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GI II Exam 2 > Lecture 9: GI Bleeds and GI/Abdominal Emergencies > Flashcards

Lecture 9: GI Bleeds and GI/Abdominal Emergencies Flashcards

1
Q

Acute upper GI bleeds occur proximal to which anatomic landmark?

A

Proximal to the Ligament of Treitz

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2
Q

Which imaging modality is used for diagnosing Upper GI Bleeds?

A

EGD

*Also therapeutic

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3
Q

Small, cherry red lesions caused by dilations of venules that may be part of systemic conditions or occur sporadically are descriptive of what?

A

Telangiectasias

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4
Q

Aberrant, large-caliber submucosal arteries most commonly in the prox. stomach that cause recurrent, intermittent bleeding, are known as what?

A

Dieulafoy lesion

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5
Q

Upon admission to the ICU for an acute GI bleed what is the initial assessment that needs to be done?

A

Hemodynamic status

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6
Q

Which BP finding and HR is a sign of shock in a patient presenting with GI bleed?

A
  • Hypotension: systolic <90 mmHg
  • Tachycardia: HR >90 bpm
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7
Q

During stabilization of a patient with GI bleed in the ICU what should be started prior to further diagnostic tests?

A

Two large bore“18-gauge or larger” IV lines

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8
Q

For a patient presenting with a GI bleed in the ICU that seems unstable (i.e., signs of impending shock) what should be given?

A

IVFs –> 0.9% saline (aka normal saline) or Lactated Ringer

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9
Q

Which acid inhibitory therapy should be given to someone in the ICU for an upper GI bleed?

A
  1. IV PPIs
  2. Oral PPIs
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10
Q

Which drug is administered promptly to all patients with active upper GI bleeding and evidence of liver disease or portal HTN?

A

Ocreotide

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11
Q

Which lab finding is often found markedly elevated in patients with GI hemorrhage as a complication of PUD?

A

BUN

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12
Q

If hypotension is present early with the onset of pain in someone with suspected ulcer perforation, which 3 other abdominal emergencies should be considered?

A
  1. Ruptured aortic aneurysm
  2. Mesenteric infarction
  3. Acute pancreatitis
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13
Q

Lower GI Bleeding is defined as bleeding that arises below which structure?

A

Distal to Ligament of Treitz

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14
Q

How is evaluation of lower GI bleeding done in a stable patient?

A

Colonoscopy

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15
Q

Increased risk of lower GI bleeds in patients taking what agents?

A
  • Aspirin
  • Nonaspirin antiplatelet agents
  • NSAIDs
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16
Q

Most common cause of lower GI bleeds in patients <40 yo?

A
  • Neoplasms (stromal tumors, lymphomas, adenocarcinomas, carcinoids)
  • Chron disease
  • Celiac Disease
  • Meckel diverticulum
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17
Q

In a patient over 50 yo w/ significant hematochezia what are 4 common causes?

A
  1. Diverticulosis
  2. Angiectasias
  3. Malignancy
  4. Ischemia
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18
Q

What is the most common cause of major lower GI bleeding?

Often presents how?

A
  • Diverticulosis
  • Acute, painless, large-volume maroon or bright red hematochezia in patients over age 50
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19
Q

What is the most common cause of painless lower GI bleeding which can range from melena or hematochezia to occult blood loss in patients >70 yo and in those with chronic renal failure?

A

Angioectasias (angiodysplasias)

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20
Q

Crampy abdominal pain, followed by frank bloody diarrhea in an older patient with atherosclerotic disease or young person using vasoconstricting recreational drugs is characteristic of?

A

Ischemic colitis

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21
Q

Black stools that are tarry/sticky (melena) predict a source of the bleed where?

A

Proximal to Ligament of Treitz

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22
Q

Large volumes of bright red bloody stool suggests a bleed where?

A

Colon

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23
Q

Brown stools mixed or streaked with blood predict the source of the bleed to be where?

A

Rectosigmoid or anus

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24
Q

Painless large-volume bleeding from the lower GI suggests what source?

A

Diverticular bleeding

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25
Q

When diagnosing a suspected lower GI bleed what needs to be excluded first?

Which imaging modalities can be used?

A
  • Exclude UGIB (NGT (not completely exclusive), EGD)
  • Anoscopy and sigmoidoscopy
  • Colonoscopy
  • Nuclear bleeding scans and angiography
  • Small intestine push enteroscopy or capsule imaging
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26
Q

Diverticulosis is most commonly found where in the colon?

A

Sigmoid

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27
Q

Herniations or saclike protrusions of the mucosa through the muscularis at points of nutrient artery penetration defines what?

A

Diverticulosis

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28
Q

90% of patients with diverticulosis are what?

A

Asymptomatic

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29
Q

Hemorrhage associated w/ diverticulosis usually occurs in the absence of ?

A

Diverticulitis

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30
Q

Periumbilical pain out of proportion to tenderness (i.e., pt is writhing in pain, but PE isn’t impressive) is characteristic of what GI problem?

A

Acute Mesenteric Ischemia

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31
Q

What will abdominal XR show in patient with Acute Mesenteric Ischemia?

Characteristic sign?

A
  • Bowel distention and Air-fluid levels
  • Thumb-printing (submucosal edema)
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32
Q

What is the diagnostic study of choice for Acute Mesenteric Ischemia?

Early celiac and mesenteric ________ is recommended?

A
  • CT angiography = study of choice
  • Early celiac and mesenteric arteriography is recommended
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33
Q

Which procedure is indicated in Acute Mesenteric Ischemia to restore intestinal blood flow obstructed by embolus or thrombosis or to resect necrotic bowel?

A

Laparotomy

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34
Q

Ischemic colitis is characterized by what symptoms and signs?

A

Severe lower abdominal pain followed by rectal bleeding

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35
Q

Abdominal XR of ischemic colitis will show what?

A
  • Colonic dilation
  • Thumb-printing
36
Q

Differentiate acute mesenteric ischemia from ischemic colitis?

A
  • AMI = periumbilical pain out of proportion to tenderness
  • IC = severe LOWER abdominal pain followed by rectal bleeding
37
Q

Linear or rocket-shaped ulcers that are usually <5mm in length wihtin the anal canal defines?

A

Anal fissures

38
Q

Define Occult GI bleeding?

A

Bleeding that is not apparent to the patient

39
Q

How is occult GI bleeding identified (3 ways)?

A
  1. Fecal occult blood test (FOBT)
  2. Fecal immunochemical test (FIT)
  3. Iron deficiency anemia in absence of visible blood loss
40
Q

Although iron-deficiency anemia is associated with occult GI blood loss, why is it also a common finding in pre-menopausal women?

A
  • Menstruation
  • Pregnancy-associated iron loss
41
Q

What are 6 of the most common causes of occult bleeding w/ iron-deficiency?

A

1) Neoplasms
2) Vascular abnormalities (angioectasias)
3) Acid-peptic lesions (esophagitis, PUD, erosions in hiatal hernia)
4) Infections (nematodes: especially hookwork; tuberculosis)
5) Meds (especially NSAIDs or aspirin)
6) IBD

42
Q

Patients with iron-deficiency anemia should be evaluated for possible Celiac Disease, how?

A
  • IgA anti-TtG
  • Duodenal biopsy
43
Q

In pts >60 yo with occult bleeding and a normal initial endoscopic evaluation with no other worrisom signs/symptoms the most common underlying etiology for the blood loss is likely?

A

Angioectasias

44
Q

Asymptomatic adults with positive FOBTs or FITs that are performed for routine colorectal cancer screening should undergo?

A

Colonoscopy

45
Q

What is the most useful method of diagnosis for Meckel’s Diverticulitis?

A

Technetium-99m scan

46
Q

Meckel’s diverticulitis is often clinically indistinguishable from what other pathology?

A

Acute appendicits

47
Q

Management of Meckel’s Diverticulitis is done via?

A

Surgical resection

48
Q

What are 3 possible underlying disorders which can result in Toxic Megacolon?

A
  1. IBD (ulcerative colitis)
  2. C. difficile colitis
  3. Ogilvie Syndrome
49
Q

Most common cause of Acute Liver Failure?

A

Acetaminophen

50
Q

Toxic Megacolon carries a high risk for what complication?

Treated how?

A
  • Perforation
  • Treatment w/ surgery
51
Q

Perforated Viscus refers to what?

Significant why?

A
  • Any hollow organ (esophagus, stomach, intestine, uterus, bladder) perforation
  • EMERGENCY SURGERY!
52
Q

Perforated viscus is visualized with what imaging modality?

What is seen?

A
  • CT or plain XR
  • Free air under diaphragm or air in mediastinum (Pneumoperitoneum = below diaphragm and Pneumomediastinum = above diaphragm)
53
Q

Low grade fever is typical of appendicitis, but what is a high-grade fever or rigors (chills) suggestive of?

A
  • Appendiceal perforation
  • Septic thrombophlebitis (pylephlebitis) = rare
54
Q

Psoas sign vs. Obturator sign for Appendicitis?

A

Psoas sign - pain on passive extension of the right hip

Obturator sign - pain w/ passive flexion and IR of the right hip

55
Q

Moderate ________ with _______ is a common lab finding in appendicitis

A

Moderate leukocytosis with neutrophilia is a common lab finding in appendicitis

56
Q

What are 2 useful imaging modalities for the diganosis of appendicits?

A
  1. Ultrasound
  2. CT
57
Q

What are the most common symptoms/signs of Intestinal Obstruction?

A
  • Colicky abdominal pain
  • N/V –> Feculent vomiting (common)
  • Abdominal distention
  • Absence of flatus or stooling
58
Q

How is the diagnosis of intestinal obstruction made?

A

Plain radiographs or CT scan

59
Q

What is the treatment for Intestinal Obstruction?

If due to adhesions?

A
  • NG tube decompression and fluid resuscitation
  • Urgent laparotomy for lysis of adhesions (LOA) must be performed before bowel ischemia develops
60
Q

In terms of hernias, what does irreducible mean?

A

Hernia contents cannot be manipulated back into abdominal cavity

61
Q

Patient has abnormal vital signs with a tender, firm, irreducible mass (hernia) this indicates what is occuring to the bowel and what treatment needs to be done?

A
  • Bowel is infarcted/dying
  • Needs emergent surgery!
62
Q

Condition in which there is neurogenic failure or loss of peristalsis in the intestine in the absence of any mechanical obstruction describes?

A

Acute paralytic ileus

63
Q

Direct vs. Indirect Inguinal Hernia?

A
  • Direct = occurs near the opening of the inguinal canal
  • Indirect = occurs AT the opening of the inguinal canal
64
Q

What are 5 precipitating factors for Acute Paralytic Ileus?

A
  1. Surgery
  2. Peritonitis
  3. Electrolyte abnormalities
  4. Meds
  5. Severe medical illness
65
Q

Acute Colonic Pseudo-obstruction (Ogilvie Syndrome) is characterized by what?

Arises when?

A
  • Severe abdominal distention —> MASSIVE dilation of CECUM or RIGHT colon (megacolon)w/no mechanical obstruction
  • Arises in post-op state or w/ severe medical illness
66
Q

The risk of rupture of abdominal aortic aneurysms is related to what?

A
  • Size
  • >5cm = 20-40% chance of rupture
67
Q

AAA’s are often asymptomatic and instead discovered how?

A
  • Routine exam as a palpable, pulsatile, expansive, and nontender mass
  • As incidental finding via abdominal imaging study for something else
68
Q

What is typically a signal of AAA about to rupture?

Is there usually a warning before AAA’s rupture?

A
  • Aneurysmal pain
  • More often, acute rupture occurs without prior warning and this complication is always life threatening
69
Q

Which signs/symptoms occur with rupture of AAA and this requires?

A
  • Acute pain and hypotension
  • Emergency operation
70
Q

Who needs to be screened for AAA’s and what imaging modality is used?

A
  • Men age 65-75 yo who have ever smoked
  • Abdominal ultrasound
71
Q

Most common cause of AAA?

A

Atherosclerosis

72
Q

Which finding on transvaginal US with serum beta-hCG >2000 milli-units/mL is indicative of ectopic pregnancy?

A

No intrauterine pregnancy

73
Q

What are 4 conditions that predispose to an ectopic pregnancy?

A
  1. Hx of infertility
  2. Pelvic inflammatory diseae
  3. Ruptured appendix
  4. Prior tubal surgery
74
Q

In the US, what is one of the most common causes of maternal death during the first trimester?

A

Undetected ectopic pregnancy

75
Q

Which symptom occurs in almost every case of ectopic pregnancy?

A

Severe lower quadrant pain (right- or left- sided) generally 6-8 wks after last period

76
Q

Ovarian torsion is most often due to?

A

Rupture, bleeding, or torsion of ovarian cysts

77
Q

How serious is an Ovarian Torsion?

A

Surgical emergency requiring prompt diagnosis to preserve ovarian function

78
Q

The majority of ovarian torsions occur on what side?

A

Right side

79
Q

What is the classic presentation for a patient presenting with an Ovarian Torsion?

A
  • Sudden-onset, SEVERE, unilateral, lower abdominal pain
  • May develop after episodes of exertion
  • N/V common
80
Q

What is the primary imaging/diagnostic modality use for suspected Ovarian Torsions?

Most commonly shows what?

A
  • Transvaginal US w/ doppler
  • Ovary >4cm in size due to cyst, tumor, or edema
81
Q

Which finding needs to be considered in males with acute scrotal pain due to it being a urologic emergency?

A

Testicular torsion

82
Q

Testicular torsion has a bimodal age presentation with peaks occuring during what 2 stages of life?

A
  1. Immediate neonatal period
  2. Early puberty
83
Q

What is the most common age for boys presenting with testicular torsions?

A

Between 12-18 yo

84
Q

What is the standard of care for prenatal torsions in neonates?

Salvageable?

A
  • Not salvageable
  • May be taken to OR on a semi-elective basis when infant is a few months of age to decrease the anesthesia risk
85
Q

Which imaging modality is the diagnostic study of choice for Testicular Torsion?

A

Doppler US

GI II Exam 2 (15 decks)

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