Intro to Dworken (GI)

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Intro to Dworken (GI)

• Intern Boot Camp
• Jacob Sadik, PGY3

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What You Will Learn

• How to survive Dworken
• How to recognize when a GI patient is sick
• How to diagnose/manage a few commonly-encountered
  GI diseases
• (Biliary disease, transaminitis, comprehensive
  discussion on GIB, hepatitis and cirrhosis
  covered in other boot camp lectures)

High-Yield Slides
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Dworken

• Lksd 55 is your home
• 2 interns, 1 senior, 2 fellows, 2 attendings
  (liver, GI)
• Spend time in the endoscopy lab when you can!
• Your senior/fellow are always there to help!!

The only stupid question is the one you didnt
ask!
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Dworken Patients

• Take a GI-focused history
• Prior GI diagnoses
• Prior endoscopic studies (EGD, C-scope, CE, ERCP)
• NSAIDs, anti-platelets, anticoagulation
• Shadow of a doubt?...make NPO!
• Know your overnight admissions well!!!
• Notify primary gastroenterologist re admission
• Rectal exams on all bleeding patients (even if
  done in the ED)
• No consults for hemoccult positive stools!!!
• OARRS. is.everything

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The OARRS Report

• Ohio reporting system for narcotics and other
  controlled substances
• Get access today!
• https//www.ohiopmp.gov/Portal/Registration/Defaul
  t.aspx

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Case 1

• A 56 y/o M with a h/o DMT2, DLD, PUD and EtOH
  abuse arrives on Lksd 55 from the ED with a
  1-week h/o progressively worsening, gnawing
  epigastric abdominal pain radiating to his back.
• VS T 36.1, P 118, R 20, BP 100/80, SpO2 96 RA
• Orthostatics negative
• FOCUSED EXAM
• HEENT Sclera anicteric, no palatal jaundice
• SKIN No jaundice, axillary sweat, no truncal
  ecchymoses
• ABD Soft, ND, significant TTP over epigastrium
  without peritoneal signs, no organomegaly
• NEURO AAOx3
• PERTINENT LABS
• Hgb 15
• BUN 10, Cr 0.9, lipase 4600

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Acute Pancreatitis
Classification

• Type
• Edematous, interstitial acute pancreatitis
• Necrotizing acute pancreatitis
• Severity
• Mild-mod (absence/transient organ failure lt48
  hrs)
• Severe (persistent organ failure gt48 hrs)

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Acute Pancreatitis
Diagnosis

• Requires 2 or more of the following
• 1) Acute, persistent, severe epigastric abdominal
  pain (often radiating to the back)
• 2) Elevated serum lipase or amylase 3x upper
  limit of normal
• 3) CT/MRI/ultrasound evidence of AP
• (NOTE imaging is not required for uncomplicated
  mild AP if 1 and 2 are present)

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Acute Pancreatitis
Initial Evaluation

• Assess severity. ICU transfer may be indicated if
  1 or more of the following are present
• P lt40 or gt150
• SBP lt80
• RR gt35
• PaO2 lt50 mmHg
• pH lt7.1
• Anuria
• Coma

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Acute Pancreatitis
APACHE II SCORING SYSTEM
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Acute Pancreatitis
Surgical Abdomen

• Be concerned about
• Rigidity, guarding, rebound tenderness,
  ill-appearance
• Portable KUB STAT
• Acute care surgery consult STAT
• ICU transfer
• If no acute surgical intervention per ACS
• Your senior/fellow will help you with this

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Acute Pancreatitis
Think About Etiology

• Gallstones
• EtOH
• Hypertriglyceridemia (TG gt1000s)
• Trauma (e.g. panc laceration, post-ERCP)
• Drugs
• Steroids, azathioprine, Januvia, tetracycline,
  furosemide, thiazides, flagyl, valproate, HAART,
  etc..
• Infection
• Other mechanical
• Autoimmune
• Toxins (e.g. scorpion sting)
• Hypercalcemia
• Idiopathic

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Acute Pancreatitis
Supportive Workup

• RFP(includes Ca) and CBC
• LFTs
• Lipid panel (for TG level)
• Lactate
• Blood EtOH level (if indicated)
• Abdominal ultrasound
• ABG (if altered, SpO2 lt90, bicarb low, etc)
• CT abd/pelv with contrast
• CAUTION in those with AKI
• Diagnostic or to assess for complications in
  severe AP
• EUS/MRCP vs. ERCP (in suspected or overt
  gallstone pancreatitis)

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Acute Pancreatitis
Management

• 1) Fluid resuscitation!!!
• Generally gt200 cc/hr
• Decreases morbidity/mortality w/in the 1st 12-24
  hrs
• Monitor for improvement (via VS, BUN, Cr, Hct,
  UOP)
• 2) Pain control
• IV opiates
• 2) Bowel rest
• NPO ? CLD ? Soft, low-residue, low-fat, soft diet
• NJ feeding (post-ligament of Treitz) gt TPN/PPN
• 4) Metabolic/electrolyte correction

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Acute Pancreatitis
AP Sequelae

• Non-discrete peri-pancreatic fluid collections
• Walled off fluid collections (or pseudocysts)
• Necrotizing pancreatitis (/- secondary
  infection)
• Pancreatic ascites
• Hemorrhagic pancreatitis
• Abdominal compartment syndrome
• Pseudoaneurysms

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Acute Pancreatitis
Non-Discrete Fluid Collections
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Acute Pancreatitis
Walled-Off Fluid Collections
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Acute Pancreatitis
Pancreatic Necrosis
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Acute Pancreatitis
Management of Infected Necrosis

• Empiric antibiotics with good pancreatic
  penetration (e.g. carbapenems, quinolones,
  flagyl)
• Cover GNRs and anaerobes
• Trend towards conservative management with ABx
  and observation for several weeks vs. immediate
  surgical resection
• Limited role for CT-guided FNA
• Open/endoscopic partial/total necrosectomy may
  eventually be required

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Acute Pancreatitis
Hemorrhagic Pancreatitis
Cullens Sign ?
? Grey Turners Sign
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Acute Pancreatitis
Pancreatitis Take Home Points

• Once Dx is known, assess severity first
• Does your patient need ICU level care?
• FLUIDS!
• Close monitoring (VS, UOP, BUN, lactate, etc.)
• Etiology will help guide management
• Be mindful of complications

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Case 2

• A generous NF resident gives you an overnight
  patient. Pt is a 56 y/o M who presents to the ED
  with a 1-week h/o progressively worsening left
  quadrant/flank pain and fever. Endorses
  associated anorexia, nausea and fatigue. Had a
  colonoscopy 1 week ago, revealing scattered,
  non-bleeding diverticuli.
• VS T 38.2, P 100, R 22, BP 128/86, SpO2 100 on
  RA
• FOCUSED EXAM
• GEN Well-nourished CM in mod distress d/t pain
• SKIN No jaundice
• ABD Soft, ND, mild TTP over LLQ without
  peritoneal signs, no organomegaly
• NEURO AAOx3
• PERTINENT LABS
• WBC 13K with left shift, CRP 10

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What is your DDx?

• Pyelonephritis
• Acute uncomplicated/complicated diverticulitis
• Nephrolithiasis
• Iatrogenic microperforation
• Acute pancreatitis
• Infectious colitis
• Crohns disease
• CRC
• Acute appendicitis

What do you order next?
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A CT scan! What is the Dx?
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Acute Diverticulitis
Presentation

• Mean age 60s
• LLQ abd pain
• Fever
• Leukocytosis
• N/V/constipation
• Recurrence is 20-40 after initial attack and
  20 may have chronic abd pain

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Acute Diverticulitis
Classification

• 1) Uncomplicated
• 2) Complicated
• Perforation
• Abscess
• Fistulas
• Obstruction
• Peritonitis

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Acute Diverticulitis
Management

• Bowel rest
• Antibiotics covering GNRs and anerobes
• Amp/sulbactam, pip/tazo
• May be transitioned to PO Augmentin prior to
  discharge
• Pain control with IV opiates
• /- Surgery consult
• Indicated for acute complications
• Surgery decided on case-by-case basis
• lt40 y/o, R-sided disease, immunocompromised

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Acute Diverticulitis
Management

• Colonoscopy due at least 6-8 weeks out from onset
  to exclude CRC
• NOT during acute flare given risk of iatrogenic
  perforation

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Acute Diverticulitis
Your patient asks, I read that seeds, nuts and
popcorn are bad for my diverticulitis. What do
you think?
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Case 3
You get called from the DACR at 650 because a 68
y/o F with a h/o osteoarthritis and SLE (on
chronic hydroxychloroquine and prednisone) is in
the ED complaining of a 2-day h/o frequent black,
tarry stools and lightheadedness. She has been
taking Ibuprofen for the past 7 days because of
knee pain. VS T 37, P 120, R 24, BP 104/80, SpO2
99 on RA Orthostatics negative FOCUSED
EXAM GEN Lethargic, in NAD HEENT Conjunctival
pallor, dry mucous membranes ABD Soft, ND,
epigastric TTP without rebound/rigidity/guarding N
EURO AAOx3 LABS Hgb 6.4 (baseline 12) BUN 18,
Cr 1.34, bicarb 18, K 3.2 Lactate 1.8
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GIB
What else do you want to know?

• Use of NSAIDs, anti-platelets, anticoagulants
• Abdominal pain? Relation to food?
• Stool color, character, quantity
• Previous GIB
• Previous EGD/colonoscopy/CE?
• EtOH abuse
• H/o cirrhosis or visualized varices
• Primary thrombophilia
• Recent pepto or iron ingestion ? darkens stools

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GIB
Initial Management

• NPO
• CBCs q6h and active TS with blood consent
• RFP, LFTs, coags
• 2 18-gauge (large-bore) PIVs
• Bolus NS/LR for orthostatic hypotension
• Stop all NSAIDs, anti-platelets and
  anticoagulants
• Hold pharmacologic DVT prophylaxis
• /- NG lavage
• Oxygen as needed
• Abdominal pain? ? KUB prior to endoscopy
• Transfer to ICU? (discuss with your senior)

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GIB
Transfusion Goals

• Transfuse pRBCs for Hgb lt7 (consider lt8 in
  patients with cardiac disease)
• Transfuse platelets for
• Active bleeding with PLT lt50K
• Pre-procedural PLT lt50K with/without bleeding
• Any PLT lt10K
• Transfuse FFP for INR gt1.5 in the setting of
  active bleeding or pre-procedural in some cases

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GIB
Prep Basics

• EGD
• NPO
• /- erythromycin 3 mg/kg IV q8h (off-label) to
  clear stomach contents for better visualization
  ask GI
• Flexible sigmoidoscopy or ileoscopy
• Tap water enemas 30 minutes apart x 3 or until
  clear
• Colonoscopy
• Golytely split-prep (2L in the evening, 2L in
  the early morning i.e. 7PM, 3AM)
• Movi-Prep (Gatorade)
• NG tube if refusing PO

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GIB
Concerning GIB

• Active bloody bowel movements
• Hemodynamic instability
• Drop in Hgb gt/ 2 gm/dL or poorly incrementing
  Hgb after transfusion (1 unit pRBCs should bump
  Hgb by 1-1.5 g/dL)
• Change in mental status or symptomatic anemia
• REMEMBER! Blood is a laxative. Hemodynamically-sig
  nificant GI blood loss will present itself.

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Case 4

• Your covering the Dworken team pager on NF when
  you are paged by nursing about a 36 y/o F with a
  h/o ulcerative colitis who is having multiple,
  small-volume bloody bowel movements. She has been
  taking Keflex for the past week for a soft tissue
  infection. What do you do?!?
• Examine the patient
• VSS? Pain? Mentation? Abd exam? DRE?
• Show me the stool!
• CBC STAT
• Orthostatics
• Send C.diff PCR!

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IBD
IBD

• 2nd-3rd decade of life
• Crohns disease has bimodal distribution (7th-8th
  decade)
• Disease predilection for developed countries and
  the northern hemisphere
• Look for extraintestinal manifestations
• Episcleritis, uveitis, iritis
• Ankylosing spondylitis
• Pyoderma gangrenosum
• Eythema nodosum

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IBD
Genetic Predisposition
IBD
Immune System Dysregulation
Environmental Triggers
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IBD
Crohns Disease

• Risk factors smoking, western diet
• Protective factors high-fiber diet
• Transmural bowel wall inflammation
• Entire GI tract (TI most commonly involved)
• Skip cobblestone lesions
• Rectal sparing

• Abdominal pain, diarrhea, fatigue, weight loss,
  kidney stones

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IBD
Diagnosis of CD

• Colonoscopy with intubation of the terminal ileum
  and biopsy acquisition is the gold standard
• MRE is preferred for initial Dx of small bowel CD
• Consider CE in difficult-to-diagnose cases
• MRI or EUS to evaluate perianal CD

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IBD
Tx Strategies in CD

• Step-Up

• Top-Down

• Biologic agent
• Immunomodulator

• Slow-release 5-ASA for ileitis
• Sulfasalazine for colitis

• Slow-release 5-ASA for ileitis
• Sulfasalazine for colitis

• Antibiotics if not improving

• Biologic agent
• Immunomodulator

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IBD
Ulcerative Colitis

• Bloody diarrhea, tenesmus, fecal urgency, fatigue
  weight loss and sometimes fever
• DDx infectious, ischemic, CD, radiation-induced
• High CRC risk
• Predisposition to C.diff colitis

• Erythematous, engorged mucosa
• Rectal involvement with continuous progression
• Crypt abscesses

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IBD
Dx of UC

• Consider flex sig if inpatient for severe active
  flare due to risk of iatrogenic complications
  with colonoscopy
• Colonoscopy if flare not severe

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IBD
Acute IBD Flares

• Severe flares
• Fever (gt/ 37.5C)
• Tachycardia
• Anemia (Hgb lt7 g/dL)
• Elevated inflammatory markers (ESR, CRP)
• Corticosteroids
• NPO
• Fluid resuscitation
• Electrolyte correction
• Consider 5-ASA compound (for those who are not on
  maintenance therapy)

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IBD
Back to our Patient

• Initiate supportive care
• CRP, ESR, CBC, RFP, LFTs
• C.diff PCR, stool studies first
• If C.diff PCR negative, would start steroids
• High-dose 5-ASA compound (e.g. sulfasalazine)

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Now you know a little bit about.

• The Dworken team
• How to recognize a sick patient
• Prep Basics
• Acute pancreatitis
• Diverticular Disease
• GI bleeding (briefly)
• IBD (briefly)