Signs of hypovolemia (dizziness, SOB, CP,
  syncope)

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What are you looking for on physical exam?

• Vital signs hypotension/ tachycardia
• HEENT conjunctival colors (pale/icteric..), JVD
• Skin color pale, lesion, itching signs
• Chest telangiectasia, gynecomastia, hair loss
• Heart tachycaria
• Abdomen ascitis, caput medusae, prominent
  umbilicus, rectal exam (important to assess
  bleeding and prostate)
• Extremities edema, pulse
• Neuro oriented, cooperent, asterixis

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What will you order?

• NPO
• 2 big IV lines
• PPI drip
• Stat CBC/INR/type and cross/BUN
• Octreotide drip (if cirrhotic)
• Antibiotics (if cirrhotic)
• GI consult (stat if cirrhotic)
• To consider ICU consult
• HH every 6-8 hours
• Naso-gastric lavage not always needed
• Correct coagulopathy if needed (high INR give
  FFP)

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Frequent causes of upper GI bleeding

• Esophagus
• Varices
• Mallory Weiss tear
• Esophagitis
• NG trauma
• Duodenum
• Duodenal ulcer
• Aortoenteric fistula (previous AAA graft)
• AVM

• Stomach
• PUD
• Gastric cancer
• Gastritis
• Dieu la foy Lesion
• Gastric varices

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Laboratory

• CBC in rapid blood loss the initial Hct may not
  accurately reflect the amount of blood loss as
  equilibration of the extravascular fluid may take
  several hours.
• PTT, PT/INR, LFTs
• Type and cross
• BUN, Creatinine ratio gt101 suggestive of a
  UGIB. Occurs as a result of breakdown of blood
  proteins by bacteria to urea and re-uptake of
  this from the gut
• Very important to repeat lab values in several
  hours to follow clinical course

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Management

• The initial evaluation of a patient with an
  upper GI bleed involves an assessment of the
  hemodynamic stability and resuscitation if
  necessary.
• 1. ABCs
• 2 large bore IVs, patient should be placed in a
  monitored area
• Fluid resuscitation normal saline
• Type and cross match pRBCs
• Correct any coagulopathy
• 2. Keep NPO - in case of sudden repeat bleed, may
  need urgent endoscopy or even intubation
• 3. EKG/ transfer to a tele bed looking for signs
  of ischemia or infarct
• 4. PPI IV pantoprazole for hemodynamically
  unstable UGIB (Call MAR GI fellow!)
• 5. Endoscopy
• - attempts to identify the source of bleeding
  /- therapeutic
• intervention to achieve hemostasis

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Case 2

• You are the team 2 night float intern. You are in
  the callroom, just about to reach for the last
  chocolate chip cookie. You pager goes off and
  its the nurse on 8
• Doctor, the patient in 863d just had a large,
  bloody bowel movement! What do you want me to
  do?

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• You arrive on the floor to find an 83-year old
  female in mild distress. She complains of diffuse
  abdominal discomfort but no CP/SOB or
  dizziness.
• She is afebrile, her blood pressure is 130/80,
  pulse is 80 and irregular.
• Past medical history includes CAD, HTN, chronic
  atrial fibrillation, AAA (s/p repair) and colon
  polyps.
• Abdominal exam is diffuse mild tenderness but no
  rebound or guarding. Rectal shows bright red
  blood with clots.

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• What else do you want to know on history?
• What is your differential diagnosis?
• What investigations will you order?
• How will you manage the patient?

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Frequent causes of lower GI Bleeding

• Small Bowel
• AVM
• Crohns disease
• Neoplasm
• Meckels diverticulum
• Vasculitis
• Anal
• Hemorrhoid
• Fissure

• Colon
• Diverticulosis
• AVMs (angiodysplasia)
• Ischemic gut
• Infectious
• Inflammatory bowel disease
• Neoplasm
• Coagulopathy

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History

• Make sure that you are not dealing with a severe
  upper GI Bleed gt NG lavage needed most of the
  time
• As with the upper GI bleed it is very important
  to ask question regarding the symptoms of
  hemodynamic instability
• These bleeding episodes are usually bright red,
  as the blood is not first degraded in the gut
• Other questions should be directed at the
  character of bleeding or other associated
  symptoms

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• 1. Volume
• Occult blood loss is associated with colon
  cancer
• Small amounts on the tissue or surface of
  stool associated with hemorrhoids or fissures
• Hematochezia
• Massive blood loss likely due to either
  diverticulosis, angiodysplasia, or occasionally
  aortoenteric fistula
• Must always rule out a massive UGIB! Usually
  site is distal to the pylorus
• 2. Symptoms associated with inflammatory bowel
  disease or any other systemic disease
• 3. Constitutional symptoms or recent change in
  bowel habits suggesting a malignancy
• 4. Food intake which may give a false impression
  of rectal bleeding beets or iron
• 5. Infectious symptoms or recent ingestion of any
  poorly cooked meat

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Management

• Volume resuscitation and management of ABCs
  should be the first priority
• If hemodynamically stable with low volume blood
  loss, the patient can be followed clinically with
  volume resuscitation and blood as needed
• Once the bleeding has settled, the patient can be
  prepped for colonoscopy and the cause of bleeding
  determined

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• If hemodynamically unstable with rapid rates of
  blood loss, other investigations can be arranged
  (CALL MAR, GI FELLOW and ICU fellow)
• 1. Tagged red blood cell scan
• Non-invasive, but only localized bleeding to
  areas of the abdomen. Accuracy ranges from 24-91
  
• Can be positive with 0.1cc/min but diagnostic
  in less then 50
• Once tagged can be easily rescanned
• 2. Angiography
• Needs blood flow of 0.5cc/min to be positive
• Identifies site in 60 of bleeds, 50-80 are a
  result of bleeding from the superior mesenteric
  artery
• Allows for therapeutic intervention
• 3. Surgery
• Consider in patients with ongoing bleeding and
  hemodynamic instability but with failure of other
  therapeutic maneuvers.
• Colonoscopy is not useful in the setting of
  ongoing bleeding so there is no urgent indication.

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Case 3

• You are called by a nurse for the patient on
  926wn.
• 75 y/o F admitted for DVT, now is having
  tachycardia.
• The nurse tells you that this patient need to be
  transferred to a tele bed
• What do you think?
• What should you do?

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Case 4

• You are in the ER doing an admission for a 78y/o
  patient who p/w syncope.
• The ER is admitting him to R/O TIA
• While doing his admission you realize that this
  patients Hgb is 9.9 (however it was 12 one
  month ago) and the HR is 96/min.
• What should you do?

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Case 5

• 37 y/o M, no PMH, admitted for RUQ pain/N/V
  diagnosed with gallstones.
• You got called overnight by the nurse, because
  the patient is febrile at 101.7, tachycardic and
  is having chills and abdominal pain.

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• What else are you looking for on history?
• What are you looking for on physical exam?
• What is the differential diagnosis?
• What will you order?
• How will you initially manage the patient?

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Physical exam

• VS 101.7- 110/min- 100/75
• HEENT jaudiced
• Abd Soft, RUQ tenderness, Positive for murphy
  sign, BS positive.
• No signs of cirrhosis

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Laboratory

• WBC 18
• Hgb 12
• Plt 300

• Tot bili 5
• Direct bili 3.7
• Alk Phos 600
• AST 200
• ALT150

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Case 6

• A nurse calls you from the new building.
• Doctor, my patient is complaining of some
  abdominal pain..
• I had her for the last 2 days and her belly is
  more distended today.

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• What else are you looking for on history?
• What are you looking for on physical exam?
• What is the differential diagnosis?
• What will you order?
• How will you initially manage the patient?

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Any questions?
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Thank you