GI bleeds and emergencies DSA Flashcards
acute upper GI bleeding- essential of diagnosis
- hematemesis (bright red blood or “Coffee grounds”)
- melena in most cases; hematochezia in massive bleeds
- volume status to determine severity of blood loss; hematocrit is a poor early indicator of blood loss
- endoscopy diagnostic and may be therapeutic
Esophageal varices- essentials of diagnosis
- develop secondary to portal HTN
- found in 50% of pts with cirrhosis
- 1/3 will develop upper GI bleeding!
- dx- upper endoscopy
bleeding esophageal varices- sx
- acute GI hemorrhage
- severe!- hypovolemia`
Acute LGIB- essentials of diagnosis
- hematochezia usually present
- 10% of hematochezia cases due to upper GI source
- evaluation with colonoscopy in stable pts
- massive active bleeding calls for evaluation with sigmoidoscopy, upper endoscopy, angiography, or nuclear bleeding scan
Acute LGIB- where? etiology?
- below ligament of Treitz (small intestine or colon)
- 95% arise from colon
- <50 yo- infectious colitis, anorectal dz, IBD
- > 50- diverticulosis, angiectasias, malignancy, ischemia
Acute LGIB- diverticulosis
- in 3-5% of pts with diverticulosis
- most common cause of major lower tract bleeding!!- 50% of cases
- painless, large volume bright red hematochezia in pts over 50 yo
Acute LGIB- angioectasias
- painless bleeding
- flat, red lesions with ectatic peripheral vessels radiating from a central vessel
- most common- >70 yo, chronic renal failure
Acute LGIB- color of stool
- brown mixed/streaked with blood- rectosigmoid or anus
- large volumes of bright red blood- colon
- maroon- right colon or small intestine
- black (melena)- proximal to ligament of Treitz
Acute LGIB- diagnostic tests
- exclusion of upper tract source
- anoscopy and sigmoidoscopy- if <40 yo- look for anorectal dz, IBD, infectious colitis; if >40 yo, look for tumor (colonoscopy)
- colonoscopy- preferred when large volume bleeding!!
- nuclear bleeding scans and anigography
- small intestine push enteroscopy or capsule imaging
Familial Mediterranean Fever
- rare, AD disorder, unknown pathogenesis
- Mediterranean ancestry
- lack a protease in serosal fluids that normally inact IL-8 and chemotactic complement factor 5A
- sx- b/f 20 yo- episodic bouts of acute peritonitis, that may be assoc with serositis involving joints and pleura
- peritoneal attacks- fever, abd pain, abd tenderness
- tx- colchicine!
Appendicitis- essentials of diagnosis
- early- periumbilical pain
- later- RLQ pain and tenderness
- anorexia, N/V, obstipation
- tenderness, rigidity at McBurney point
- low-grade fever and leukocytosis
Appendicitis- imaging
-abd US and CT scanning
Appendicitis- complications
-perforation- 20% of pts
Appendicitis- treatment
- surgical appendectomy!- early, uncomplicated appendicitis
- emergency appendectomy- perforated appendicitis with generalized peritonitis
Acute Pancreatitis- essentials of diagnosis
- abrupt onset of deep epigastric pain, often with radiation to back
- Hx of previous episodes, often related to alcohol intake
- N/V, sweating, weakness
- abd tenderness, distention, fever
- leukocytosis, elevated serum amylase and lipase
Acute Pancreatitis- assessment of severity
Ranson Criteria: 3 or more predict a severe course complicated by pancreatic necrosis with a sensitivity 60-80%): ->55 yo -WBC > 16,000 -blood glucose> 200 -serum lactic dehydrogenase > 350 -aspartate aminotransferase > 250 Development of the following in the first 48 hrs indicates a worsening prognosis: -Hematocrit drop 10% points -BUN rise > 5 -arterial PO2 < 60 -serum calcium < 8 -base deficit over 4 mEq/L -fluid sequestration of > 6 L *0-2 (1%); 3-4 (16%), 5-6 (40%), 7-8 (100%)- mortality rate
Acute Pancreatitis- CT Grade Severity Index
- normal pancreas- 0
- pancreatic enlargement- 1
- pancreatic infl and/or peripancreatic fat- 2
- single acute peripancreatic fluid collection- 3
- 2 or more acute peripancreatic fluid collections or retroperitoneal air- 4
revised atlanta classification of severity of acute pancreatitis
- mild dz- absence of organ failure and local (pancreatic necrosis or fluid collections) or systemic complications
- moderate- transient organ failure or local or systemic complications
- severe- persistent (>48 hrs) organ failure
Acute Pancreatitis- imaging
- gallstones
- “Sentinel loop”- segment of air-filled small intestine
- “colon cutoff sign”- gas-filled transverse colon, abruptly ending at area of pancreatic infl
serum amylase also elevated in?
high intestinal obstruction, gastroenteritis, mumps, ectopic pregnancy, opioids, abdominal surgery
Acute Pancreatitis- complications
- intravascular volume depletion
- necrotizing pancreatitis- 5-10%- assoc with fever, leukocytosis, shock, organ failure
- ARDS
- pancreatic abscess
- pseudocysts
Acute Pancreatitis- mild dz- treatment
- in most pts- subsides spontaneously
- pancreas “rested”- withhold food and liquids by mouth, bed rest
- fluid resuscitation
- pain controlled with meperidine
Acute pancreatitis- severe dz- treatment
- leakage of fluids- need IV fluids!!
- hemodynamic monitoring in ICU!
Chronic pancreatitis- essentials of diagnosis
- chronic or intermittent epigastric pain, steatorrhea, weight loss, abnormal pancreatic imaging
- predisposing factors- TIGARO- toxic-metabolic, idiopathic, genetic, autoimmune, recurrent and severe acute pancreatitis, or obstructive
Chronic pancreatitis- lab findings
- amylase and lipase- elevated during acute attacks
- pancreatic insufficiency- response to therapy with pancreatic enzyme supplements; secretin stimuation test
Chronic pancreatitis- imaging
plain films- calcifications due to pancreaticolithiasis- in 30%
- CT- calcifications, ductal dilatation, atrophy
- ERCP- most sensitive
- MRCP And EUS- less invasive
- EUS- hyperechoic foci with shadowing (calculi in main pancreatic duct) and lobularity with honeycombing of pancreatic parenchyma
