Esophageal FB/GI bleeds Flashcards
Esophageal Foreign Bodies
Esophagus
pic is abcess from embedded fish bone.
Esophagus
Most common site of foreign body impaction
Lodge in areas of physiologic or pathologic luminal narrowing
Sphincters (UES and LES)
Strictures
Tumors
Previous surgery (adhesions)
Underlying disorder/disease (achalasia, eosinophilic esophagitis)
Causes of impaction
Food (steak, hot dogs, grapes, peanuts, candies)
Bones (fish bones)
Inedible objects (coins, batteries, magnets)
FB
complications
complete much more serious
FB
S/Sx
Dysphagia: Main presenting symptom
Unable to swallow oral secretions (complete obstruction)
Hypersalivation
Retrosternal fullness
Regurgitation
Anxiety → hyperventilation
Dyspnea and auscultatory findings of stridor or wheezing → foreign body in the airway and not the esophagus
pain behind the sternum
FB
imaging
Imaging studies
Plain film x-rays (2 views)
Detect metallic foreign objects and bones
Detect signs of perforation (free air in the mediastinum or peritoneum)
CT scan
Objects not identifiable on plain film x-ray (wood, plastic, glass)
Dangerous ingestions (packets of illicit drugs)
Confirm and localize the foreign body prior to endoscopy
Oral contrast should be avoided due to risk of aspiration and possible leakage of contrast with perforation
History & physical examination
History suggesting ingestion and symptoms consistent with esophageal foreign body
Common Anatomic Locations for Foreign Bodies
Proximal esophagus at the level of the cricopharyngeus muscle (thoracic inlet) → in line with the clavicles on x-ray
(most common in kids)
Mid-esophagus at the level of the aortic arch → at the carina on x-ray
Lower esophageal sphincter → 2-4 vertebral levels above the gastric bubble on x-ray
FB
Emergency situations
Complete esophageal obstruction - inability to handle oral secretions
Disk batteries in the esophagus
Sharp-pointed objects in the esophagus
FB
Urgent (within 12 to 24 hours) situations
Esophageal objects that are not sharp-pointed
Food impactions without complete obstruction
Sharp-pointed objects in the stomach or duodenum
Objects greater than 6 cm in length above the duodenum
Multiple magnets (or single magnet plus another ferromagnetic object within endoscopic reach)
Coins in esophagus
FB
Nonurgent
Objects in the stomach greater than 2.5 cm diameter
Disk battery in stomach up to 48 hours if asymptomatic
Blunt objects that fail to pass stomach in 3 to 4 weeks
Treatment for Food Impaction (3)
GI bleeds
Upper and lower are divided by
Ligament of Treitz: suspensory ligament and important surgical landmark; runs from the left diaphragm to the junction of the duodenum and jejunum (structure is green in the photo)
GI bleeds
classifications of bleeds
Acute vs chronic
Classified as:
Acute (<3 days) or chronic (>3 days) bleeding
Overt or occult bleeding
Overt: visible bleeding
Occult: only detectable by chemical testing of a stool specimen
GI bleeds
Risk Factors
History of GI bleeding
Helicobacterpyloriinfection
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Anticoagulant use
Alcohol use
Cirrhosis
Vascular disease
Older age
GI bleeds and NSAIDS
PGE2 provides gastroprotection by increasing mucus secretion and inhibiting gastric acid secretion
NSAIDs inhibited production of prostaglandins (PGs) through the inhibition of two cyclooxygenase enzymes, COX-1 and COX-2
Upper GI bleed
etiology
Peptic ulcer disease
Gastric ulcer
Duodenal ulcer
Erosive gastritis
Erosive esophagitis
Esophageal or gastric varices
Esophageal cancer
Mallory-Weiss tears
lower GI bleeding
etiology
Diverticular disease -Diverticulosis and Diverticulitis
Hemorrhoids
Infectious colitis
Anal fissures
Inflammatory bowel diseases
Crohn’s disease
Ulcerative colitis
Colorectal cancer
Iatrogenic – after biopsy or radiation
GI bleeding
S/Sx
Patients with occult bleeding
Patients with occult bleeding may be asymptomatic
Symptoms of anemia:
Fatigue/weakness
Dyspnea
Pallor
Lightheaded
Heartburn
Abdominal pain
Weight loss…should make you think?
GI Bleeds
Hematemesis
Indicates an upper GI bleed
Vomiting of red blood or “coffee-ground” material
Coffee-ground emesis
Vomit that is dark brown and resembling coffee
Conversion of red hemoglobin to brown hematin by gastric acid
GI bleeds
Hematochezia
Indicates a lower GI bleed or a vigorous upper GI bleed with rapid transit through the intestines
Passage of gross blood from the rectum
Bright red
GI bleeds
Melena
Typically indicates an upper GI bleed, but can occur with a small intstinal or proximal colonic bleed
Black, tarry stool
GI Bleeds
Hemodynamic Instability
Primary and advanced parameters
Occurs when there is a decrease in blood pressure leading to lowered blood flow to the body’s organs
Primary hemodynamic parameters include:
heart rate (HR) and blood pressure (BP)
Advanced hemodynamic parameters include:
stroke volume (SV), cardiac output (CO), and total peripheral resistance (TPR)
Evaluation of GI Bleeding - History
medications
Medications that can increase risk of bleeding: NSAIDs, aspirin, clopidogrel, anticoagulants, SSRIs
GI bleeds
HPI questions for Heamtemiesis
Distinguish hematemesis from hemoptysis
Blood passed with initial vomiting or after an initial (or several) non-bloody bouts of emesis?
GI bleed
HPI questions for rectal bleeding
Pure blood passed? Blood mixed with stool, pus, or mucus?
Blood on the toilet tissue or coated the toilet water?
Bloody diarrhea – recent travel or possible exposure to GI pathogens?
GI bleed
HPI associated Sx questions
Associated symptoms
Abdominal discomfort, weight loss, easy bleeding or bruising, symptoms of anemia?
GI bleeds
PE
Vital signs including orthostatic measurements
Indicators of shock or hypovolemia
Tachycardia, tachypnea, pallor, diaphoresis, confusion, oliguria
Why would a patient with a GI bleed present with oliguria?
Signs of anemia
External stigmata of bleeding disorders
Petechiae or ecchymosis
Signs of chronic liver disease
Spider angiomas, ascites, palmar erythema, dilated abdominal wall veins, splenomegaly
Digital rectal exam
Stool color, masses, or fissures
Stool specimen for occult blood
GI bleeds
Labs
History and physical exam will suggest a diagnosis in >50% of patients
Confirmatory testing is required
Labs
CBC with differential
Type and cross-match *
Coagulation profile
Fecal occult blood testing
Liver tests (bilirubin, alkaline phosphatase, albumin, AST, ALT)
Basic metabolic panel
Iron and ferritin
GI bleed
Nasogastric aspiration and lavage
Patients with suspected upper GI bleeding
GI bleeds
Upper endoscopy/EGD – modality of choice for upper GI bleed
Examination of the esophagus, stomach, and duodenum
Diagnostic and therapeutic
GI blood
Flexible sigmoidoscopy and anoscopy
Typical symptoms hemorrhoidal bleeding
GI bleeds
Colonoscopy indications
modality of choice for lower GI bleed
Often done electively after routine preparation
Significant bleeding – rapid prep delivered via NG tube for patients with hematochezia
GI Bleeds
CT angiography indications
Bleeding rate
Bleeding rate of at least 0.5–1 mL/min is required for detection.
Reserved forpatients who cannot undergoendoscopydue to hemodynamic instability
GI bleeds
non pharm Tx
Secure airway – intubation may be required
2 large-gauge peripheral IVs and/or central line
IV fluid resuscitation
Blood transfusion (hemoglobin < 7)
Packed RBCs, platelets, fresh frozen plasma
NPO
GI and/or surgical consultation
GI Bleeds
Pharm Tx
IV Proton pump inhibitor (PPI) for all upper GI bleeding
Octreotide for suspected variceal bleeding
Prophylactic antibiotics for suspected variceal bleeding in patient with cirrhosis (prevention of spontaneous bacterial peritonitis)
GI bleeds
Hemostasis Tx
GI bleeding stops spontaneously in ~80% of patients
Specific hemostatic therapy depends on the bleeding site
