GI Emergencies

1. GI Emergencies Jasleen Singh, PGY-5 July 15, 2019

2. Objectives • Recognize common GI emergencies • Be able to triage GI emergencies • Know when to call a GI consult • Know how to communicate information to GI • Understand and prepare patients with GI recommendations

3. Outline • Acute GI bleeding • Sigmoid volvulus • Food impaction/foreign body • Cholangitis • Acute liver failure • Colonic pseudo-obstruction or Ogilvie’s syndrome • Acute Pancreatitis* • Scenarios *not an emergency but frequently seen

4. Acute GI Bleeding • Defined as <3 days duration • Upper GI bleed (UGIB): • Proximal to the ligament of Treitz • Hematemesis, melena, bright red blood per rectum (if brisk) • Lower GI bleed (LGIB): • Distal to the ligament of Treitz • Bright red blood per rectum, occasionally melena • Tend to be hemodynamically stable but can present unstably

5. Differential Diagnosis for GIB • UGIB • Varices, PUD, esophagitis, Mallory-Weiss tear, AVMs, Dieulafoy lesions, malignancy • LGIB • Diverticulosis, AVMs, Dieulafoy lesions, ulcers, IBD, hemorrhoids, malignancy, rectal varices

6. Color of the Stool: Why do we care so much about the DRE? • Melena: black, tarry, malodorous • Usually indicates an upper GI bleed but can be a lower GI bleed • Bright red: mixed in with stool vs liquid blood with normal colored stool • Lower GI bleed or brisk upper GI bleed • Maroon: beware the eye of the beholder • Can be upper or lower GI bleed, depends on the context • The more DRE’s, the merrier

7. My patient is bleeding… Now what? • Evaluate the patient • When you first walk in, what does the patient look like? • History: age, when did bleeding start, quantify bleeding, history of cirrhosis, alcohol use, NSAID use, previous GI bleeds, any cardiac conditions, previous endoscopies, associated symptoms • Medications: anticoagulation, antiplatelets, NSAIDs

8. My patient is bleeding… Now what? • Check vitals! • Blood pressures: resuscitate! • Tachycardia: indicates patient still needs resuscitation • Physical Exam: • DRE! • NG lavage  can predict high risk lesions on endoscopy but can be equivocal for others • Any stigmata of cirrhosis? • Heart/lungs  i.e., is patient in decompensated heart failure? Anything that may make any procedures unsafe?

9. My patient is bleeding… Now what? • Labs: • Know the hb and baseline • Also know platelets and INR • BUN and Cr! • BUN/Cr ratio is very sensitive (approaching 90%) and specific as well  the higher the ratio (i.e., >30, the more predictive it can be) • LFTs  any concern there may be cirrhosis? • AVOID FECAL OCCULT BLOOD TESTS

10. Glasgow-Blatchford Score Scores of 6 or more need intervention more often and thus inpatient admission

11. Rockall Score Scores of 0-2 are lower risk of re-bleeding and death

12. My patient is bleeding… Now what? • 2 large bore IVs  14g or 16g • Resuscitation with IVF and/or blood • NPO • IV PPI BID if any concern for UGIB  NOW dose • Trend hb q8hr-q12hr depending on clinical status • Transfusion goals tend to be >8 in cardiac patients and >7 in everyone else • If coagulopathic, trend plts and INR (fibrinogen in cirrhotics) • If no contraindication, give reglan or erythromycin x1

13. A Brief Word on IV PPIs • How do PPIs actually help in GI bleeds? • Promote platelet aggregation • In nonvariceal UGIB, no statistical difference in mortality, rebleeding or progression to surgery • However in nonvariceal UGIB, reduces rates of high-risk stigmata identified on endoscopy and need for endoscopic intervention • Intermittent vs continuous PPI therapy: no statistical significance between the two, hence intermittent

14. What about cirrhotics? • History of cirrhosis, stigmata or HPI that may indicate cirrhosis • Same initial measures: 2 large bore IVs, trend hb, resuscitate • IV PPI BID • Octreotide: lowers portal pressures and can prevent rebleeding; continue for 72hr • Antibiotics (ceftriaxone): SBP and mortality in variceal bleeders; continue for a total of 5 days

15. When to call GI • After you have collected the history, seen the patient (performed DRE) • Resuscitated patient, repeated hb and come up with a plan for patient • Make sure to relay pertinent information to GI

16. Sigmoid Volvulus

17. Sigmoid Volvulus • Sigmoid colon wraps itself around on the mesentery • Usually sudden onset • Classic triad of symptoms: abdominal pain, abdominal distention and constipation • X-ray is most often diagnostic of this • Can lead to ischemia, necrotic bowel, abdominal compartment syndrome

18. Treatment of Sigmoid Volvulus • Ensure NPO status • Know labs: can see electrolyte derangements, check INR and plts • Flexible endoscopic detorsion is first line for treatment • If evidence of perforation or ischemia, patient needs to go to surgery • If unsuccessful detorsion, patient needs to go to surgery

20. Food impaction/Foreign body • Usually presents in the ED but can also occur on the floor • Important information to know: when did the event occur? What did they swallow? Are they able to tolerate secretions? • Call GI immediately • If at or above cricopharyngeus, call ENT

21. Foreign Bodies

22. Food Impactions • Try glucagon  1mg IV • Can be urgent vs emergent based on patient’s clinical status (how patient is tolerating secretions)

24. Acute Cholangitis • Evidence of systemic inflammation + biliary obstruction • ERCP is gold standard for diagnosis

25. Tokyo Guidelines

27. Acute Liver Failure • Rapid deterioration in liver function • Altered mental status • Coagulopathy (INR 1.5 or greater) • Duration of <26 weeks • Absence of pre-existing liver disease

28. Diagnosis of ALF • If acute hepatitis and suspicion for ALF, check INR and examine patient (looking for mental status) • Obtain history: any medications or toxins, exposures (such as IVDU, tattoos, etc.) • Physical Exam: check mental status (asterixis), stigmata of chronic liver disease

29. Etiology of ALF • Drug-induced (tylenol) • Viral • Wilson disease • Autoimmune liver disease • Acute fatty liver of pregnancy • Ischemia • Malignancy • Budd-Chiari

30. Drug-Induced Liver Inury

31. Management of ALF • Call hepatology • Labs: INR, CMP, ABG, arterial lactate, CBC, blood type and screen, APAP level, UDS, anti-HAV IgM, HbsAg, anti-Hb core IgM, anti-HEV,anti-HepC, HCV RNA, HSV1 IgM, VZV, ceruloplasmin, hCG, arterial ammonia, ANA, ASMA, immunoglobulins, HIV, amylase and lipsase • But really, just wait for hepatology to see the patient

33. OLT – who benefits?

35. Colonic Pseudo-obstruction = Ogilvie’s syndrome • Severe colonic distention • Can lead to ischemia and perforation • Cecal diameter >12cm  emergency

36. Conservative Management of Ogilvie’s Syndrome • Conservative management with limiting anti-motility agents such as narcotics, calcium channel blockers, etc. • Get patient out of bed • Ensure electrolytes are repleted and within normal limits

37. Management of Ogilvie’s Syndrome • If patient fails conservative management, can try neostigmine in cardiac-monitored unit • Can repeat dose • If patient fails neostigmine, may need colonoscopic decompression • If patient fails decompression, may need cecostomy with surgery

39. Acute Pancreatitis • Diagnosis requires at least 2 of the following: • Characteristic abdominal pain • Amylase or lipase >3 times the upper limit of normal • Radiographic evidence of pancreatitis on cross-sectional imaging

40. Management of Acute Pancreatitis • Goal-directed fluid resuscitation • Data on how much fluids or which fluids to give is weak • Adequate resuscitation important in helping prevent pancreatic necrosis • Goal-directed towards HR, MAP, CVP, UOP, BUN and hematocrit • Maintenance IVF vs bolus fluids; watch volume status closely • Clear liquid diet within 24hr as tolerated • Enteral feeding preferred over parenteral feeding

41. Scenario 1 It’s 3am and you get paged by the nurse, “Mrs. Jones just vomited blood.” What do you do next? • Ask for vitals and go evaluate the patient immediately. • Tell your senior and await further instructions. • Call GI immediately. • Do nothing. It’s just tomato juice, probably.

42. Scenario 2 It’s 5pm and you just admitted a patient with abdominal pain. The abdominal x-ray just came back and it shows a large bean-shaped sigmoid colon. What do you do next? • Call surgery. No one really needs their sigmoid colon. • Wait to call GI in the morning. • Sign out to the night intern immediately and tell them to call GI. • Call GI immediately.

43. Scenario 3 It’s 4am and your psych patient that’s admitted to general medicine decides to swallow a razor. Patient is completely asymptomatic and running around the halls, probably naked. What do you do next? • Call surgery. He has probably perforated his esophagus. • Nothing. Patient is asymptomatic. • Check an FOBT. • Call GI immediately.

44. Scenario 4 It’s 10am and you admit a patient with RUQ pain and fevers. Temperature is 101.6F, BP 80/60, HR 110. He is tachypneic. Labs show a total bili 5, ALT 300, AST 400, alkphos 300; labs were previously normal. CT shows intrahepatic and extrahepatic ductal dilation with an ill-defined mass in the head of the pancreas. What do you do next? • Consider admission to the ICU. Get blood cultures, start antibiotics, IVF. Call GI. • Admit to the ICU, start antibiotics, IVF. Call GI tomorrow; that mean GI fellow is on today. • Call surgery. There is a pancreatic head mass that is causing compression of the biliary tree. • Talk to your senior. You’re not sure what is going on.

45. Scenario 5 There’s a transfer from Loretto Hospital overnight with elevated LFTs. The patient is homeless and is an IV drug user. The ED states that the patient is fine, just needs transfer to Loyola because there is no gastroenterologist at Loretto. You review the labs and note ALT 2000, AST 3000, alkphos 100, total bilirubin 1. What do you do next? • Admit to the floor. Check repeat set of labs. Send acute hep panel. • Go evaluate patient immediately for mental status changes. Check INR. Consider admission to ICU. • Call hepatology first. Those numbers are really elevated and patient could have acute liver failure. • Ask the ED to admit patient to hepatology.

46. Scenario 6 It’s 2am and you get a call from the nurse that Mr. Smith is complaining of abdominal bloating. You quickly look in the chart and see no BMs in the last week. You are very astute and decide to order a KUB, which shows significant colonic dilation with cecum up to 12cm. What do you do next? • Go evaluate the patient. The patient has some bloating but no peritoneal signs so nothing to do. • Call surgery. The patient might perforate. • Go evaluate the patient and call GI. • Administer neostigmine on the floor immediately.

47. Scenario 7 You see a 27yo male with a history of alcohol abuse in the ED. He is having epigastric pain radiating to the back. Lipase is 12,000. CT abd/pelvis shows fat stranding around the head of the pancreas. What do you do next? • IVF, pain meds, NPO for pancreatitis. • Is this really pancreatitis? It could also be gallstones. • IVF, pain meds, clear liquid diet. • Call GI immediately. It’s the pancreas. Not even sure what that organ does.

48. How to communicate with GI • Evaluate the patient before calling a consult • Be ready with vitals, physical exam (DRE in most cases!), labs (hb, BUN, Cr, plts, INR) • Know about anticoagulation/antiplatelets and whether these can be held • Know previous procedures • Ensure NPO status if you think patient may need a procedure

50. Thank you!