Lecture 9: GI Bleeds and GI/Abdominal Emergencies

Question 1

Acute upper GI bleeds occur proximal to which anatomic landmark?

Answer 1

Proximal to the Ligament of Treitz

Question 2

Which imaging modality is used for diagnosing Upper GI Bleeds?

Answer 2

EGD

*Also therapeutic

Question 3

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

Answer 3

Telangiectasias

Question 4

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

Answer 4

Dieulafoy lesion

Question 5

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

Answer 5

Hemodynamic status

Question 6

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

Answer 6

• Hypotension: systolic <90 mmHg
• Tachycardia: HR >90 bpm

Question 7

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

Answer 7

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

Question 8

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

Answer 8

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

Question 9

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

Answer 9

1. IV PPIs
2. Oral PPIs

Question 10

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

Answer 10

Ocreotide

Question 11

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

Answer 11

BUN

Question 12

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

Answer 12

1. Ruptured aortic aneurysm
2. Mesenteric infarction
3. Acute pancreatitis

Question 13

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

Answer 13

Distal to Ligament of Treitz

Question 14

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

Answer 14

Colonoscopy

Question 15

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

Answer 15

• Aspirin
• Nonaspirin antiplatelet agents
• NSAIDs

Question 16

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

Answer 16

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

Question 17

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

Answer 17

1. Diverticulosis
2. Angiectasias
3. Malignancy
4. Ischemia

Question 18

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

Often presents how?

Answer 18

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

Question 19

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?

Answer 19

Angioectasias (angiodysplasias)

Question 20

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?

Answer 20

Ischemic colitis

Question 21

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

Answer 21

Proximal to Ligament of Treitz

Question 22

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

Answer 22

Colon

Question 23

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

Answer 23

Rectosigmoid or anus

Question 24

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

Answer 24

Diverticular bleeding

Question 25

When diagnosing a suspected lower GI bleed what needs to be excluded first? Which imaging modalities can be used?

Answer 25

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

Question 26

Diverticulosis is most commonly found where in the colon?

Answer 26

Sigmoid

Question 27

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

Answer 27

Diverticulosis

Question 28

90% of patients with diverticulosis are what?

Answer 28

Asymptomatic

Question 29

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

Answer 29

Diverticulitis

Question 30

**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?

Answer 30

Acute Mesenteric Ischemia

Question 31

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

Answer 31

- Bowel distention and Air-fluid levels - **Thumb-printing (submucosal edema)**

Question 32

What is the diagnostic study of choice for Acute Mesenteric Ischemia? Early celiac and mesenteric ________ is recommended?

Answer 32

- **CT angiography** = **study of choice** - Early celiac and mesenteric **arteriography** is recommended

Question 33

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

Answer 33

Laparotomy

Question 34

Ischemic colitis is characterized by what symptoms and signs?

Answer 34

**Severe** lower abdominal **pain** followed by **rectal bleeding**

Question 35

Abdominal XR of ischemic colitis will show what?

Answer 35

- Colonic dilation - Thumb-printing

Question 36

Differentiate acute mesenteric ischemia from ischemic colitis?

Answer 36

- **AMI** = **periumbilical** pain out of proportion to tenderness - **IC** = **severe LOWER abdominal** pain **followed by** rectal bleeding

Question 37

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

Answer 37

Anal fissures

Question 38

Define Occult GI bleeding?

Answer 38

Bleeding that is **not** apparent to the patient

Question 39

How is occult GI bleeding identified (3 ways)?

Answer 39

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

Question 40

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

Answer 40

- Menstruation - Pregnancy-associated iron loss

Question 41

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

Answer 41

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

Question 42

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

Answer 42

- IgA anti-TtG - Duodenal biopsy

Question 43

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?

Answer 43

Angioectasias

Question 44

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

Answer 44

Colonoscopy

Question 45

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

Answer 45

Technetium-99m scan

Question 46

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

Answer 46

Acute appendicits

Question 47

Management of Meckel's Diverticulitis is done via?

Answer 47

Surgical resection

Question 48

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

Answer 48

1. IBD (ulcerative colitis) 2. *C. difficile* colitis 3. Ogilvie Syndrome

Question 49

Most common cause of Acute Liver Failure?

Answer 49

Acetaminophen

Question 50

Toxic Megacolon carries a high risk for what complication? Treated how?

Answer 50

- Perforation - Treatment w/ surgery

Question 51

Perforated Viscus refers to what? Significant why?

Answer 51

- Any hollow organ (esophagus, stomach, intestine, uterus, bladder) **perforation** - **EMERGENCY SURGERY!**

Question 52

Perforated viscus is visualized with what imaging modality? What is seen?

Answer 52

- CT or plain XR - **Free air** under diaphragm or air in mediastinum (Pneumoperitoneum = **below** diaphragm and Pneumomediastinum = **above** diaphragm)

Question 53

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

Answer 53

- Appendiceal perforation - Septic thrombophlebitis (pylephlebitis) = rare

Question 54

Psoas sign vs. Obturator sign for Appendicitis?

Answer 54

**Psoas sign** - pain on passive **extension** of the right hip **Obturator sign** - pain w/ passive **flexion and IR** of the right hip

Question 55

Moderate ________ with _______ is a common lab finding in appendicitis

Answer 55

Moderate **leukocytosis** with **neutrophilia** is a common lab finding in appendicitis

Question 56

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

Answer 56

1. Ultrasound 2. CT

Question 57

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

Answer 57

- Colicky abdominal pain - N/V --\> Feculent vomiting (common) - Abdominal distention - Absence of flatus or stooling

Question 58

How is the diagnosis of intestinal obstruction made?

Answer 58

Plain radiographs or CT scan

Question 59

What is the treatment for Intestinal Obstruction? If due to adhesions?

Answer 59

- NG tube decompression and fluid resuscitation - Urgent laparotomy for lysis of adhesions (LOA) **must be performed** before bowel ischemia develops

Question 60

In terms of hernias, what does irreducible mean?

Answer 60

Hernia contents **cannot be manipulated back into abdominal cavity**

Question 61

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?

Answer 61

- Bowel is **infarcted/dying** - Needs **emergent surgery!**

Question 62

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

Answer 62

Acute paralytic ileus

Question 63

Direct vs. Indirect Inguinal Hernia?

Answer 63

- **Direct** = occurs **near** the opening of the inguinal canal - **Indirect** = occurs **AT** the opening of the inguinal canal

Question 64

What are 5 precipitating factors for Acute Paralytic Ileus?

Answer 64

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

Question 65

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

Answer 65

- **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**

Question 66

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

Answer 66

- **Size** - **\>5cm** = 20-40% chance of rupture

Question 67

AAA's are often asymptomatic and instead discovered how?

Answer 67

- **Routine exam** as a palpable, pulsatile, expansive, and nontender mass - As **incidental finding** via abdominal imaging study for something else

Question 68

What is typically a signal of AAA about to rupture? Is there usually a warning before AAA's rupture?

Answer 68

- Aneurysmal pain - More often, acute rupture occurs **without** prior warning and this complication is **always life threatening**

Question 69

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

Answer 69

- Acute pain and hypotension - Emergency operation

Question 70

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

Answer 70

- Men age 65-75 yo who have **ever** smoked - Abdominal **ultrasound**

Question 71

Most common cause of AAA?

Answer 71

Atherosclerosis

Question 72

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

Answer 72

No **intrauterine** pregnancy

Question 73

What are 4 conditions that predispose to an ectopic pregnancy?

Answer 73

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

Question 74

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

Answer 74

Undetected ectopic pregnancy

Question 75

Which symptom occurs in almost every case of ectopic pregnancy?

Answer 75

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

Question 76

Ovarian torsion is most often due to?

Answer 76

Rupture, bleeding, or torsion of ovarian cysts

Question 77

How serious is an Ovarian Torsion?

Answer 77

**Surgical emergency** requiring prompt diagnosis to preserve ovarian function

Question 78

The majority of ovarian torsions occur on what side?

Answer 78

Right side

Question 79

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

Answer 79

- **Sudden-onset**, SEVERE, **unilateral, lower abdominal pain** - May develop after episodes of **exertion** - N/V common

Question 80

What is the primary imaging/diagnostic modality use for suspected Ovarian Torsions? Most commonly shows what?

Answer 80

- Transvaginal US w/ **doppler** - Ovary \>4cm in size due to cyst, tumor, or edema

Question 81

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

Answer 81

Testicular torsion

Question 82

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

Answer 82

1. Immediate **neonatal period** 2. Early **puberty**

Question 83

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

Answer 83

Between **12-18 yo**

Question 84

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

Answer 84

- 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

Question 85

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

Answer 85

**Doppler US**