GI Emergencies - McGowan Flashcards
Hematemesis associated with alcohol use and persistent vomiting, in an otherwise healthy person is most likely _
Mallory Weiss tear
GI Ulcer associated with elevated intracranial pressure
Cushing’s ulcer
GI ulcer associated with severe burn
Curling ulcer
what is red wale marking
endoscopic sign suggestive of recent hemorrhage, or propensity to bleed, seen in people with esophageal varices
best initial treatment of active bleed to lower risk of rebleeding of the esophagus
Variceal banding
what is fetor hepaticus
aka breath of the dead or hepatic foetor, seen in portal HTN where portosystemic shunting allows thiols to pass directly into lungs
Upper GI bleed is proximal to
ligament of Treitz
Common causes of upper GI bleed
- peptic ulcer disease (MOST COMMON)
- Portal HTN
- mallory-Weiss Tears
- Angiodysplasias
- Telangiectasias
- Dieulfoy lesion
- Neoplasms
- Erosive gastritis
- Aortoenteric fistula
Systemic blood pressure lower than _ is at high risk of acute bleed
100
T or F: pt with acute bleed needs to have one 18 gauge or larger IV lines
False. Needs to have two*
Pt with BUN:Cr 30:1 with no renal issues, think what
Upper GIB - absorption of blood nitrogen from small intestine and prerenal azotemia
If a patient shows hemodynamic compromise or overt active bleed, what is the first thing you should try to fix?
Replenish fluid with 0.9 % (Normal) saline or LR
- type and cross match 2-4 units of PRBCs
Pt with active bleed, packed RBC should be given to maintain hbg at what level?
7-9
when is blood transfusion indicated in a GIB pt?
when is platelet transfuction indicated? plasma?
Transfuse blood in an actively bleeding pt whose hgb is below 7.
Transfuse platelet if count is <50,000
Transfuse fresh frozen plasma if pt has coagulopathy with INR > 1.8
EGD are usually safe with INR less than
2.5
what are clinical predictors of increased risk of rebleeding and death?
- age over 60
- comorbid illnesses
- SBP <100
- HR >100
- bright red blood in NG aspirate or on rectal exam
Virtually all patients with UGIB should undergo _ within 24 hrs of arriving to ED
endoscopy
Portal HTN pts with UGIB should be given what meds?
PPI plus IV octreotide which reduces splanchnic blood flow and decreases portal blood pressure
when is transvenous intrahepatic portosystemic shunts (TIPS) indicated?
in liver patient that fails endoscopic modalities
when is surgery for peptic ulcer disease indicated?
- uncontrolled bleeding
- performation
- obstruction
- intractable disease
- suspected malignancy
How is esophageal variceal bleed treated?
- Hemodynamic resuscitation
- FFP for coagulopathy, platelet if indicated
- ABX prophylaxix (3rd gen cephalosporin)
- Somatostatin and octreotide
- Endoscopic therapy (banding)
- Vit K for cirrhotic pts
- Lactulose for encephlopathy
- Balloon tube tamponade used if cannot be controlled by meds or endoscopic techniques
How is esophageal variceal rebleed prevented?
- BB (nadolol, propranolol) plus banding
- TIPS
- Liver transplant
what are some etiologies of lower GI bleed?
- < 50: infectious colitis, anorectal disease, IBD
- > 50: diverticulosis, angioectasias, malignancy, or ischemia
- Diverticulosis: most common cause of major LGIB (acute, painles, large volume, maroon or bright red hematochezia
- Angioectasias (common in pts >70 with CKD
- neoplasms
- IBD
- anorectal disease
- Ischemic colitis: crampy abd pain followed by rectal bleeding and no more abd pain, self limited
most common cause of intestinal obstruction
peritoneal adhesions. can occur at anytime after a laparotomy. intra-abd infection, ischemia, and peritonitis are at increased risk
How does intestinal obstruction present/
- colicky abd pain, nausea, vomiting (including feculent vomit), abd distention, and absence of flatus or stooling
- CT may show air-fluid levels, dilated bowels and decompressed bowel distal to the site of obstruciton
how is intestinal obstruction treated?
- NG tube decompression and fluid resuscitation
- urgent laparotomy for lysis of adhesions must be performed before bowel ischemia develops
what are some complications of hernias?
- Irreducible (hernia contents cannot be manipuated back into abd cavity
- Incarcerated (contents of sac are literallly inprisoned in the sac of hernia)
- Obstruction ( the loop of bowel become non functioning with normal blood supply)
- Strangulated (cut off the blood supply to the content sac )
Toxic megacolon is a comlication of
IBD and C diff colitis. risk of performation
How would a pt with spontaneous bacterial peritonitis present?
- fever, abd pain, peritoneal signs, ascitic fluid netrophil count >250, change in mental status
Common bugs associated with spontaneous bacterial peritonitis
Gram (-): E coli, Klebsiella
Gram (+): strep pneumo, strep viridans, enterococcus
what drugs can help prevent spontaneous bacterial peritonitis?
- once daily nofloxacin or ciprofloxacin or TMP-SMX
How is Spontaneous bacterial peritonitis treated?
3rd gen cephalosproin or combo beta lactam/lactamase agents
- IV albumin to increase effective arterial circulating volume and renal perfusion helps decrease kidney injury (hepatorenal syndrome) and mortality
- Stop BB, it increases risk of hepatorenal syndrome
What are secondary cause of bacterial peritonitis?
- treatment with broad spectrum enteric coverage for aerobic and anaerobic flora (3rd gen cephalosproin and metronidazole)
major sign of hallow organ perforation
- pneumoperitoneum
- free air on xray or CT
what is the most common abd surgical emergency?
appendicitis
common cause of appendicitis
obstruction of appendix by a fecalith, inflammation, foreign body, or neoplasm –> increase intraluminal pressure, venous congestion, infection, thrombosis of intramural vessels –> gangrenous and perforates within 36hrs if untreated
what is familial mediterranean fever?
autosomal recessive disorder of unkown pathogenesis, seen in younger than 20 of mediterranean ancestry, lacks protease in serosal fluids that normally inactivates IL8 and complement factor 5A
how do familial mediterranean fever patients present?
- episodic bouts of acute peritonitis
- associated with serositis invlving joints and pleura
what’s the treatment for familial mediterranean fever?
- self limited within 24-48 hours.
- symptoms resmeble surgical peritonitis and pts undergo unnecessary explorative laprotomy
- Colchicine can decrease severity and attacks
