Intern Survival Series GI EMERGENCIES

1. Intern Survival SeriesGI EMERGENCIES Adib Chaaya MD, PGY5 ACP, AGA, ASGE 7/9/9

2. Case 1 • You are the team 1 short call intern. A nurse from 10 north pages you in a panic… • “The patient in 1023w is vomiting blood!” • You arrive on the floor to find a middle-aged male in bed, well awake, vomiting bright red blood into a basin. • What is your next step?

3. Always First thing : ABC • Vitals: He is afebrile, blood pressure is 90/60, pulse is 120/min, sats 96% on room air • Then review the chart or discuss with the patient the different medical problems…

4. The nurse tells you that this is a 56-year old male with history of alcoholism and IV drug abuse admitted for pneumonia.

5. What else are you looking for on history? • What are you looking for on physical exam? • What is the differential diagnosis? • What will you order? • How will you initially manage the patient?

6. What else are you looking for on history? • History of liver disease/ portal hypertension (cirrhotic with variceal bleed) • Anticoagulation (warfarin/heparin drip) • Use of NSAIDs, Plavix, ASA, Steroids. • Multiple episodes of vomiting (Mallory Weiss Tear…)/ nausea • Melena ,hematokezia. • History of AAA repair • Signs of hypovolemia (dizziness, SOB, CP, syncope…)

7. What are you looking for on physical exam? • Vital signs: hypotension/ tachycardia • HEENT: conjunctival colors (pale/icteric..), JVD • Skin color: pale, lesion, itching signs… • Chest: telangiectasia, gynecomastia, hair loss • Heart: tachycaria • Abdomen: ascitis, caput medusae, prominent umbilicus, rectal exam (important to assess bleeding and prostate…) • Extremities: edema, pulse • Neuro : oriented, cooperent, asterixis

9. What will you order? • NPO • 2 big IV lines • PPI drip • Stat CBC/INR/type and cross/BUN • Octreotide drip (if cirrhotic) • Antibiotics (if cirrhotic) • GI consult (stat if cirrhotic) • To consider ICU consult • H&H every 6-8 hours • Naso-gastric lavage not always needed • Correct coagulopathy if needed (high INR give FFP)

10. Esophagus: Varices Mallory Weiss tear Esophagitis NG trauma Duodenum: Duodenal ulcer Aortoenteric fistula (previous AAA graft) AVM Stomach PUD Gastric cancer Gastritis Dieu la foy Lesion Gastric varices Frequent causes of upper GI bleeding

11. Laboratory • CBC – in rapid blood loss the initial Hct may not accurately reflect the amount of blood loss as equilibration of the extravascular fluid may take several hours. • PTT, PT/INR, LFTs • Type and cross • BUN, Creatinine – ratio >10:1 suggestive of a UGIB. Occurs as a result of breakdown of blood proteins by bacteria to urea and re-uptake of this from the gut • Very important to repeat lab values in several hours to follow clinical course

12. Management The initial evaluation of a patient with an upper GI bleed involves an assessment of the hemodynamic stability and resuscitation if necessary. 1. ABC’s • 2 large bore IVs, patient should be placed in a monitored area • Fluid resuscitation – normal saline • Type and cross match pRBCs • Correct any coagulopathy 2. Keep NPO - in case of sudden repeat bleed, may need urgent endoscopy or even intubation 3. EKG/ transfer to a tele bed– looking for signs of ischemia or infarct 4. PPI – IV pantoprazole for hemodynamically unstable UGIB (Call MAR & GI fellow!) 5. Endoscopy - attempts to identify the source of bleeding +/- therapeutic intervention to achieve hemostasis

13. Case 2 • You are the team 2 night float intern. You are in the callroom, just about to reach for the last chocolate chip cookie. You pager goes off and it’s the nurse on 8: • “Doctor, the patient in 863d just had a large, bloody bowel movement! What do you want me to do?”

14. You arrive on the floor to find an 83-year old female in mild distress. She complains of diffuse abdominal “discomfort” but no CP/SOB or dizziness. • She is afebrile, her blood pressure is 130/80, pulse is 80 and irregular. • Past medical history includes CAD, HTN, chronic atrial fibrillation, AAA (s/p repair) and colon polyps. • Abdominal exam is diffuse mild tenderness but no rebound or guarding. Rectal shows bright red blood with clots.

15. What else do you want to know on history? • What is your differential diagnosis? • What investigations will you order? • How will you manage the patient?

16. Small Bowel AVM Crohn’s disease Neoplasm Meckel’s diverticulum Vasculitis Anal Hemorrhoid Fissure Colon Diverticulosis AVMs (angiodysplasia) Ischemic gut Infectious Inflammatory bowel disease Neoplasm Coagulopathy Frequent causes of lower GI Bleeding

17. History • Make sure that you are not dealing with a severe upper GI Bleed => NG lavage needed most of the time • As with the upper GI bleed it is very important to ask question regarding the symptoms of hemodynamic instability • These bleeding episodes are usually bright red, as the blood is not first degraded in the gut • Other questions should be directed at the character of bleeding or other associated symptoms

18. 1. Volume: • Occult blood loss is associated with colon cancer • Small amounts on the tissue or surface of stool associated with hemorrhoids or fissures • Hematochezia • Massive blood loss likely due to either diverticulosis, angiodysplasia, or occasionally aortoenteric fistula • Must always rule out a massive UGIB! Usually site is distal to the pylorus 2. Symptoms associated with inflammatory bowel disease or any other systemic disease 3. Constitutional symptoms or recent change in bowel habits suggesting a malignancy 4. Food intake which may give a false impression of rectal bleeding – beets or iron 5. Infectious symptoms or recent ingestion of any poorly cooked meat

19. Management • Volume resuscitation and management of ABC’s should be the first priority • If hemodynamically stable with low volume blood loss, the patient can be followed clinically with volume resuscitation and blood as needed • Once the bleeding has settled, the patient can be prepped for colonoscopy and the cause of bleeding determined

20. If hemodynamically unstable with rapid rates of blood loss, other investigations can be arranged (CALL MAR, GI FELLOW and ICU fellow) 1. Tagged red blood cell scan • Non-invasive, but only localized bleeding to areas of the abdomen. Accuracy ranges from 24-91% • Can be positive with 0.1cc/min but diagnostic in less then 50% • Once tagged can be easily rescanned 2. Angiography • Needs blood flow of 0.5cc/min to be positive • Identifies site in 60% of bleeds, 50-80% are a result of bleeding from the superior mesenteric artery • Allows for therapeutic intervention 3. Surgery • Consider in patients with ongoing bleeding and hemodynamic instability but with failure of other therapeutic maneuvers. • Colonoscopy is not useful in the setting of ongoing bleeding so there is no urgent indication.

22. Case 3: • You are called by a nurse for the patient on 926wn. • 75 y/o F admitted for DVT, now is having tachycardia. • The nurse tells you that this patient need to be transferred to a tele bed • What do you think? • What should you do?

23. Case 4: • You are in the ER doing an admission for a 78y/o patient who p/w syncope. • The ER is admitting him to R/O TIA • While doing his admission you realize that this patient’s Hgb is 9.9 (however it was 12 one month ago) and the HR is 96/min. • What should you do?

24. Case 5: • 37 y/o M, no PMH, admitted for RUQ pain/N/V diagnosed with gallstones. • You got called overnight by the nurse, because the patient is febrile at 101.7, tachycardic and is having chills and abdominal pain.

25. What else are you looking for on history? • What are you looking for on physical exam? • What is the differential diagnosis? • What will you order? • How will you initially manage the patient?

26. Physical exam • VS: 101.7- 110/min- 100/75 • HEENT: jaudiced • Abd: Soft, RUQ tenderness, Positive for murphy sign, BS positive. • No signs of cirrhosis

27. WBC: 18 Hgb: 12 Plt: 300 Tot bili: 5 Direct bili: 3.7 Alk Phos: 600 AST: 200 ALT:150 Laboratory

28. Case 6: • A nurse calls you from the new building. • Doctor, my patient is complaining of some abdominal pain.. • I had her for the last 2 days and her belly is more distended today.

29. What else are you looking for on history? • What are you looking for on physical exam? • What is the differential diagnosis? • What will you order? • How will you initially manage the patient?

31. Any questions?

32. Thank you