GI bleeds and emergencies DSA

Question 1

acute upper GI bleeding- essential of diagnosis

Answer 1

• 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

Question 2

Esophageal varices- essentials of diagnosis

Answer 2

• develop secondary to portal HTN
• found in 50% of pts with cirrhosis
• 1/3 will develop upper GI bleeding!
• dx- upper endoscopy

Question 3

bleeding esophageal varices- sx

Answer 3

• acute GI hemorrhage

- severe!- hypovolemia`

Question 4

Acute LGIB- essentials of diagnosis

Answer 4

• 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

Question 5

Acute LGIB- where? etiology?

Answer 5

• below ligament of Treitz (small intestine or colon)
• 95% arise from colon
• <50 yo- infectious colitis, anorectal dz, IBD
• > 50- diverticulosis, angiectasias, malignancy, ischemia

Question 6

Acute LGIB- diverticulosis

Answer 6

• 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

Question 7

Acute LGIB- angioectasias

Answer 7

• painless bleeding
• flat, red lesions with ectatic peripheral vessels radiating from a central vessel
• most common- >70 yo, chronic renal failure

Question 8

Acute LGIB- color of stool

Answer 8

• 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

Question 9

Acute LGIB- diagnostic tests

Answer 9

• 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

Question 10

Familial Mediterranean Fever

Answer 10

• 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!

Question 11

Appendicitis- essentials of diagnosis

Answer 11

• early- periumbilical pain
• later- RLQ pain and tenderness
• anorexia, N/V, obstipation
• tenderness, rigidity at McBurney point
• low-grade fever and leukocytosis

Question 12

Appendicitis- imaging

Answer 12

-abd US and CT scanning

Question 13

Appendicitis- complications

Answer 13

-perforation- 20% of pts

Question 14

Appendicitis- treatment

Answer 14

• surgical appendectomy!- early, uncomplicated appendicitis

- emergency appendectomy- perforated appendicitis with generalized peritonitis

Question 15

Acute Pancreatitis- essentials of diagnosis

Answer 15

• 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

Question 16

Acute Pancreatitis- assessment of severity

Answer 16

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

Question 17

Acute Pancreatitis- CT Grade Severity Index

Answer 17

• 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

Question 18

revised atlanta classification of severity of acute pancreatitis

Answer 18

• 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

Question 19

Acute Pancreatitis- imaging

Answer 19

• gallstones
• “Sentinel loop”- segment of air-filled small intestine
• “colon cutoff sign”- gas-filled transverse colon, abruptly ending at area of pancreatic infl

Question 20

serum amylase also elevated in?

Answer 20

high intestinal obstruction, gastroenteritis, mumps, ectopic pregnancy, opioids, abdominal surgery

Question 21

Acute Pancreatitis- complications

Answer 21

• intravascular volume depletion
• necrotizing pancreatitis- 5-10%- assoc with fever, leukocytosis, shock, organ failure
• ARDS
• pancreatic abscess
• pseudocysts

Question 22

Acute Pancreatitis- mild dz- treatment

Answer 22

• in most pts- subsides spontaneously
• pancreas “rested”- withhold food and liquids by mouth, bed rest
• fluid resuscitation
• pain controlled with meperidine

Question 23

Acute pancreatitis- severe dz- treatment

Answer 23

• leakage of fluids- need IV fluids!!

- hemodynamic monitoring in ICU!

Question 24

Chronic pancreatitis- essentials of diagnosis

Answer 24

• 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

Question 25

Chronic pancreatitis- lab findings

Answer 25

• amylase and lipase- elevated during acute attacks

- pancreatic insufficiency- response to therapy with pancreatic enzyme supplements; secretin stimuation test

Question 26

Chronic pancreatitis- imaging

Answer 26

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