DSA - GI Bleeds & GI Abdominal Emergencies (Completed) Flashcards
Three symptoms of Acute Gastrointestinal Bleeding (UGIB)
Hematemesis Melena Hematochezia
Vomit bright red blood or “coffee grounds”
Hematemesis
Develops after as little as 50-100 mL blood loss in most cases
black tarry stool
Melena
Bright red blood per rectum in massive UGIB (1000 mL or more of blood loss)
usually due to lower GI bleed
Hematochezia
What are the differential diagnosis considerations for UGIB?
- PUD - peptic ulcer disease (#1)
- Portal Hypertension (esophageal varices)
- Mallory-Weiss Tear (micro tears at esophogastric junction)
- Vascular Anomaly
- Erosive Gastritis
- Erosive esophagitis
- Aortoenteric fistula
For UGIB one of the differential diagnostic considerations is Vascular Anomaly: Angioectasis
- Bright red stellate appearance
- distorted submucosal vessels
- occurs throughout GI (commonly right colon)
For UGIB one of the differential diagnostic considerations is Vascular Anomaly: Telangiectasias
- Dilation of venules
- small cherry red lesions
- Hereditary forms: Osler-Weber-Rendu & CREST
For UGIB one of the differential diagnostic considerations is Vascular Anomaly: Dieulafoy lesion
- Aberrant (abnormal), large caliber submucosal artery
- commonly in proximal stomach
- recurrent intermittent bleeding
Clinical predictors of increased risk of re-bleeding and death for UGIB include:
- > 60 y/o
- comorbid illness
- systolic < 90 mm Hg
- pulse > 90 bpm
- bright red blood (nasogastric aspirate or rectal exam)
What are the two most important questions with regards to the initial evaluation and treatment of a patient with acute gastrointestinal bleeding (UGIB)?
Sick or not sick (stable or unstable)
do they need to be admitted to the ICU
For a patient in hypovolemic shock what are the important blood value indicators?
Metabolic acidosis
elevated serum lactic acid (lactate)
What differentiates the upper from the lower GI tract?
Ligament of Treitz
Why is hematocrit not a reliable indicator of the severity of acute bleeding?
Because the hematocrit may take 24-72 hours to equilibrate with the extravascular fluid
What should be established immediately in patient who is hemodynamically unstable?
2 large bore (18 gauge) IVs
What is the initial therapy in a patient who is hemodynamically unstable?
0.9% NaCl or lactated ringers (LR)
What are the workup considerations for acute upper gastrointestinal bleeding (UGIB)?
- Complete blood count
- prothrombin time w/ INR
- serum creatinine (BUN:Cr —> 30:1)
- liver enzymes
- blood type and screen
Within 24 hours all patients with upper tract bleeding should undergo upper endoscopy. What are the benefits to this?
- Identify source of bleeding
- determine risk of rebleeding and guide triage
- to provide therapy (cautery, injection, endoclips)
Pharmacologic therapies can be administered via upper endoscopy. Acid inhibitor therapy and octreotide are two such therapies. What is acid inhibitor therapy?
- Intravenous proton pump inhibitors
- oral proton pump inhibitors
Pharmacologic therapies can be administered via upper endoscopy. Acid inhibitor therapy and octreotide are two such therapies. What is the role of octreotide?
Tx portal HTN (reduces splanchnic and portal BP)
What would physical exam (think outside the body) show for a ulcer perforation?
- Ill appearing patient
- rigid, quiet abdomen
- rebound tenderness
In patients with a perforated ulcer if hypotension is present early with the onset of pain what other abdominal emergencies should be considered?
- Ruptured aortic aneurysm
- mesenteric infarction
- acute pancreatitis
What are three diagnostic indicators of ulcer perforation?
- Leukocytosis
- mildly elevated serum amylase (<2x)
- Abdominal CT
In addition to a laparoscopic perforation closure what else should be administered to a patient with ulcer perforation?
- IV fluids
- nasogastric suction
- PPI (IV route)
- broad-spectrum antibiotics
With ulcer perforation of the posterior wall of the duodenum or stomach what structures might the ulcer perforate into?
- Pancreas
- liver
- biliary tree
How do you diagnose an ulcer penetration?
- Severe/constant pain that radiates to the back and is unresponsive to antacids
- mild amylase elevations (sometimes)
- endoscopy confirms ulceration
- abdominal CT demonstrates the penetration
Edema or cicatricial narrowing of the pylorus or duodenal bulb
Gastric Outlet Obstruction
What diseases/conditions are associated with Gastric Outlet Obstruction?
- Gastric neoplasms
- Intraabdominal neoplasms (duodenal obstruction)
What is the protocol for diagnosis of gastric outlet obstruction?
upper endoscopy after 24-72 hours to figure out the nature of the obstruction and rule out gastric neoplasm
What do we associate with Mallory-Weiss Syndrome?
- Hematemesis
- incomplete tear: affects only mucosa/submucosa
tear on the gastric side of the gastroesophagela junction that can extend to distal esophagus associated with vomiting from heavy drinking
What do we associate with Boerhaave’s Syndrome?
- Chest pain and shock
- subcutaneous emphysema
- complete rupture of lower Thoracic esophagus (gastric contents enter thoracic cavity)
- Hamman’s sign
Crunching sound upon auscultation of the heart due to pneumomediastinum. Seen in Boerhaave’s Syndrome.
Hamman’s sign
Dilated submucosal veins in the esophagus. Most common etiology?
Esophageal varices
Most common cause of GIB due to portal HTN
What symptoms are associated with esophageal varices? What symptoms may be present, but are not neccesarily due to varices?
Variceal bleeding —> hypovolemia —> postural vital signs/shock
commonly seen symptoms:
- dyspepsia
- dysphagia
- retching
What factors (of the lesion) put patients at increased risk of bleeding from esophageal varices?
- size > 5mm
- red wale markings (endoscopy)
- severity of liver disease (Child scoring C>B>A)
- active alcohol abuse (pt’s with cirrhosis)
Longitudinal dilated venules on the varied surface seen on endoscopy in esophageal varices
Red wale markings
Following acute resuscitation in the ICU what is the initial management of emergent esophageal varices?
- Fresh frozen plasma or platelets (coagulopathy)
- vitamin K IV (coagulopathy)
- IV Fluoroquinolones or
- IV third generation cephalosporins
- Somatostation & Octreotide - reduce portal HTN
- Lactulose —> encephalopathy
Patients with esophageal varices are treated prophylactically with antibiotics due to associated infection by gram-negative organisms from the gut. What associated infections can arise with esophageal varices?
- Bacterial peritonitisi
- pneumonia
- UTI
Long-term treatment of _________ __________ reduces the incidence of rebleeding to about 30% in patients with previous esophageal varices
Band ligation
What nonselective beta-adrenergic blockers can be used to reduce the risk of rebleeding in patients with previous esophageal varices?
- Propranolol
- Nadolol
Describe emergent esophageal varies invasive treatment
Once hemodynamically stabile patient is treated with banding
- Banding has better outcomes then sclerotherapy (treatment of choice)
Method used to control bleeding in esophageal varix bleeding that can’t be controlled by endoscopic techniques. High rate of complication
Balloon Tube Tamponade
- ET tube placement recommended first
- TIPS decompressive therapy after balloon tamponade
What is Transvenous intrahepatic portosystemic shunts (TIPS)?
Creates a portosystemic shunt from portal vein to hepatic vein
What patient should receive TIPS?
- Patients who have two or more episodes of variceal bleeding and have failed with other interventions
- Lowers the risk of rebleeding but doesn’t decrease mortality
Acute Lower Gastrointestinal Bleeding (LGIB) is defined as ________ to the _____________ ______ __________
Distal; ligament of treitz
What is the hallmark symptom associated with acute lower gastrointestinal bleeding (LGIB)?
Hematochezia
- Bright red blood per rectum (1000 mL or more of blood loss)
What patients are at increased risk for developing lower gastrointestinal bleeding?
Patients taking:
- aspirin
- nonaspirin antiplatelet agents
- NSAIDs
What are differential diagnosis considerations for patients over 50 with LGIB?
Significant hematochezia leading to:
- diverticulosis (Not diverticulitis)
- angiectasias
- malginancy
- ischemia
What is the most common cause of major lower tract bleeding
Diverticulosis
In addition, to diverticulosis what are three other causes of LGIB?
- angiodysplasia (angioectasias) - pts > 70 w/ chronic renal failure
- ischemic colitis - crampy abdominal pain followed by frank bloody diarrhea (hematochezia)
- neoplasms
The color of the stool helps distinguish upper from lower gastrointestinal bleeding.
Brown stools mixed/streaked with blood
Rectosigmoid or anus
The color of the stool helps distinguish upper from lower gastrointestinal bleeding.
Large volumes of bright red blood
suggests a colonic source
The color of the stool helps distinguish upper from lower gastrointestinal bleeding.
Maroon stools
right colon or small intestine
The color of the stool helps distinguish upper from lower gastrointestinal bleeding.
Black stools [tarry sticky] (melena)
Proximal to the ligament of Treitz
The color of the stool helps distinguish upper from lower gastrointestinal bleeding.
Painless large-volume bleeding
diverticular bleeding
The color of the stool helps distinguish upper from lower gastrointestinal bleeding.
Bloody diarrhea associated with cramping abdominal pain, urgency, or tenesmus
- Inflammatory bowel disease
- infectious colitis
- ischemic colitis
What diagnostic tests are used to evaluate for acute lower gastrointestinal bleeding (LGIB)?
- Anoscopy (anal speculum, few inches into anus)
- nuclear bleeding scans
- small intestine push enteroscopy
- capsule imaging
What is diverticulosis and where is it most commonly found?
saclike herniations of mucosa through muscularis at the point of nutrient artery penetration
Most common in sigmoid colon
90% of patients with diverticular disease have ___________ ____________
Uncomplicated diverticulosis
Asymptomatic - detected incidentally by barium enema or colonoscopy
What sign/symptom is characteristically present in diverticulosis, but not diverticulitis?
Hemorrhage usually in absence of diverticulitis often from ascending colon and typically self-limited
Patient presents with periumbilical pain out of proportion to tenderness (so they are writhing in pain, but physical exam isn’t impressive, maybe mild tenderness). Abdominal x-ray shows thumb-printing (submucosal edema). CT angiography is the diagnostic study of choice.
Acute mesenteric ischemia
What is the indicated treatment to restore intestinal blood flow obstructed by embolus or thrombosis or to respect necrotic bowel in acute mesenteric ischemia?
Laparotomy
Severe lower abdominal pain followed by rectal bleeding. Abdominal x-ray shows colonic dilation and thumb-printing (submucosal edema). Rectum is spared of ulceration.
Ischemic colitis
Bleeding that is not apparent to the patient. Chronic GI blood loss of less than 100 mL/day may cause no appreciable change in stool appearance.
Occult Gastrointestinal Bleeding
In the abscence of visible blood loss how do we confirm bleeding in occult gastrointestinal bleeding?
- FOBT (fecal occult blood test)
- FIT (fecal immunochemical test)
- Iron deficiency anemia
While patients with iron deficiency anemia may have occult gastrointestinal bleeding what else should they be screened for?
Celiacs disease with either IgA anti-tissue transglutaminase (IgA Anti-tTG) or duodenal biopsy
Remnant of the vitelline duct
Meckel’s Diverticulitis
The Rule of 2’s applies to what condition?
Meckel’s Diverticulitis
- 2 ft from ileoceccal valve
- Present in 2% of population
- 2 inches long
- 2 types of ectopic tissue (gastric or pancreatic)
What is the most useful method of diagnosis of Meckel’s Diverticulitis and is dependent on the uptake of the isotope into heterotopic tissue?
Technetium-99m scan
Treated by surgical resection
What is perforated viscous?
Any hollow organ that perforates
- esophagus
- stomach
- intestine
- uterus
- bladder
What is the major complication with perforated viscous and how is it treated?
Surgical emergency due to free air that will form under diaphragm or in mediastinum
Identified by CT or X-ray
A condition initiated by obstruction due to fecalith increasing intraluminal pressure and causing infection
Appendicitis
Fecalith - stony mass of feces
What is a rare complication of appendicitis?
Septic thrombophlebitis (pylephlebitis) of the portal venous system
- fever
- chills
- bacteremia
- jaundice
Appendectomy before the age of 21 is protective against the development of what?
Ulcerative colitis (Inflammatory Bowel Disease - IBD)
What is the most common cause of intestinal obstruction?
Peritoneal adhesions
can lead to peritonitis and ischemia
Severe abdominal distention with massive dilation of cecum or right colon (megacolon). No mechanical obstruction is present. Arises in postoperative state.
Acute Colonic Pseudo-Obstruction (Ogilvie Syndrome)
Who is strongly recommended to undergo screen for aortic aneurysm?
Men age 65-75 years who have ever smoked
What is the most common cause of maternal death during the first trimester and presents with severe lower quadrant pain in almost every case?
Ectopic Pregnancy
History of:
- PUD
- rupture appendix
- prior tubal surgery (adhesions)
- history of infertility
Where do nearly 70% of ovarian torsions occur?
Right side due to increasead length of utero-ovarian ligament
sigmoid colon on the left limits movement (preventative)
What is the classical presentation of ovarian torsion?
- Sudden-onset, severe, unilateral, lower abdominal pain
- may develop after episode of exertion
An ovary greater than _______ as detected by ________ ______ with ________ is due to cyst, tumor, or edema and is the most common finding associated with ovarian torsion
4 cm; transvaginal US; Doppler
Patients presents with abrupt, severe pain accompanied by nausea and vomiting. Patient has a wide-based gait and complains of extreme scrotal pain. You observe ipsilateral loss of the cremaster reflex. What age is this patient most likely?
Testicular torsion
Most boys with testicular torsion present between 12 and 18 years of age
