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Gastrointestinal II > DSA - GI Bleeds & GI Abdominal Emergencies (Completed) > Flashcards

DSA - GI Bleeds & GI Abdominal Emergencies (Completed) Flashcards

1
Q

Three symptoms of Acute Gastrointestinal Bleeding (UGIB)

A

Hematemesis Melena Hematochezia

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2
Q

Vomit bright red blood or “coffee grounds”

A

Hematemesis

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3
Q

Develops after as little as 50-100 mL blood loss in most cases

black tarry stool

A

Melena

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4
Q

Bright red blood per rectum in massive UGIB (1000 mL or more of blood loss)

usually due to lower GI bleed

A

Hematochezia

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5
Q

What are the differential diagnosis considerations for UGIB?

A
  1. PUD - peptic ulcer disease (#1)
  2. Portal Hypertension (esophageal varices)
  3. Mallory-Weiss Tear (micro tears at esophogastric junction)
  4. Vascular Anomaly
  5. Erosive Gastritis
  6. Erosive esophagitis
  7. Aortoenteric fistula
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6
Q

For UGIB one of the differential diagnostic considerations is Vascular Anomaly: Angioectasis

A
  • Bright red stellate appearance
  • distorted submucosal vessels
  • occurs throughout GI (commonly right colon)
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7
Q

For UGIB one of the differential diagnostic considerations is Vascular Anomaly: Telangiectasias

A
  • Dilation of venules
  • small cherry red lesions
  • Hereditary forms: Osler-Weber-Rendu & CREST
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8
Q

For UGIB one of the differential diagnostic considerations is Vascular Anomaly: Dieulafoy lesion

A
  • Aberrant (abnormal), large caliber submucosal artery
  • commonly in proximal stomach
  • recurrent intermittent bleeding
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9
Q

Clinical predictors of increased risk of re-bleeding and death for UGIB include:

A
  • > 60 y/o
  • comorbid illness
  • systolic < 90 mm Hg
  • pulse > 90 bpm
  • bright red blood (nasogastric aspirate or rectal exam)
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10
Q

What are the two most important questions with regards to the initial evaluation and treatment of a patient with acute gastrointestinal bleeding (UGIB)?

A

Sick or not sick (stable or unstable)

do they need to be admitted to the ICU

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11
Q

For a patient in hypovolemic shock what are the important blood value indicators?

A

Metabolic acidosis

elevated serum lactic acid (lactate)

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12
Q

What differentiates the upper from the lower GI tract?

A

Ligament of Treitz

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13
Q

Why is hematocrit not a reliable indicator of the severity of acute bleeding?

A

Because the hematocrit may take 24-72 hours to equilibrate with the extravascular fluid

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14
Q

What should be established immediately in patient who is hemodynamically unstable?

A

2 large bore (18 gauge) IVs

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15
Q

What is the initial therapy in a patient who is hemodynamically unstable?

A

0.9% NaCl or lactated ringers (LR)

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16
Q

What are the workup considerations for acute upper gastrointestinal bleeding (UGIB)?

A
  • Complete blood count
  • prothrombin time w/ INR
  • serum creatinine (BUN:Cr —> 30:1)
  • liver enzymes
  • blood type and screen
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17
Q

Within 24 hours all patients with upper tract bleeding should undergo upper endoscopy. What are the benefits to this?

A
  1. Identify source of bleeding
  2. determine risk of rebleeding and guide triage
  3. to provide therapy (cautery, injection, endoclips)
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18
Q

Pharmacologic therapies can be administered via upper endoscopy. Acid inhibitor therapy and octreotide are two such therapies. What is acid inhibitor therapy?

A
  • Intravenous proton pump inhibitors
  • oral proton pump inhibitors
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19
Q

Pharmacologic therapies can be administered via upper endoscopy. Acid inhibitor therapy and octreotide are two such therapies. What is the role of octreotide?

A

Tx portal HTN (reduces splanchnic and portal BP)

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20
Q

What would physical exam (think outside the body) show for a ulcer perforation?

A
  • Ill appearing patient
  • rigid, quiet abdomen
  • rebound tenderness
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21
Q

In patients with a perforated ulcer if hypotension is present early with the onset of pain what other abdominal emergencies should be considered?

A
  • Ruptured aortic aneurysm
  • mesenteric infarction
  • acute pancreatitis
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22
Q

What are three diagnostic indicators of ulcer perforation?

A
  • Leukocytosis
  • mildly elevated serum amylase (<2x)
  • Abdominal CT
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23
Q

In addition to a laparoscopic perforation closure what else should be administered to a patient with ulcer perforation?

A
  • IV fluids
  • nasogastric suction
  • PPI (IV route)
  • broad-spectrum antibiotics
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24
Q

With ulcer perforation of the posterior wall of the duodenum or stomach what structures might the ulcer perforate into?

A
  • Pancreas
  • liver
  • biliary tree
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25
Q

How do you diagnose an ulcer penetration?

A
  • 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
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26
Q

Edema or cicatricial narrowing of the pylorus or duodenal bulb

A

Gastric Outlet Obstruction

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27
Q

What diseases/conditions are associated with Gastric Outlet Obstruction?

A
  • Gastric neoplasms
  • Intraabdominal neoplasms (duodenal obstruction)
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28
Q

What is the protocol for diagnosis of gastric outlet obstruction?

A

upper endoscopy after 24-72 hours to figure out the nature of the obstruction and rule out gastric neoplasm

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29
Q

What do we associate with Mallory-Weiss Syndrome?

A
  • 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

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30
Q

What do we associate with Boerhaave’s Syndrome?

A
  • Chest pain and shock
  • subcutaneous emphysema
  • complete rupture of lower Thoracic esophagus (gastric contents enter thoracic cavity)
  • Hamman’s sign
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31
Q

Crunching sound upon auscultation of the heart due to pneumomediastinum. Seen in Boerhaave’s Syndrome.

A

Hamman’s sign

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32
Q

Dilated submucosal veins in the esophagus. Most common etiology?

A

Esophageal varices

Most common cause of GIB due to portal HTN

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33
Q

What symptoms are associated with esophageal varices? What symptoms may be present, but are not neccesarily due to varices?

A

Variceal bleeding —> hypovolemia —> postural vital signs/shock

commonly seen symptoms:

  • dyspepsia
  • dysphagia
  • retching
34
Q

What factors (of the lesion) put patients at increased risk of bleeding from esophageal varices?

A
  1. size > 5mm
  2. red wale markings (endoscopy)
  3. severity of liver disease (Child scoring C>B>A)
  4. active alcohol abuse (pt’s with cirrhosis)
35
Q

Longitudinal dilated venules on the varied surface seen on endoscopy in esophageal varices

A

Red wale markings

36
Q

Following acute resuscitation in the ICU what is the initial management of emergent esophageal varices?

A
  • Fresh frozen plasma or platelets (coagulopathy)
  • vitamin K IV (coagulopathy)
  • IV Fluoroquinolones or
  • IV third generation cephalosporins
  • Somatostation & Octreotide - reduce portal HTN
  • Lactulose —> encephalopathy
37
Q

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?

A
  • Bacterial peritonitisi
  • pneumonia
  • UTI
38
Q

Long-term treatment of _________ __________ reduces the incidence of rebleeding to about 30% in patients with previous esophageal varices

A

Band ligation

39
Q

What nonselective beta-adrenergic blockers can be used to reduce the risk of rebleeding in patients with previous esophageal varices?

A
  • Propranolol
  • Nadolol
40
Q

Describe emergent esophageal varies invasive treatment

A

Once hemodynamically stabile patient is treated with banding

  • Banding has better outcomes then sclerotherapy (treatment of choice)
41
Q

Method used to control bleeding in esophageal varix bleeding that can’t be controlled by endoscopic techniques. High rate of complication

A

Balloon Tube Tamponade

  • ET tube placement recommended first
  • TIPS decompressive therapy after balloon tamponade
42
Q

What is Transvenous intrahepatic portosystemic shunts (TIPS)?

A

Creates a portosystemic shunt from portal vein to hepatic vein

43
Q

What patient should receive TIPS?

A
  • 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
44
Q

Acute Lower Gastrointestinal Bleeding (LGIB) is defined as ________ to the _____________ ______ __________

A

Distal; ligament of treitz

45
Q

What is the hallmark symptom associated with acute lower gastrointestinal bleeding (LGIB)?

A

Hematochezia

  • Bright red blood per rectum (1000 mL or more of blood loss)
46
Q

What patients are at increased risk for developing lower gastrointestinal bleeding?

A

Patients taking:

  • aspirin
  • nonaspirin antiplatelet agents
  • NSAIDs
47
Q

What are differential diagnosis considerations for patients over 50 with LGIB?

A

Significant hematochezia leading to:

  • diverticulosis (Not diverticulitis)
  • angiectasias
  • malginancy
  • ischemia
48
Q

What is the most common cause of major lower tract bleeding

A

Diverticulosis

49
Q

In addition, to diverticulosis what are three other causes of LGIB?

A
  • angiodysplasia (angioectasias) - pts > 70 w/ chronic renal failure
  • ischemic colitis - crampy abdominal pain followed by frank bloody diarrhea (hematochezia)
  • neoplasms
50
Q

The color of the stool helps distinguish upper from lower gastrointestinal bleeding.

Brown stools mixed/streaked with blood

A

Rectosigmoid or anus

51
Q

The color of the stool helps distinguish upper from lower gastrointestinal bleeding.

Large volumes of bright red blood

A

suggests a colonic source

52
Q

The color of the stool helps distinguish upper from lower gastrointestinal bleeding.

Maroon stools

A

right colon or small intestine

53
Q

The color of the stool helps distinguish upper from lower gastrointestinal bleeding.

Black stools [tarry sticky] (melena)

A

Proximal to the ligament of Treitz

54
Q

The color of the stool helps distinguish upper from lower gastrointestinal bleeding.

Painless large-volume bleeding

A

diverticular bleeding

55
Q

The color of the stool helps distinguish upper from lower gastrointestinal bleeding.

Bloody diarrhea associated with cramping abdominal pain, urgency, or tenesmus

A
  • Inflammatory bowel disease
  • infectious colitis
  • ischemic colitis
56
Q

What diagnostic tests are used to evaluate for acute lower gastrointestinal bleeding (LGIB)?

A
  • Anoscopy (anal speculum, few inches into anus)
  • nuclear bleeding scans
  • small intestine push enteroscopy
  • capsule imaging
57
Q

What is diverticulosis and where is it most commonly found?

A

saclike herniations of mucosa through muscularis at the point of nutrient artery penetration

Most common in sigmoid colon

58
Q

90% of patients with diverticular disease have ___________ ____________

A

Uncomplicated diverticulosis

Asymptomatic - detected incidentally by barium enema or colonoscopy

59
Q

What sign/symptom is characteristically present in diverticulosis, but not diverticulitis?

A

Hemorrhage usually in absence of diverticulitis often from ascending colon and typically self-limited

60
Q

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.

A

Acute mesenteric ischemia

61
Q

What is the indicated treatment to restore intestinal blood flow obstructed by embolus or thrombosis or to respect necrotic bowel in acute mesenteric ischemia?

A

Laparotomy

62
Q

Severe lower abdominal pain followed by rectal bleeding. Abdominal x-ray shows colonic dilation and thumb-printing (submucosal edema). Rectum is spared of ulceration.

A

Ischemic colitis

63
Q

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.

A

Occult Gastrointestinal Bleeding

64
Q

In the abscence of visible blood loss how do we confirm bleeding in occult gastrointestinal bleeding?

A
  • FOBT (fecal occult blood test)
  • FIT (fecal immunochemical test)
  • Iron deficiency anemia
65
Q

While patients with iron deficiency anemia may have occult gastrointestinal bleeding what else should they be screened for?

A

Celiacs disease with either IgA anti-tissue transglutaminase (IgA Anti-tTG) or duodenal biopsy

66
Q

Remnant of the vitelline duct

A

Meckel’s Diverticulitis

67
Q

The Rule of 2’s applies to what condition?

A

Meckel’s Diverticulitis

  • 2 ft from ileoceccal valve
  • Present in 2% of population
  • 2 inches long
  • 2 types of ectopic tissue (gastric or pancreatic)
68
Q

What is the most useful method of diagnosis of Meckel’s Diverticulitis and is dependent on the uptake of the isotope into heterotopic tissue?

A

Technetium-99m scan

Treated by surgical resection

69
Q

What is perforated viscous?

A

Any hollow organ that perforates

  • esophagus
  • stomach
  • intestine
  • uterus
  • bladder
70
Q

What is the major complication with perforated viscous and how is it treated?

A

Surgical emergency due to free air that will form under diaphragm or in mediastinum

Identified by CT or X-ray

71
Q

A condition initiated by obstruction due to fecalith increasing intraluminal pressure and causing infection

A

Appendicitis

Fecalith - stony mass of feces

72
Q

What is a rare complication of appendicitis?

A

Septic thrombophlebitis (pylephlebitis) of the portal venous system

  • fever
  • chills
  • bacteremia
  • jaundice
73
Q

Appendectomy before the age of 21 is protective against the development of what?

A

Ulcerative colitis (Inflammatory Bowel Disease - IBD)

74
Q

What is the most common cause of intestinal obstruction?

A

Peritoneal adhesions

can lead to peritonitis and ischemia

75
Q

Severe abdominal distention with massive dilation of cecum or right colon (megacolon). No mechanical obstruction is present. Arises in postoperative state.

A

Acute Colonic Pseudo-Obstruction (Ogilvie Syndrome)

76
Q

Who is strongly recommended to undergo screen for aortic aneurysm?

A

Men age 65-75 years who have ever smoked

77
Q

What is the most common cause of maternal death during the first trimester and presents with severe lower quadrant pain in almost every case?

A

Ectopic Pregnancy

History of:

  • PUD
  • rupture appendix
  • prior tubal surgery (adhesions)
  • history of infertility
78
Q

Where do nearly 70% of ovarian torsions occur?

A

Right side due to increasead length of utero-ovarian ligament

sigmoid colon on the left limits movement (preventative)

79
Q

What is the classical presentation of ovarian torsion?

A
  • Sudden-onset, severe, unilateral, lower abdominal pain
  • may develop after episode of exertion
80
Q

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

A

4 cm; transvaginal US; Doppler

81
Q

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?

A

Testicular torsion

Most boys with testicular torsion present between 12 and 18 years of age

Gastrointestinal II (4 decks)

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