“Approach to Lower GI Bleeding” · Hematemesis Vomiting of fresh red blood or old blood...
Transcript of “Approach to Lower GI Bleeding” · Hematemesis Vomiting of fresh red blood or old blood...
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GASTROINTESTINAL
EMERGENCIES
Ganesh R. Veerappan, MD, FACG AGAF
Akron Digestive Disease Consultants, Inc.
July 12th, 2019
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Outline
Acute abdominal pain
Acute upper GI bleeding
- Non-variceal upper GI bleeding
- Variceal upper GI bleeding
Acute lower GI bleeding
Food Impaction
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Acute Abdominal Pain
Abdominal pain of less than 24 hours
History and physical exam are most important in making a diagnosis
Labs and radiographic studies to confirm diagnosis
When diagnosis is obscure, and patient is stable serial exams
When diagnosis is obscure, and patient is unstable surgical exploration
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Acute Abdominal PainHistory
Chronology – onset, duration, progression
Location
Intensity and character
Aggravating and relieving factors – food, BM’s,
medicine
Associated symptoms and ROS
Past medical history
Family and social history
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Acute Abdominal PainPhysical Exam
Vital signs
Systemic exam
Abdominal exam
Genital, rectal, pelvic exam
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Acute Abdominal Pain –Diagnostics
Labs
- CMP, CBC/diff, Amylase/Lipase, Lactate
- β-hCG in women of reproductive age
- PT/INR in liver disease
Radiology
Plain abdominal series
U/S
CT scan
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Acute Abdominal PainSpecial Circumstances (1)
Elderly
– History and physical exam may be unreliable
– Labs may be normal even with severe intra-
abdominal process
– Biliary tract disease, malignancy, obstruction,
complicated PUD, incarcerated hernia
Pregnancy
– Appendicitis, cholecystitis, pyelonephritis, adnexal
problems, ovarian torsion, ovarian cyst , ectopic
pregnancy
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Acute Abdominal Pain Special Circumstances (2)
Immunocompromised host– Organ transplant, chemotherapy, chronic immune
suppression, immunodeficiency syndromes
– General population disease vs. unique disease (neutropenic enterocolitis, pneumatosis intestinalis, graft-vs.-host disease, CMV, fungal infections, lymphoma, Kaposi’s, etc.)
The ICU patient– History and physical exam not ideal
– Greater role of imaging (i.e., CT scan)
– Overlooked trauma injuries, post-op complications, ileus/obstruction, acalculous cholecystitis, stress ulcer, ischemia
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Acute Abdominal Pain –Common Causes (1)
CONDITION ONSET SITE CHARACTER TYPE RADIATION INTENSITY
Appendicitis Gradual Periumbil-
icalRLQ
Diffuse
localized
Ache None +
Cholecystitis Rapid RUQ Localized Constricting Scapula ++
Pancreatitis Rapid Epigastric,
back
Localized Boring Midback ++ to +++
Diverticulitis Gradual LLQ Localized Ache None + to ++
Perforated
peptic ulcer
Sudden Epigastric Localized
diffuse
Burning None +++
Small bowel
obstruction
Gradual Periumbil-
ical
Diffuse Crampy None ++
Gastro-
enteritis
Gradual Periumbil-
ical
Diffuse Spasmodic None + to ++
+ = Mild, ++ = Moderate, +++ = Severe
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Acute Abdominal Pain –Common Causes (2)
CONDITION ONSET SITE CHARACTER TYPE RADIATION INTENSITY
Mesenteric
ischemia
Sudden Periumbil-
ical
Diffuse Agonizing None +++
Ruptured
AAA
Sudden Abdominal,
back, flank
Diffuse Tearing Back, flank +++
Pelvic
inflammatory
disease
Gradual RLQ, LLQ,
or pelvic
Localized Ache Upper thigh ++
Ruptured
ectopic
pregnancy
Sudden RLQ, LLQ,
or pelvic
Localized Light-
headed
None ++
+ = Mild, ++ = Moderate, +++ = Severe
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Acute Appendicitis
Younger patients (teens, 20s)
Pain, anorexia, nausea, fever
Vague peri-umbilical pain migrates to RLQ
Mild leukocytosis
CT aids in diagnosis
Antibiotics and surgical resection
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Acute Cholecystitis
Persistent dull ache, RUQ, radiates to
back or scapula
Pain resolves in biliary colic but persists
with cholecystitis
Nausea, vomiting, low-grade fever
+ Murphy’s sign
Mildly elevated WBC’s, LFT’s
Diagnosed with RUQ US
Cholecystectomy treatment
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Acute Cholangitis
Charcot’s triad
- fever, RUQ pain, jaundice ( TB)
Reynold’s pentad
- above + MS changes and hypotension
A medical emergency; may lead to biliary
sepsis/septic shock, with high mortality
US to look for stones and CBD dilation; MRCP
IV ABX – (i.e., Zosyn, etc.)
RX: biliary decompression – ERCP – within 12
hours if stable; emergent if not stable
Cholecystectomy prior to discharge from hospital
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Acute Pancreatitis
Most commonly due to gallstones and ETOH
Boring abd pain radiate straight through back
Fever, anorexia, nausea, vomiting
Amylase and lipase > 2-3X NL values
Not all enzyme elevations are pancreatitis!
CT abdomen but not necessary to confirm dx
Hypoactive BS’s, mild leukocytosis
NPO/IVFs/Analgesics
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Acute Diverticulitis
Older population
Sigmoid colon most common site
Fever, LLQ tenderness, palpable mass
Leukocytosis
CT used to make dx and R/O perforation
IV/PO antibiotics
Outpatient colonoscopy
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Perforated Peptic Ulcer
Epigastric, sudden, sharp severe pain
Tachypnea, tachycardia
Hypotension, rigid abdomen
X-ray: free air 75% of the time
Immediate surgery
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Small Bowel Obstruction
70% of cases in adults due to adhesions
Sudden, crampy, peri-umbilical abd pain
Nausea and vomiting temporary relief
Distended abdomen &
hyperactive bowel sounds
X-ray – dilated loops of bowels
& fluid levels
RX- conservative (NPO, NG)
vs. surgery
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Acute Mesenteric Ischemia• Decreased perfusion in gastrointestinal vasculature
leading to ischemia and high mortality
• 4 major categories
1) embolic arterial occlusion (50%)
2) thrombotic arterial occlusion (15%)
3) nonocclusive mesenteric ischemia (20%)
4) venous thrombosis (15%)
• RFs include older age, CAD, PVD, arrhythmias
• Acute onset crampy periumbilical “pain out of
proportion” to exam, nausea, vomiting, fear of food
• ↑ WBC’s; acidosis late finding
• CT with angiography best initial test
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Acute Aortic Aneurysm (AAA)
Rupture or dissection of AAA
Acute, sudden onset, severe tearing mid-abdominal pain
Lightheadedness, diaphoresis, nausea
75%: Classic triad: hypotension, pulsatile mass, and abdominal pain
Emergency surgery
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Extra-abdominal Causes of
Acute Abdominal Pain
CARDIACMyocardial ischemia/infarction
Myocarditis
Endocarditis
Congestive heart failure
METABOLICUremia
Diabetes mellitus
Porphyria
Acute adrenal insufficiency
Hyperlipidemia
Hyperparathyroidism
THORACIC INFECTIONSPneumonitis Herpes zoster
Pleurodynia Osteomyelitis
Pneumothorax Typhoid fever
Empyema
Esophagitis HEMATOLOGICEsophageal spasm Sickle cell anemia
Esophageal rupture Hemolytic anemia
Henoch-Schönlein
MISCELLANEOUS Acute leukemia
Muscular
Narcotic withdrawal
Familial Mediterranean fever NEUROLOGICPsychiatric disorders Radiculitis
Heat stroke Abdominal epilepsy
Tabes dorsalis
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GI Bleeding
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GI Bleeding
Upper GI Bleeding
Bleeding proximal to the ligament of Trietz
Lower GI Bleeding
Bleeding distal to the ligament of Trietz
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GI BleedingHematemesis Vomiting of fresh red blood or old blood
(“coffee grounds”)
Melena Black, tarry, foul-smelling stools
Degradation of blood to hematin by bacteria
DDX: bismuth (Pepto-Bismol), iron
Hematochezia Passage of bright red or maroon blood
per rectum
May or may not be mixed with stool
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GI Bleeding
Obscure GI bleeding No bleeding source found on initial EGD and
colonoscopy
Obscure-overt GI bleeding Frank bleeding is noted (hematemesis, melena,
hematochezia)
Obscure-occult GI bleeding No frank bleeding, but iron deficiency anemia
and/or hemoccult (+) stool
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GI BleedingVital Signs
VITAL
SIGNS
BLOOD
LOSS (%)
BLEED
SEVERITY
Shock
(Resting
hypotension)
20-25 Massive
Postural
(Orthostatic
tachycardia/
hypotension)
10-20 Moderate
Normal < 10 Minor
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Upper GI Bleeding - CausesCommon- Gastric ulcer - Duodenal ulcer
- Esophageal varices - Mallory-Weiss tear
Less frequent- Dieulafoy’s lesions - Vascular ectasia
- Portal hypertensive gastropathy - Gastric varices
- Gastric antral vascular ectasia - Esophagitis
- Gastric erosions - Neoplasia
Rare- Esophageal ulcer - Pancreatic source
- Erosive duodenitis - Crohn’s disease
- Aortoenteric fistula - Hemobilia
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Causes of Upper GI bleeding
Active ulcer bleeding Esophageal Varices Duodenal ulcer
Mallory Weiss Tear GAVEPortal Hypertensive
Gastropathy
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Non-Variceal UGI Bleeding: Predictors of Recurrent Bleeding
Clinical factors Endoscopic factors- Age > 65 - Active bleeding
- Shock (SBP < 100 mm Hg) - Visible vessel
- Health Status (ASA Class) - Clot
- Co-morbid illness - Ulcer size > 2 cm
- Abnormal mental status ��� - Ulcer location: lesser curvature
- Ongoing bleeding , superior or posterior walls
- Transfusion requirement
Bleeding presentation Lab factors- Melena - Hgb < 10 g/dL
- Hematemesis - Coagulopathy
- Red blood on rectal exam
- Blood in gastric aspirate or stomach
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Variceal Upper GI Bleeding –Risks for Recurrent Bleeding
Early Rebleeding
(<6 weeks)
- Age >60 years
- Severity of initial bleed
- Ascites
- Renal failure
- Active bleeding on
endoscopy
- Red signs on varicies
Late Rebleeding
(>6 weeks)
- Severity of liver failure
- Red signs on varicies
- Ascites
- Hepatoma
- Active alcoholism
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GI Bleeding – Initial Approach
- Assess hemodynamics with vital signs
- RESUSCITATION!!- Place 2 large bore IV’s and begin normal saline infusion
- Type/cross blood; transfuse blood once available
- LABS- NO ROLE FOR GASTROCCULT!!
- CBC, CMP, PT/INR
- Consider troponin/CPK’s in elderly, massive bleed, or patient with cardiac HX
- Hgb may not reflect degree of blood loss for 72 hrs
- Elevated BUN – suggests UGIB
- Role of NG tube?
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GI Bleeding – Initial Treatment
-Non-variceal upper GI bleeding
- PO/IV Protonix
-Variceal upper GIB
- Octreotide IV infusion 50mcg bolus and 50 mcg/hr drip
- Cirrhotic pt with acites + GIB
-- IV ABX (Cipro)
-All GI bleeds consult gastroenterologist for endoscopy
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Upper GI Bleeding: An Algorithm
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Acute Lower GI BleedingCauses
Common Diverticulosis
Angiodysplasia
Uncommon Neoplasia, Postpolypectomy
Inflammatory Bowel Disease (IBD)
Colitis (Infection, Ischemic, Radiation)
Hemorrhoids
Small bowel source
Upper GI source
No lesion identified
Rare Dieulafoy’s lesion
Colonic ulceration (NSAID, solitary)
Rectal varices, Portal colopathy,
Intussusceptions
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Acute Lower GI BleedingCauses
Diverticular bleeding Angiodysplasia Ischemic Colitis
Malignancy Post polypectomy bleed
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Acute Lower GI Bleeding Associations with certain history
Important part of history associated with particular diagnosis Elderly: diverticula or angiodysplasia
Young: infectious or inflammatory etiology
HIV: most common cause – CMV
Painless: diverticula or angiodysplasia
Painful: inflammatory or ischemic
History of radiation, prior surgery (vascular), constipation, change in bowel habits, anorectal disease, hypotension, recent polypectomy
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Acute Lower GI Bleeding Evaluations
COLONOSCOPY
Only after patient resuscitated and not significantly bleeding
Urgent purge bowel prep
After upper GI bleeding ruled out by HX, PE, or EGD
BLEEDING SCAN
Bleeding rate >0.1-0.5 ml/min
Noninvasive; no associated morbidity
Usually done because of active bleeding, stable patient
MESENTERIC ANGIOGRAM
Bleeding rate >0.5-1.0 ml/min or unstable bleeding patient
Accurate localization of rapidly bleeding lesions
Potential for hemostasis – drugs, coil, glue
Multiple possible complications
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Acute Lower GI Bleeding
Definitive diagnosis:
Endoscopic or angiographic evidence of active bleeding
Presumptive diagnosis:
Bleeding found on colonoscopy in area of bleeding scan
Prognosis Lower GI bleed better prognosis than upper GI bleeds
Shock, orthostasis, transfusions less than upper GIB
1/3 orthostasis, 10% syncope, 9% cardiovascular collapse
Bleeding stops spontaneously in 80% of cases
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Lower GI Bleeding: An Algorithm
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Acute Lower GI BleedingSurgery
15-25% patients require surgery
Indications Hypotension and shock despite resuscitation
Continued or recurrent bleeding (> 4 URBC’s in 24 hours or 10 UPRB’s overall)
No diagnosis by emergency colonoscopy, push enteroscopy, scintigraphy, and angiography
No hemostasis despite endoscopic/angiographic therapy
Active bleeding from a mass amenable to cure by surgery
Cautions to surgery Patient is good candidate for emergency surgery (comorbidity, life
expectancy)
Accurate preoperative localization minimizes morbidity and mortality
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Case
• 22yo male with sudden difficulty
swallowing after eating some chicken a
few hours ago. Cannot tolerate water and
is drooling at the mouth. He seems really
uncomfortable. VS are all normal and GI is
consulted.
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Endoscopy
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Food Impaction
• Acute onset of dysphagia and cannot even
swallow own saliva (spitting up)
• Patient is at risk for perforation and needs
urgent endoscopy
• Consider using versed or glucagon may
relieve symptoms without endoscopy
• Even if it resolves spontaneously, GI should
be informed and decide if endoscopy
needed to identify underlying cause
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Causes of Food Impaction
Esophageal Ring Concentric Rings in
Eosinophilic EsophagitisEsophageal Stricture
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One more GI emergency
83yo female with multiple comorbidities
(DM, HTN, CAD, CHF) living in nursing
home suddenly with difficulty swallowing.
In ER, x-ray revealed a radioopaque
object in midesophagus. GI is called and
they perform an endoscopy.
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Chew on this
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Question 1
89 Y/O woman hospitalized with pneumonia
develops acute onset severe generalized
abdominal pain associated with multiple lower
GI bleeding.
Vitals: HR 110, BP 91/58. Exam reveals
moderate abdominal distension, voluntary
guarding, no rebound, decreased bowel sounds.
Labs reveal amylase 200, lipase 160, lactate
normal. WBC is 33, up from 18 day prior at ER
admission. Creatinine 2.1, up from 1.4.
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Question 1 – con’t
What would you do next?
A Prep patient for urgent colonoscopy
B Order stool studies including C. diff
C Treat patient for acute pancreatitis: IVFs,
analgesia, gut rest
D CT scan of the abdomen/pelvis with oral
contrast only
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Question 1 – con’t
What would you do next?
A Prep patient for urgent colonoscopy
B Order stool studies including C. diff
C Treat patient for acute pancreatitis: IVFs,
analgesia, gut rest
D CT scan of the abdomen/pelvis with oral
contrast only
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Question 2
67 Y/O man has 3 episodes of melena 8 hrs after
after an emergent heart catherization for STEMI.
He had received integrelin, heparin, ASA, and
Plavix. He is on chronic prednisone for COPD.
Vitals: HR 130, SBP 78/43. Abdominal exam
benign. NG tube negative. Rectal exam: melena.
Hgb 13 (last month 12.9).
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Question 2 – con’t
Which statement is true?
A He has a lower GI bleed because the NG was
negative.
B A STAT angiogram is indicated at this time.
C An urgent colonoscopy is indicated after
resuscitation.
D An urgent EGD is indicated after resuscitation.
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Question 2 – con’t
Which statement is true?
A He has a lower GI bleed because the NG was
negative.
B A STAT angiogram is indicated at this time.
C An urgent colonoscopy is indicated after
resuscitation.
D An urgent EGD is indicated after resuscitation.
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Question 3
45 Y/O man with 3 large episodes of hematemesis
at home and 1 episode in ER. Vitals: HR 160,
BP 80/43. Abdominal exam benign. Rectal
exam negative. Patient refuses NG tube. Hgb 9
(last month was 12).
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Question 3 – con’t
What is the most important next step:
A Call gastroenterologist for emergent endoscopy.
B 2 large bore IVs, IVFs resuscitation, and blood
transfusions when available.
C STAT CT scan of the abdomen/pelvis.
D STAT bleeding scan.
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Question 3 – con’t
What is the most important next step:
A Call gastroenterologist for emergent endoscopy.
B 2 large bore IVs, IVFs resuscitation, and blood
transfusions when available.
C STAT CT scan of the abdomen/pelvis.
D STAT bleeding scan.