Intro to Dworken (GI)

Intern Boot CampJacob Sadik, PGY3

What You Will Learn How to survive Dworken How to recognize when a GI patient is sick How to diagnose/manage a few commonly-

encountered GI diseases

(Biliary disease, transaminitis, comprehensive discussion on GIB, hepatitis and cirrhosis covered in other boot camp lectures)

High-Yield Slides

Lksd 55 is your home 2 interns, 1 senior, 2

fellows, 2 attendings (liver, GI)

Spend time in the endoscopy lab when you can!

Your senior/fellow are always there to help!!

The only stupid question is the one you didn’t ask!

Dworken

Dworken Patients Take a GI-focused history

Prior GI diagnoses Prior endoscopic studies (EGD, C-scope, CE, ERCP) NSAIDs, anti-platelets, anticoagulation Shadow of a doubt?...make NPO!

Know your overnight admissions well!!! Notify primary gastroenterologist re: admission Rectal exams on all bleeding patients (even if

done in the ED) No consults for hemoccult positive stools!!! OARRS…. is….everything

Ohio reporting system for narcotics and other controlled substances

Get access today! https://www.ohiopmp.gov/Portal/Registration/Def

ault.aspx

The OARRS Report

A 56 y/o M with a h/o DMT2, DLD, PUD and EtOH abuse arrives on Lksd 55 from the ED with a 1-week h/o progressively worsening, gnawing epigastric abdominal pain radiating to his back.VS: T 36.1, P 118, R 20, BP 100/80, SpO2 96% RAOrthostatics negativeFOCUSED EXAM:HEENT: Sclera anicteric, no palatal jaundiceSKIN: No jaundice, +axillary sweat, no truncal ecchymosesABD: Soft, ND, significant TTP over epigastrium without peritoneal signs, no organomegalyNEURO: AAOx3PERTINENT LABS:Hgb 15BUN 10, Cr 0.9, lipase 4600

Case 1

Type Edematous, interstitial acute pancreatitis Necrotizing acute pancreatitis

Severity Mild-mod (absence/transient organ failure <48

hrs) Severe (persistent organ failure >48 hrs)

Acute Pancreatitis

Classification

Acute Pancreatitis

Diagnosis Requires 2 or more of the following:

1) Acute, persistent, severe epigastric abdominal pain (often radiating to the back)

2) Elevated serum lipase or amylase ≥3x upper limit of normal

3) CT/MRI/ultrasound evidence of AP (NOTE: imaging is not required for uncomplicated

mild AP if #1 and 2 are present)

Assess severity. ICU transfer may be indicated if 1 or more of the following are present: P <40 or >150 SBP <80 RR >35 PaO2 <50 mmHg pH <7.1 Anuria Coma

Initial Evaluation

Acute Pancreatitis

Acute Pancreatitis

APACHE II SCORING SYSTEM

Be concerned about… Rigidity, guarding, rebound tenderness, ill-

appearance Portable KUB STAT Acute care surgery consult STAT ICU transfer

If no acute surgical intervention per ACS Your senior/fellow will help you with this

“Surgical” Abdomen

Acute Pancreatitis

Gallstones*** EtOH*** Hypertriglyceridemia (TG >1000s) Trauma (e.g. panc laceration, post-ERCP) Drugs

Steroids, azathioprine, Januvia, tetracycline, furosemide, thiazides, flagyl, valproate, HAART, etc..

Infection Other mechanical Autoimmune Toxins (e.g. scorpion sting) Hypercalcemia Idiopathic

Think About Etiology…

Acute Pancreatitis

Acute Pancreatitis

Supportive Workup RFP(includes Ca) and CBC LFTs Lipid panel (for TG level) Lactate Blood EtOH level (if indicated) Abdominal ultrasound ABG (if altered, SpO2 <90%, bicarb low, etc) CT abd/pelv with contrast

CAUTION in those with AKI Diagnostic or to assess for complications in severe AP

EUS/MRCP vs. ERCP (in suspected or overt gallstone pancreatitis)

1) Fluid resuscitation!!! Generally ~>200 cc/hr Decreases morbidity/mortality w/in the 1st 12-24

hrs Monitor for improvement (via VS, BUN, Cr, Hct,

UOP) 2) Pain control

IV opiates 2) Bowel rest

NPO CLD Soft, low-residue, low-fat, soft diet NJ feeding (post-ligament of Treitz) > TPN/PPN

4) Metabolic/electrolyte correction

Management

Acute Pancreatitis

Non-discrete peri-pancreatic fluid collections Walled off fluid collections (or “pseudocysts”) Necrotizing pancreatitis (+/- secondary

infection) Pancreatic ascites Hemorrhagic pancreatitis Abdominal compartment syndrome Pseudoaneurysms

Acute Pancreatitis

AP Sequelae

Non-Discrete Fluid Collections

Acute Pancreatitis

Walled-Off Fluid Collections

Acute Pancreatitis

Pancreatic Necrosis

Acute Pancreatitis

Management of Infected Necrosis

Acute Pancreatitis

Empiric antibiotics with good pancreatic penetration (e.g. carbapenems*, quinolones, flagyl)

Cover GNRs and anaerobes Trend towards conservative management with

ABx and observation for several weeks vs. immediate surgical resection

Limited role for CT-guided FNA Open/endoscopic partial/total necrosectomy

may eventually be required

Acute Pancreatitis

Cullen’s Sign

Grey Turner’s Sign

Hemorrhagic Pancreatitis

Once Dx is known, assess severity first Does your patient need ICU level care?

FLUIDS! Close monitoring (VS, UOP, BUN, lactate, etc.) Etiology will help guide management Be mindful of complications

Pancreatitis Take Home Points

Acute Pancreatitis

A generous NF resident gives you an overnight patient. Pt is a 56 y/o M who presents to the ED with a 1-week h/o progressively worsening left quadrant/flank pain and fever. Endorses associated anorexia, nausea and fatigue. Had a colonoscopy ~1 week ago, revealing scattered, non-bleeding diverticuli.VS: T 38.2, P 100, R 22, BP 128/86, SpO2 100% on RAFOCUSED EXAM:GEN: Well-nourished CM in mod distress d/t painSKIN: No jaundice ABD: Soft, ND, mild TTP over LLQ without peritoneal signs, no organomegalyNEURO: AAOx3PERTINENT LABS:WBC 13K with left shift, CRP 10

Case 2

Pyelonephritis Acute uncomplicated/complicated

diverticulitis Nephrolithiasis Iatrogenic microperforation Acute pancreatitis Infectious colitis Crohns disease CRC Acute appendicitis

What is your DDx?

What do you order next?

A CT scan! What is the Dx?

Presentation

Acute Diverticulitis

Mean age ~60s LLQ abd pain Fever Leukocytosis N/V/constipation Recurrence is ~20-40% after initial attack and

20% may have chronic abd pain

Classification

Acute Diverticulitis

1) Uncomplicated 2) Complicated

Perforation Abscess Fistulas Obstruction Peritonitis

Management

Acute Diverticulitis

Bowel rest Antibiotics covering GNRs and anerobes

Amp/sulbactam, pip/tazo May be transitioned to PO Augmentin prior to

discharge Pain control with IV opiates +/- Surgery consult

Indicated for acute complications Surgery decided on case-by-case basis <40 y/o, R-sided disease, immunocompromised

Management

Acute Diverticulitis

Colonoscopy due at least 6-8 weeks out from onset to exclude CRC NOT during acute flare given risk of iatrogenic

perforation

Acute Diverticulitis

Your patient asks, “I read that seeds, nuts and popcorn are bad for my diverticulitis. What do you think?

Case 3You get called from the DACR at 6:50 because a 68 y/o F with a h/o osteoarthritis and SLE (on chronic hydroxychloroquine and prednisone) is in the ED complaining of a 2-day h/o frequent black, tarry stools and lightheadedness. She has been taking Ibuprofen for the past 7 days because of knee pain.VS: T 37, P 120, R 24, BP 104/80, SpO2 99% on RAOrthostatics negativeFOCUSED EXAM:GEN: Lethargic, in NADHEENT: Conjunctival pallor, dry mucous membranesABD: Soft, ND, epigastric TTP without rebound/rigidity/guardingNEURO: AAOx3LABS:Hgb 6.4 (baseline 12)BUN 18, Cr 1.34, bicarb 18, K 3.2Lactate 1.8

Use of NSAIDs, anti-platelets, anticoagulants Abdominal pain? Relation to food? Stool color, character, quantity Previous GIB Previous EGD/colonoscopy/CE? EtOH abuse H/o cirrhosis or visualized varices Primary thrombophilia Recent pepto or iron ingestion darkens

stools

GIB

What else do you want to know?

GIB

Initial Management NPO CBCs q6h and active T&S with blood consent RFP, LFTs, coags 2 18-gauge (large-bore) PIVs Bolus NS/LR for orthostatic hypotension Stop all NSAIDs, anti-platelets and

anticoagulants Hold pharmacologic DVT prophylaxis +/- NG lavage Oxygen as needed Abdominal pain? KUB prior to endoscopy Transfer to ICU? (discuss with your senior)

GIB

Transfusion Goals Transfuse pRBCs for Hgb <7 (consider <8 in

patients with cardiac disease) Transfuse platelets for…

Active bleeding with PLT <50K Pre-procedural PLT <50K with/without bleeding Any PLT <10K

Transfuse FFP for INR >1.5 in the setting of active bleeding or pre-procedural in some cases

GIB

Prep Basics EGD

NPO +/- erythromycin 3 mg/kg IV q8h (off-label) to clear

stomach contents for better visualization – ask GI Flexible sigmoidoscopy or ileoscopy

Tap water enemas 30 minutes apart x 3 or until clear

Colonoscopy Golytely “split-prep” (2L in the evening, 2L in the

early morning; i.e. 7PM, 3AM) Movi-Prep (Gatorade) NG tube if refusing PO

GIB

Concerning GIB Active bloody bowel movements Hemodynamic instability Drop in Hgb >/= 2 gm/dL or poorly

incrementing Hgb after transfusion (1 unit pRBCs should bump Hgb by 1-1.5 g/dL)

Change in mental status or symptomatic anemia

REMEMBER! Blood is a laxative. Hemodynamically-significant GI blood loss will present itself.

Case 4 Your covering the Dworken team pager on NF when

you are paged by nursing about a 36 y/o F with a h/o ulcerative colitis who is having multiple, small-volume bloody bowel movements. She has been taking Keflex for the past week for a soft tissue infection. What do you do?!?

Examine the patient VSS? Pain? Mentation? Abd exam? DRE?

“Show me the stool!” CBC STAT Orthostatics Send C.diff PCR!

IBD 2nd-3rd decade of life

Crohns disease has bimodal distribution (7th-8th decade)

Disease predilection for developed countries and the northern hemisphere

Look for extraintestinal manifestations Episcleritis, uveitis, iritis Ankylosing spondylitis Pyoderma gangrenosum Eythema nodosum

IBD

IBD

IBD

Immune System

Dysregulation

Genetic Predispositi

on

Environmental Triggers

Crohns Disease Risk factors: smoking, “western” diet Protective factors: high-fiber diet Transmural bowel wall inflammation Entire GI tract (TI most commonly involved) “Skip” cobblestone lesions Rectal sparing

IBD

Abdominal pain, diarrhea, fatigue, weight loss, kidney stones

Diagnosis of CD Colonoscopy with intubation of the terminal

ileum and biopsy acquisition is the gold standard MRE is preferred for initial Dx of small bowel CD Consider CE in difficult-to-diagnose cases MRI or EUS to evaluate perianal CD

IBD

Tx Strategies in CD

IBD

“Step-Up” “Top-Down”

Slow-release 5-ASA for ileitis

Sulfasalazine for colitis

Antibiotics if not improving

Biologic agent Immunomodulat

or

Slow-release 5-ASA for ileitis

Sulfasalazine for colitis Biologic agent

Immunomodulator

Ulcerative Colitis Bloody diarrhea, tenesmus, fecal urgency, fatigue

weight loss and sometimes fever DDx: infectious, ischemic, CD, radiation-induced High CRC risk Predisposition to C.diff colitis

IBD

Erythematous, engorged mucosa

Rectal involvement with continuous progression

Crypt abscesses

Dx of UCConsider flex sig if inpatient for severe active flare due to risk of iatrogenic complications with colonoscopyColonoscopy if flare not severe

IBD

Acute IBD Flares Severe flares

Fever (>/= 37.5C) Tachycardia Anemia (Hgb <7 g/dL) Elevated inflammatory markers (ESR, CRP)

Corticosteroids NPO Fluid resuscitation Electrolyte correction Consider 5-ASA compound (for those who

are not on maintenance therapy)

IBD

Back to our Patient…Initiate supportive careCRP, ESR, CBC, RFP, LFTsC.diff PCR, stool studies firstIf C.diff PCR negative, would start steroidsHigh-dose 5-ASA compound (e.g. sulfasalazine)

IBD

Now you know a little bit about….

The Dworken team How to recognize a sick patient Prep Basics Acute pancreatitis Diverticular Disease GI bleeding (briefly) IBD (briefly)