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1/16/2007 UNSOM: EMR
Gastroenterology
UNSOM Emergency Medicine
Review
1/16/2007 UNSOM: EMR
Dysphagia (1)• Difficulty swallowing• Solids: mechanical/obstructive• Solids/liquids: motility disorder• Oropharyngeal dysphagia (transfer): neuromuscular disorder
(CVA)• Progressive (CA) vs. non-progressive (web)• Strictures 2° reflux (can mimic CA)• Work up
EsophagramEndoscopyEsophageal motility studies
1/16/2007 UNSOM: EMR
Dysphagia (2)• Infectious: Botulism, diptheria, polio, rabies,
Sydenham’s chorea (rheumatic fever), tetanus• Immunologic: Scleroderma, multiple sclerosis,
myasthenia, ALS, polymyositis, amyloidosis• Motor dysfunction:
CN palsy (posterior CVA), diabetic neuropathyAchalasia (vomit undigested food)
Aperistalsis of esophagus (loss of Auerbach’s plexus in the esophagus)
Tx: CCB (Diltiazem, nifedipine) –Botox, dilation, myomotomy
1/16/2007 UNSOM: EMR
• A 32-year-old woman presents with chest pain that has worsened over the past 2 months. She says it gets worse when she lies flat or exercises and after she eats or drinks quickly. She has no significant past medical history, but her husband says she has lost about 10 pounds recently and has been throwing up undigested food. What are the expected diagnostic findings?
• A. Diffuse ST-segment elevation and PR-interval depression
• B. Dilated esophagus proximal to a beaklike lower esophageal sphincter
• C. Gastric inflammatory changes• D. White matter plaques in the brainstem
1/16/2007 UNSOM: EMR
• A 32-year-old woman presents with chest pain that has worsened over the past 2 months. She says it gets worse when she lies flat or exercises and after she eats or drinks quickly. She has no significant past medical history, but her husband says she has lost about 10 pounds recently and has been throwing up undigested food. What are the expected diagnostic findings?
• A. Diffuse ST-segment elevation and PR-interval depression
• B. Dilated esophagus proximal to a beaklike lower esophageal sphincter
• C. Gastric inflammatory changes• D. White matter plaques in the brainstem
1/16/2007 UNSOM: EMR
Dysphagia (3)Mechanical
• Zenker’s diverticulum Pharyngoesophageal pouchProximal: above the UESElderly, regurgitation of undigested food
• Cancer: MCC = squamousRisk factors: smoking, achalasia, caustic ingestion
• Extraluminal obstruction / tumor
1/16/2007 UNSOM: EMR
Dysphagia (4)Mechanical
• StricturesGERD, chronic inflammation, occur in distal
esophagus• Schatzki’s ring
Fibrous structure distal esophagusMCC of intermittent dysphagia, steakhouse
syndrome• Webs (occurs intermittently)
Circumferential mucosal outpouchings Congenital or acquiredPlummer - Vinson Syndrome = symptomatic
hypopharyngeal webs + iron deficiency anemia
1/16/2007 UNSOM: EMR
Odynophagia• Odynophagia - pain upon swallowing
spasm - painful muscle contraction• Causes of esophagitis
RefluxInfection: candida, herpes, immunosuppression:
(HIV, DM, steroid use, CA)Inflammatory conditions: infection, radiation,
trauma, foreign body• Admit dysphagia, odynophagia
BleedingRuptureSevere dehydrationMalnutrition
1/16/2007 UNSOM: EMR
• Which of the following patients requires oral fluconazole treatment?
• A. 17-year-old girl with both dysphagia and odynophagia refractory to acid suppression therapy who also has multiple allergies
• B. 27-year-old man with chest pain and severe odynophagia who also has asthma and is HIV positive
• C. 47-year-old man with transport dysphagia for solids initially and now liquids who also smokes
• D. 55-year-old man with halitosis, transfer dysphagia, and neck fullness
1/16/2007 UNSOM: EMR
• Which of the following patients requires oral fluconazole treatment?
• A. 17-year-old girl with both dysphagia and odynophagia refractory to acid suppression therapy who also has multiple allergies
• B. 27-year-old man with chest pain and severe odynophagia who also has asthma and is HIV positive
• C. 47-year-old man with transport dysphagia for solids initially and now liquids who also smokes
• D. 55-year-old man with halitosis, transfer dysphagia, and neck fullness
1/16/2007 UNSOM: EMR
Hiccups (Singultus)• Involuntary stimulation of the respiratory reflex
with spastic contraction of inspiratory muscles on closed glottis
• Benign causes: gastric distention, smoking, ETOH, change is environmental temperature
• Persistent: damage to vagus/phrenic nerve/CNS Continue with sleep: organic Relieved with sleep: psychogenic
• OrganicCNS: neoplasm, MS, ICPPUD, tonsillitis, goiter, pericarditis, pacemaker, STEMI
1/16/2007 UNSOM: EMR
Esophageal Rupture (1)• MCC iatrogenic
#1: Endoscopy#2: Dilation MCC in ED: NG tubeDiagnosis by esophagram
• Mallory - Weiss - partial thickness tearLocation: GE junction5-15 % of UGI bleedsVomiting, retchingRisk factors: ETOH, hiatal herniaSpontaneous resolution common
1/16/2007 UNSOM: EMR
Esophageal Rupture (2)• Boerhaave’s Syndrome - full thickness tear
Males usually, age 40-60Typically associated with alcohol (50%)Typically left posterior distal ruptureChemical, then infectious mediastinitisSevere chest pain, shock, sepsisAir in mediastinum (Hamman’s crunch) PyopneumothoraxGastrografin (water soluble) UGIFluids, Antibiotics, Surgical consult
• X-ray: mediastinal air, left pleural effusion, pneumothorax, widened mediastinum
1/16/2007 UNSOM: EMR
Pneumomediastinum / Subcutaneous Emphysema
1/16/2007 UNSOM: EMR
Esophageal Foreign Bodies• Levels of narrowing
MCC: Cricopharyngeus muscle (C6) (<4 y/o)Aortic arch (T4)Tracheal bifurcation (T6)Gastroesophageal junction (least) (T11)
• Coin x-rays AP orientation = trachea (same plane as vocal
cord orientation)Transverse orientation = esophagus
1/16/2007 UNSOM: EMR
Foreign Body
3
1/16/2007 UNSOM: EMR
Esophageal Foreign Body
1/16/2007 UNSOM: EMR
Esophageal Foreign Bodies (3)• 10-20% require some intervention• 1% demand surgical treatment• Most foreign bodies will pass if they traverse
the pylorus • Soft drink pull tabs - may not show up on x-ray
1/16/2007 UNSOM: EMR
Esophageal Foreign Bodies (4)• Indications for endoscopy
Sharp / elongatedButton batteriesPerforationNickel / quarter at C6 (pediatric)
In esophagus > 24 hours
1/16/2007 UNSOM: EMR
Esophageal Foreign Bodies (5)• Button batteries
Double density radiographicallyMust always be removed from esophagus immediatelyRapid burns with perforation < 6 hours (Lithium worse)Batteries do not need to be removed:
Passed esophagus, asymptomaticPassed the pylorus <48 hours
Most will pass completely in 48-72 hours, serial radiography• Treatment: broad-spectrum ABX, surgical consultation
1/16/2007 UNSOM: EMR
Foreign Bodies (6)Sharp objects > 5cm long & 2cm wideMagnet + metalAll others: serial exam / x-raysFish/Chicken bones or plastic CT
1/16/2007 UNSOM: EMR
Sharp Foreign Body Sharp Foreign Body
1/16/2007 UNSOM: EMR
Large-corrosive-impacted Foreign Body
1/16/2007 UNSOM: EMR
Esophageal Food Impaction• Most patients with food impaction have
underlying esophageal pathology• Must evaluate for cause after dislodgement• Treatment options:
Glucagon - relaxes distal esophageal sphincterNifedipine - reduces lower esophageal toneCarbonated beverages - gaseous distention
may push the bolus into the stomachEndoscopyNo papain (meat tenderizer)
1/16/2007 UNSOM: EMR
Caustic Ingestions (1)• Acids (+/- bad)
Coagulation necrosisNo ongoing tissue necrosis
• Alkali (bad) Liquefaction necrosis (pH 12.5)Ongoing tissue necrosis
• SeverityNature, volume and concentrationTissue contact timePresence or absence of stomach contentsTonicity of pyloric sphincter 5
1/16/2007 UNSOM: EMR
Caustic Ingestions (2)• Inconsistent relationship between oral signs /
symptoms and esophageal findings• All patients with 2-3° burns are symptomatic• Diluents - water / milk only for solid alkali• No neutralizers = exothermic generation of heat
• Complications
Early: acute airway compromise due to edema, perforation
Late: stricture, perforation
Endoscopy best diagnostic tool
1/16/2007 UNSOM: EMR
- smoking, alcohol - type O blood- NSAIDs and steroids
Peptic Ulcer Disease• Incidence decreasing in general population and
increasing in the elderly (liberal use of NSAIDs)• MCC Duodenal (80%), gastric (20%)
• Helicobacter pylori responsible for most
• Predisposing factors:
• Treatment:
• Complications:
- antibiotics against H. pylori (amox, clarithro, metro)- histamine blockers (histamines stimulate acid inhibitors) - parietal cell inhibitors (omeprazole) - ulcer surface protectants (sucralfate)
- bleeding - perforation (can cause pancreatitis) (do upright CXR for free air) - obstruction
1/16/2007 UNSOM: EMR
Bilirubin (1)• Breakdown product of hemoglobin• Hyperbilirubinemia• Unconjugated (> 85%) (“indirect reacting”)
Increased bilirubin load (hemolysis)Inability to conjugate (Gilbert’s, neonatal, sepsis)
• Conjugated (< 30%) (“direct reacting”)Decreased ability to excrete from biliary
tree = cholestasis / obstructionIntrahepatic cholestasis
Hepatocellular damageDamage to biliary endothelium
Extrahepatic cholestasisBiliary outflow obstruction (stones, mass,
congenital inflammation, CHF)
1/16/2007 UNSOM: EMR
Bilirubin (2)• Conjugated bilirubin in bowel is converted by
gut bacteria to urobilinogen
• Urobilinogen is absorbed from the gut into the circulation and excreted in urine
• If jaundice is present but urine urobilinogen is negative = excess unconjugated hyperbilirubinemia
• If jaundice is present but excess positive urine urobilinogen = excess conjugated bilirubin
1/16/2007 UNSOM: EMR
Hepatitis (1)• Causes - viral and toxic
Malaise, jaundice, increased SGOT, increased bilirubin
Alcoholic hepatitis Abnormal protime is a marker indicating
significant liver dysfunction if elevated, consider altering or holding doses of liver-metabolized drugs
• Viral Type AFecal - oral, onset 2 weeks post-exposureProphylaxis - immune globulin within 2 weeks of
exposure (travelers, household contacts)
1/16/2007 UNSOM: EMR
Hepatitis (2)• Viral Type B
Percutaneous, parenteral or sexual exposureOnset 1-6 mo (mean = 75 days) post-exposureComplications = cirrhosis, liver cancer, carrier
state (10%)• Markers
HBsAg: + early (before enzymes increase) InfectiveHBsAb: + 2-6 mo after clearance of HBsAg ImmuneHBcAb: + 2 wks after + HBsAg * persists for lifeHBeAg: + implies high infectivity *May be the only positive marker during the window
when HBsAg declining and HBsAb increasing
1/16/2007 UNSOM: EMR
Hepatitis (3)• Hepatitis B exposure - source known HBsAg
positive • Unvaccinated
HBIG ASAP + vaccination (0, 1 mo, 6 mo)• Vaccinated
Incomplete series- vaccine boosterKnown responder- test for HBsAb if > 10,
no rx; if < 10 HBIG and vaccine boosterKnown non - responder - HBIG x 2 (0, 30 days)
1/16/2007 UNSOM: EMR
Hepatitis (4)• Hepatitis B exposure - source unknown
• UnvaccinatedInitiate vaccination
• VaccinatedSame as for HBsAg positive source
• HBIG only recommended if source or situation maybe high risk for exposure
1/16/2007 UNSOM: EMR
Hepatitis (5)• Viral Type C
Percutaneous, parenteral or sexual exposureUsual cause of non-A, non-B hepatitisHigh carrier rate, higher incidence in HIVCirrhosis / liver cancer (50%)2% seroconversion
• Indications for hospitalization (any hepatitis)Encephalopathy, PT/INR significantly increased,
dehydration, hypoglycemia, bilirubin over 20, age over 45, immunosuppression, diagnosis uncertain
1/16/2007 UNSOM: EMR
Hepatic Encephalopathy• Precipitants = “LIVER” (Librium [sedatives],
Infection, Volume loss, Electrolytes disorders, Red blood cells in the gut [a major cause])
• Others: dietary protein excess, worsening hepatocellular function
• Early sign = “sleep inversion” - sleeping during the day / awake at night
• Asterixis (“liver flap”)• Ammonia levels: arterial more helpful than venous• Check for hypoglycemia!!!• Treatment: Oral or rectal neomycin / lactulose /
decrease dietary protein / avoid sedatives / avoid bicarbonate (alkalosis can worsen encephalopathy)
1/16/2007 UNSOM: EMR
Spontaneous Bacterial Peritonitis• Occurs with chronic liver disease
Portal hypertension bowel edema migration and leakage of enteric organisms (E. coli 50%, enterococcus 25%)
• Abdominal tenderness, worsening ascites, encephalopathy, fever, sepsis, shock
• Diagnosis: paracentesis with increased WBCPMN >250/ul
• Tx: Ceftriaxone, ppx: Cipro or Bactrim
1/16/2007 UNSOM: EMR
• A 57-year-old man with a history of cirrhosis presents with acute renal failure. He denies recent illness and is not taking any nephrotoxic medications. He is well hydrated; his urinalysis is negative. Which of the following is the definitive treatment?
• A. Hydration• B. Liver transplant• C. Renal transplant• D. Transjugular intrahepatic portosystemic
shunt
1/16/2007 UNSOM: EMR
• A 57-year-old man with a history of cirrhosis presents with acute renal failure. He denies recent illness and is not taking any nephrotoxic medications. He is well hydrated; his urinalysis is negative. Which of the following is the definitive treatment?
• A. Hydration• B. Liver transplant• C. Renal transplant• D. Transjugular intrahepatic portosystemic
shunt
1/16/2007 UNSOM: EMR
Gallbladder (1)• Stones = mostly bilirubin / cholesterol -
(radiolucent) • Biliary colic = pain, vomiting, due to obstruction
by stones without inflammation• Cholecystitis (stone-related = calculous)
MCC of abdominal pain in the elderly ORObstruction distention pain / vomiting /
inflammation infection (usually E. coli, Klebsiella) increased WBCs
• Rupture of stone into small bowel with obstruction at ileocecal valve = GALLSTONE ILEUSAir in biliary tree (from bowel) = pneumobilia
1/16/2007 UNSOM: EMR
Gallbladder (2)• Acalculous cholecystitis
No stones5-10% of casesUsually a complication of another process
(trauma, burn, postpartum, postop, narcotics)Patients often quite sickLikely cause of GB perforation Increased risk with diabetes and elderlyGreater morbidity than calculous variety
• Ascending cholangitis Infection spreading through biliary treeCharcot’s triad = jaundice, fever, RUQ pain
1/16/2007 UNSOM: EMR
1/16/2007 UNSOM: EMR
Gallbladder (3)
• Ultrasound initial diagnostic study of choiceUltrasound shows stones, wall thickening, duct dilatation
(not inflammation)HIDA has sensitivity/specificity 97% / 90%HIDA or PIPIDA scan is positive if GB is not visualized =
cystic duct obstruction, best test for cholecystitis
Immediate surgical consultAir in biliary tree, fever, jaundice,
diabetic, elderly, immuno-compromised
1/16/2007 UNSOM: EMR
Gallbladder Ultrasound
1/16/2007 UNSOM: EMR
Pancreatitis (1)• Causes
Alcohol or gallstones the most commonDrugs: thiazides / estrogens / salicylates /
acetaminophen / antibiotics [ metronidazole, sulfonamides, erythromycin, nitrofurantoin]
Metabolic disorders [hyperlipidemias, hypercalcemia, DKA, uremia]
Viral infections [mumps, hepatitis, mono, many others]
Bacterial infections [salmonella, streptococcus, mycoplasma, legionella, many others]
1/16/2007 UNSOM: EMR
Pancreatitis (2)
• On admissionAge > 55Glucose > 200
mg / dlWBC > 16,000SGOT > 250LDH > 350
• At 48 hoursDecreased in HCT >
10%Increase in BUN > 5
mg / dlCa++ below 8 mg / dlpAO2 < 60 mmHgBase deficit > 4 mEq / LRapid fluid sequestration
(over 6L)
• Ranson’s criteria (prognostic)
3 positives = severe disease
1/16/2007 UNSOM: EMR
Pancreatitis (3)• Amylase
Multiple non-pancreatic sources Height of amylase not necessarily related to
severity• Lipase
May be more sensitive than amylaseMore specific than amylaseClosely follows clinical course
• Plain x-ray Colon cutoff = dilation only over pancreasPancreatic calcificationSentinel loop = small bowel air over pancreasImaging study of choice - contrast CT
1/16/2007 UNSOM: EMR
Sentinel Loop (Pancreatitis)
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Pancreatitis complications• Pseudocyst, necrosis• Hyperglycemia, hypocalcemia• Volume loss, acidosis, GI bleed• ARDS, DIC, renal failure• Death
1/16/2007 UNSOM: EMR
GI Bleeding Definitions
• Hematemesis - UGI proximal to ligament of Treitz
• HematocheziaMaroon stools
Very rapid UGI bleed (uncommon)Usually colon or small bowel bleed
• Melena - black tarry stools - usually UGI bleed, color from effects of acid and digestion on blood (GI protein breakdown of blood causes increased BUN)
1/16/2007 UNSOM: EMR
Upper GI Bleeding Sites• A prior site of GI bleeding is often not the site
of subsequent bleeds (best example = variceal bleed, half of subsequent bleeds are from another site)
• UGI sitesMCC PUD (45-50%) usually duodenalGastritis (15-30%) (alcohol, NSAIDS)Varices (10-15%) 1/3 of UGI bleed deathsMallory - Weiss esophageal tears (5-10%)Esophagitis (5-10%) (MCC in pregnancyDuodenitis (less than 5%)
1/16/2007 UNSOM: EMR
Upper GI Bleeding Risk Factors for Increased Mortality
• Advancing age• SBP < 100 + hr > 100• Hematochezia• Varices• Jaundice• Hemoglobin < 10 g/dl• Co-morbid conditions
1/16/2007 UNSOM: EMR
• A 67-year-old woman presents after three episodes of hematemesis. She denies significant past medical history and is taking only an over-the-counter medication for osteoarthritis. She appears anxious and diaphoretic. During the interview, she vomits 250 mL of bright red blood. Physical examination is notable for blood pressure 79/58, pulse 122, moderate epigastric abdominal tenderness and bloody stool. Which of the following is most likely to control the bleeding?
• A. Bedside esophagogastroduodenoscopy• B. Nasogastric tube placement with lavage• C. Omeprazole infusion followed by vasopressin drip• D. Sengstaken-Blakemore tube
1/16/2007 UNSOM: EMR
• A 67-year-old woman presents after three episodes of hematemesis. She denies significant past medical history and is taking only an over-the-counter medication for osteoarthritis. She appears anxious and diaphoretic. During the interview, she vomits 250 mL of bright red blood. Physical examination is notable for blood pressure 79/58, pulse 122, moderate epigastric abdominal tenderness and bloody stool. Which of the following is most likely to control the bleeding?
• A. Bedside esophagogastroduodenoscopy• B. Nasogastric tube placement with lavage• C. Omeprazole infusion followed by vasopressin drip• D. Sengstaken-Blakemore tube
1/16/2007 UNSOM: EMR
UGIB Management• PPI (No benefit?)• Octreotide for variceal bleed, decreases
splanchnic flow (No benefit?)• Vasopressin for variceal if delay to endoscopy• Only clear benefit from antibiotics in cirrhotics• Sengstaken-Blakemore/Minnesota tube last
resort for esophageal varices
1/16/2007 UNSOM: EMR
Lower GI Bleeding (1) Sites
• MCC Upper GI bleed • Diverticulosis• Angiodysplasia (AV malformations), associated with HTN and aortic stenosis - usually right colon• Aortoenteric fistula, esp if previous AAA repair
Erosion of synthetic vascular graft into gut (often preceded by premonitory bleed)
• Cancer / polyps, IBD, rectal disease• Hemorrhoids: MCC of rectal bleeding• Anal fissure – MCC of minor LGI bleeding in infants
to age 5
1/16/2007 UNSOM: EMR
Low risk LGIB – send home?• No comorbid disease• Normal vitals• Negative or trace positive stool guiac• Negative NG lavage (if performed)• Normal H/H• Good support/reliable• 24 hour follow up
1/16/2007 UNSOM: EMR
Osler-Weber-Rendu Syndrome• Autosomal dominant vascular anomaly• Multiple small telangiectases of the skin,
mucous membranes, GI tract• Recurrent episodes of GI bleeding, gross and
occult
1/16/2007 UNSOM: EMR
Pediatric GI Bleeding (1) Under 2 Months• Upper
Bleeding diathesisSwallowed maternal bloodVascular malformation
• LowerMCC is Meckel’s diverticulum (50%)Congenital GI duplicationsIntussusceptionNecrotizing enterocolitis Swallowed maternal bloodVascular malformationVolvulus
1/16/2007 UNSOM: EMR
Pediatric GI Bleeding (2) Necrotizing Enterocolitis
• Predisposed Premature neonatesHypoxiaHypothermiaPolycythemiaUmbilical catheters
• Mucosal edema to full thickness necrosis• Distention, tenderness, dehydration, vomiting• X-ray - ileus, bowel wall thickening, pneumatosis
intestinalis (late)
1/16/2007 UNSOM: EMR
Neonatal Necrotizing Enterocolitis
Med-Challenger • EM
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Pediatric GI Bleeding (3) Under 2 Years
• UpperBleeding diathesisForeign bodyGastroenteritisTraumatic hemobiliaVascular
malformationMallory-Weiss tear
• LowerAnal fissureCongenital dupl.GastroenteritisHUSHS purpuraInflammatory bowel
diseaseIntussusceptionMeckel’s
diverticulumMilk allergyPolyps
1/16/2007 UNSOM: EMR
Pediatric GI Bleeding (4) Lower GI Bleeding Sites (1)
• Meckel’s diverticulumCongenital anomaly, 2% of populationTypically diagnosed age < 2Located 40 cm from ileocecal jnx, free or attached to
umbilicusEctopic production of gastric acid (30-50%)Peptic ulceration causes bleedMost common cause of significant LGI bleeding in
childrenCan mimic appy, may initiate intussusception, or
volvulus
Painless “bright red” bleeding(most common clinical presentation)
1/16/2007 UNSOM: EMR
• A 11-month-old boy is brought in by his mother after she noticed a large amount of dark red blood in his diaper. He appears well and has normal vital signs and a benign abdominal examination. Rectal examination is remarkable for blood without an obvious source. Which of the following is needed to confirm the suspected diagnosis?
• A. Abdominal ultrasound examination• B. Additional history on diet• C. Apt test• D. Nuclear medicine scan
1/16/2007 UNSOM: EMR
• A 11-month-old boy is brought in by his mother after she noticed a large amount of dark red blood in his diaper. He appears well and has normal vital signs and a benign abdominal examination. Rectal examination is remarkable for blood without an obvious source. Which of the following is needed to confirm the suspected diagnosis?
• A. Abdominal ultrasound examination• B. Additional history on diet• C. Apt test• D. Nuclear medicine scan
1/16/2007 UNSOM: EMR
Pediatric GI Bleeding (5) Lower GI Bleeding Sites (2)• Intussusception
Sudden, intermittent pain, vertical sausage mass in 50%
“Currant jelly” stoolSecond most common cause of lower GI
bleeding in childrenMost common cause of bowel obstruction in
first 2 yrs.BE = diagnostic and therapeutic
Lead pointsAdults = polyp, cancer
Child = Meckel’s, lymphoid patch
1/16/2007 UNSOM: EMR
Hernias (1)• Inguinal - most common
Direct - does not involve passage through the inguinal canal
Indirect - involves inguinal canal (most common)
• Femoral – femoral canal, usually female, below the inguinal ligament, strangulation / incarceration common
1/16/2007 UNSOM: EMR
Hernias (2)• Umbilical
Congenital: newborns - blacks > whites; females > males, strangulation / incarceration rare
Acquired: women, obesity, pregnancy & ascites, strangulation / incarceration common
• Pantaloon : Indirect + direct at same time• Spigelian (lateral ventral): level of arcuate line lateral
to rectus abdominus, difficult to diagnose, CT / US• Richter - incarceration of a single wall of a
hollow viscus• Incarcerated = irreducible (highest incidence of
inguinal incarceration = 1st year)• Strangulated = irreducible with vascular compromise
(don’t manually reduce)
1/16/2007 UNSOM: EMR
Ileus• Ileus = cessation of normal peristalsis without
mechanical obstruction
• Continuous pain, distention, decreased bowel sounds, minimal or no tenderness, no flatus or BM, usually self limiting
• Ileus is more common than mechanical bowel obstruction
• X-rays show entire bowel with dilated, fluid-filled loops
1/16/2007 UNSOM: EMR
Bowel Obstruction• Small bowel
(1) adhesions, (2) hernias, (3) malignancy Generally more intense pain and more vomiting
and less distention than large bowel obstructionX-ray - “step ladder” plicae circulares - traverse
bowel width• Large bowel
(1) cancer, (2) diverticulitis, (3) sigmoid volvulus
X-ray: haustral pattern (doesn’t traverse entire bowel width)
• “Closed-loop” obstruction dangerous = perforationCan occur in colon if ileocecal valve is
competent
1/16/2007 UNSOM: EMR
Small Bowel Obstruction
14
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Small Bowel Obstruction
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Volvulus• Sigmoid volvulus
Elderly, debilitatedChronic motility
disorderInsidious onset, most
recurX-ray: inverted u, loops
project obliquely to RUQ
Sigmoidoscopy may be therapeutic
• Cecal (15 -20%)Young (35 -55), runnerCongenital freely
mobile cecumAcute onset
X-ray: kidney shaped loop, LUQ,
Requires surgery
Third most common cause of large bowel obstruction behind (diverticular, tumor)
The most common cause in pregnancy
1/16/2007 UNSOM: EMR
Sigmoid Volvulus
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Cecal Volvulus
17
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Bowel Perforation• Large bowel > small bowel• Mechanism: inflammation, ulceration, trauma,
obstruction• Causes - diverticular disease (the most common
cause), appendicitis (especially at extremes of age), colitis / IBD, ischemia, cancer, foreign body, PUD, radiation
• Cecum the most common site• X-rays – may miss small amount of free air or
retroperitoneal, best view = upright chest x-ray
Ulcers are the most common cause of a visceral perforation
1/16/2007 UNSOM: EMR
Free Air; Thickened Bowel Wall
1/16/2007 UNSOM: EMR
Pediatric GI Emergencies• Obstructive GI lesions 1st year
Gut atresiaInguinal herniaMalrotation, +/- volvulusVolvulus around congenital bandIntussusceptionMeconium ileus (associated with CF)Hirschsprung’s diseaseDuplication cysts of intestine
BE is diagnostic study of choice after plain x-ray
1/16/2007 UNSOM: EMR
Pediatric GI Emergencies Obstructive Newborn GI Lesions 1st Year• Intussusception
MCC surgical abdomen/obstruction 3mo – 6yrIleocolic most common (85%)Peak incidence - age 5 to 9 months / most occur
before 2Classic triad only in 30% (colicky pain, vomiting,
currant jelly stool)Paroxysms of colicky pain is the most specific
symptomKUB: “coiled spring”Infants less than one can have profound
listlessness as wellChildren with Henoch-Schönlein purpura are at
increased riskUltrasound can be diagnostic as well as BE
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Intussusception
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Intussusception - Barium Enema
15
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Intussusception - Barium Enema
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Pediatric GI Emergencies Obstructive Newborn GI lesions 1st year• Malrotation +/- volvulus
First year of life > first monthEarly diagnosis is crucial to prevent gangrene
of midgutAbnormal rotation & fixationX-ray: loop of bowel over-riding the liver is
suggestive (double bubble)Acute abdomen, shock, rigid / distended
abdomen, bilious vomitingBilious vomiting / signs of obstruction = prompt
surgical consultation
1/16/2007 UNSOM: EMR
Pediatric GI Emergencies Obstructive Newborn GI Lesions 1st Year
• Pyloric stenosisNon-bilious projectile vomitingHypochloremic metabolic alkalosisFirst born males, familial propensity 50%Third week to third month of lifePalpable “olive”: mass lateral margin right
rectus muscle at liver edgeUltrasound (20%) false negative UGI: delayed gastric emptying, string sign
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• What is the most common cause of small bowel obstruction in children?
• A. Adhesions• B. Hernia• C. Intussusception• D. Midgut volvulus
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• What is the most common cause of small bowel obstruction in children?
• A. Adhesions• B. Hernia• C. Intussusception• D. Midgut volvulus
1/16/2007 UNSOM: EMR
Constipation• Most common digestive complaint in United States,
2.5 million visits • 30-40% > 65 years old• Acute causes: obstruction, medication (narcotics, Ca2+
blockers, psych. meds, Fe, antacids)• Common cause: fiber + fluid intake + exercise• Chronic causes: slow growing tumor, thyroid,
parathyroid, lead, neurologic dysfunction• Rectal exam for: fecal impaction, rectal mass, heme +
stool, anal fissure• Treatment: diet/behavior changes, medical adjuncts,
underlying cause
MUST RULE OUT OBSTRUCTION
1/16/2007 UNSOM: EMR
Inflammatory Bowel Disease• Crohn’s disease & ulcerative colitis• Idiopathic, chronic• High rate of colon CA with disease > 10 years• Exacerbation / remission pattern• Bimodal age distribution peaks between 20’s
and 60’s• Extracutaneous manifestations - arthritis
(20%), dermatologic (4%), hepatobiliary (4%), vascular (1.3%) - also uveitis
• Tx: sulfasalazine, mesalamine, prednisone, metronidazole, ciprofloxacin
1/16/2007 UNSOM: EMR
Regional Enteritis - Crohn’s Disease• Chronic inflammatory disease of the entire GI
tract
• Segmental involvement is characteristic = “skip lesions”
• Abdominal pain, cramps, diarrhea (sometimes bloody), fever, perianal fissures, fistulas or abscesses or rectal prolapse (90%), toxic megacolon
• Gross blood uncommon• ↑ oxalate absorption of terminal ilium leads to
nephrolithiasis
1/16/2007 UNSOM: EMR
Ulcerative Colitis• Chronic inflammatory disease - colon• Similar GI symptoms to Crohn’s disease
Major finding = bloody diarrheaToxic megacolon
Gross distention (over 8 cm)Transverse colon Systemic toxicity Peritonitis
• Rectum, small bowel not affect (unlike Crohn’s)
• Colon cancer = 10 - 30 times greater risk
1/16/2007 UNSOM: EMR
Mesenteric Ischemia • Risk factors - dysrhythmias (a. fib), low flow &
hypercoagulable states, vascular disease• Deadly / generally elderly / early angiography• Causes:
Embolic *(30%)Arterial thrombus *(10%)Venous thrombus (10%)Nonocclusive (50%)
• Leukocytosis (present in most cases), acidosis, hyperphosphatemia, hyperamylasemia - all inconsistently present
• Avoid digoxin, beta-blockers, vasopressors (decrease splanchnic blood-flow)
*Sudden onset with pain out of proportion
to physical findings
1/16/2007 UNSOM: EMR
Mesenteric Ischemia Imaging
• Thickened bowel wall• Pneumointestinalis (air in bowel wall)• Air in portal vein• “Thumb printing” = submucosal hemorrhage
All infrequently seen
Mainstay of diagnosis = arteriography
1/16/2007 UNSOM: EMR
Appendicitis (1)• Luminal obstruction inflammation infection• Anorexia often present• Increased perforation in elderly and small children• Pain migrating periumbilical to RLQ is specific• Late pregnancy - moves lateral and superior• BE - mass effect and non-filling• KUB - appendicolith (1%)• Ultrasound - dilated, non-compressible >6mm• Spiral CT – usually diagnostic
Most common cause of surgical abdomen
1/16/2007 UNSOM: EMR
Appendicolith
19
1/16/2007 UNSOM: EMR
Appendicitis (2)• Confounders = situs inversus, retrocecal, pregnancy
malrotation, very long appendixResult-uncommon pain location: right upper quadrant,
back, flank, testicular, suprapubic• Rovsing’s sign = LLQ palpation RLQ pain
Psoas sign = RLQ pain on thigh extension while lying in left lateral decubitus positionObturator sign = RLQ pain with internal rotation of the flexed right thigh
• Most common symptom: anorexia, nausea and vomiting• R sided tenderness most common sign• Rebound, rectal and referred tenderness common• Psoas/obturator sign uncommon
1/16/2007 UNSOM: EMR
Diverticular disease
1/16/2007 UNSOM: EMR
Diverticulitis (1)• Pain is the most common symptom
Steady, deep, LLQ
• Bowel habits may be altered - diarrhea or constipation
• May mimic appendicitis if copious redundant sigmoid colon
• Intraluminal pressure is greatest in the sigmoid (most diverticula there)
1/16/2007 UNSOM: EMR
Diverticulitis (2)• Manifestations = pain (inflammation / infection)
and bleeding; pain left side, bleeding right side • Free perforation is rare / most are contained to
the mesentery
• May cause urinary frequency / urgency due to
irritation of underlying GU structures
• Colon cancer may be in the differential
• Tx: fiber, abx (Cipro/Metro), analgesics
1/16/2007 UNSOM: EMR
Diarrhea• Viral
Most common cause of diarrhea 50-70% of casesMostly winter / spring / children / day careRotavirus, adenovirus calicivirus, enterovirus, Norwalk agent
- “RACE to Norwalk”
Rotavirus MCC pediatric cause of diarrhea 50%Self-limiting / fecal-oral / community outbreak
1/16/2007 UNSOM: EMR
Diarrhea - Invasive• Invades mucosa inflammation (stool WBCs)
and bleeding (degree varies by pathogen), fever, rash, arthritis, septicemia
• E. coli 0157:HS Hamburger, petting zoo, raw milk, untreated waterCan cause HUS (children) and TTP (elderly)No ABX recommended may increase risk of HUS
1/16/2007 UNSOM: EMR
Diarrhea - Invasive (2)• Shigella
Very infectious, high fever, febrile seizures, watery - bloody
• Salmonella Very common bacterial diarrhea
(U.S.) Watery / mucoid Pet turtles, amphibians, eggs,
chickens Osteomyelitis can occur in sicklers
(autosplenectomy) and those with splenectomy
Antibiotics increase carrier state (give if sick / septic)
Most commoncause of bloody
diarrheaSystemic toxicity =
typhoid fever (low WBC and relative bradycardia,
abdominal pain, no diarrhea)
1/16/2007 UNSOM: EMR
Diarrhea - Invasive (3)• Campylobacter
Most common cause of bacterial diarrheaHard to culture / water-borne (raw milk)Invasive enterotoxin60-70% with bloody diarrhea (gross or occult) Erythromycin (children), fluoroquinolone (adults)Acute infection associated with development of
Guillain-Barré syndrome• Vibrio
Parahaemolyticus - oysters, clams, crabs, 2 -12 hour latency
Vulnificus - oysters, shellfish increased morbidity / mortality with pre-existent liver disease
1/16/2007 UNSOM: EMR
Diarrhea - Invasive (4)• Yersinia enterocolitica
Invasive gram pos bacteriaIncreasing evidence, most common in
childhoodCan mimic appendicitisFeverColicky abdominal pain (may be prolonged)DiarrheaMay be persist 10-14 days
• Diagnosis: fecal WBC stain positive, stool C&S
• Treatment: uncomplicated - supportive only complicated - TMP-SMX, quinolones
1/16/2007 UNSOM: EMR
Diarrhea - Protozoan (1)• Giardia
Most common US intestinal parasite
Beavers, deer, stream contamination
Stools floating, frothy, foul-smelling, flatulence
Multiple stool specimens may be needed to
identify cysts and / or trophozoites
Metronidazole
Homosexuals, campers, pregnancy
1/16/2007 UNSOM: EMR
Diarrhea - Protozoan (2)• Amebiasis (entamoeba histolyticus)
Spread between family members and sexual partners
Fecal / oral - anal intercourseDiarrhea can be bloodyExtra-intestinal manifestations (5%)
Liver abscess most common (“chocolate cysts”)Pericarditis, pleuropulm disease, cerebral amebiasis
Wide variety of presentations Asymptomatic cyst passer ColitisCerebral amebiasis
1/16/2007 UNSOM: EMR
Diarrhea Protozoan (3)• Cryptosporidium
Intestinal protozoan parasitesMCC of chronic diarrhea in AIDSContaminated water supply; recent outbreaksChildren, animal handlers; immunocompromisedIngestion of oocysts; trophozoites attack intestinal
membrane1 week incubation, severe watery diarrhea,
abdominal pain
• Diagnosis: Oocyst in stool• Treatment: Fluid replacement, CDC rec’s
nitazoxanide, or parmomycin plus azithro
1/16/2007 UNSOM: EMR
Diarrhea - Toxigenic (1)
• Bacteria producing enterotoxin • Food-borne• Diarrhea: watery, voluminous• Minor fever, no septicemia• No WBC or RBC in stool
1/16/2007 UNSOM: EMR
Diarrhea - Toxigenic (2)• Staph (toxin)
Contaminated foodsGI overgrowth from antibioticsHam, poultry, dairy products, potato saladMCC of food-borne diseaseSymptoms within 6 hours of ingestion Usually afebrile, no abx
• E. coli Water contaminated by fecesMCC Traveler’s diarrhea No readily available diagnostic testsTMP / SMX, cipro
1/16/2007 UNSOM: EMR
Diarrhea - Toxigenic (3)• Clostridium perfringens
Common, large outbreaksMeat and poultry sourceEnterotoxin mediated6 hours (longer onset)Watery diarrheaSevere abdominal crampsFecal WBC / RBC negativeTreatment: fluids; no abx
• Vibrio – choleraCopious watery diarrhea= “rice water stools”Severe fluid & electrolyte problemsTreatment: fluids, ciprofloxacin, TMP-SMX
1/16/2007 UNSOM: EMR
Diarrhea – Toxigenic• Bacillus Cereus• Aerobic spore forming pod• Common in rice, especially Chinese
restaurants• Spores germinate when boiled rice is not
refrigerated• Two forms:
Emetic: 2 – 3 hours post ingestion (much like Staph)Diarrheal: 6 – 14 hours (much like Clostridia)
• Also from vegetables and meat• Self limited; no specific therapy or test
1/16/2007 UNSOM: EMR
Diarrhea - Toxigenic (4)• Scombroid poisoning
Named for fish (suborder) = tuna, mackerel, mahimahi (most frequent cause), related species
Heat - stable toxin from bacterial action on dark - meat fish
Histamine - like toxin / rapid symptom onset (30 min)
Fish - tastes “peppery”Facial flushing, diarrhea, throbbing headache,
abdominal cramps, palpitations Give antihistamines and H2 blockersSuspect when multiple patients have “allergic
reaction”
1/16/2007 UNSOM: EMR
Diarrhea - Toxigenic (5)• Ciguatera
S.E. US, tropical and subtropical watersGrouper, snapper, king fishFish eat certain dinoflagellates in spring /
summer, that contain toxins harmful to those eating the fish
Muscle weakness, paresthesias (perioral, burning hand / feet), distorted or reversed temperature sensation, vomiting, diarrhea
Neuro symptoms worsened with alcoholNo specific treatment, symptoms can be
permanent
1/16/2007 UNSOM: EMR
Pseudomembranous Enterocolitis • Varieties = neonatal, postop, antibiotic-related• Due to overgrowth of toxin-producing C. difficile• Begins 7 - 10 days after beginning antibiotics• Patients may be quite sick - fever, toxic, profuse
diarrhea, dehydration• Diagnosis via immunoassay for toxin • Inflammatory disease, membrane - like yellow
plaques• Treatment by stopping precipitating antibiotics • Treat with metronidazole or vancomycin orally• No anti-diarrheals
1/16/2007 UNSOM: EMR
Botulism• Characteristics
Heat-labile neurotoxin, short onset (half hour)Inadequately processed canned foodsBulbar symptoms / descending paralysis /
anticholinergic findings• Infantile
Floppy baby, constipation, feeble cry Honey can be sourceMost common in breast-fed / also less severe in
this subset• Adult
Diplopia (most common early finding), dysphonia, ptosis, dysarthria, dysphagia
Anticholinergic symptoms - urinary retention, pupil abnormalities, dry mouth, abd. cramps, nausea and vomiting
1/16/2007 UNSOM: EMR
Rectal Prolapse• Full thickness protrusion of rectum through anal
canal• Sensation of rectal mass• In children, intussusception more likely• Differentiation from internal hemorrhoids &
intussusceptionIntussusception – can place finger between
protruding rectum and anusInternal hemorrhoids – fold of mucosa radiates
out like spoke on a wheelRectal prolapse – folds of mucosa circular
1/16/2007 UNSOM: EMR
Rectal Prolapse
1/16/2007 UNSOM: EMR
Hemorrhoids• Engorgement, prolapse, or thrombosis of the
hemorrhoid veins• Internal located at 2, 5, 9 o'clock position• Risk factors: constipation, pregnancy, ascites, portal
hypertension• Painless ,self limited, BRBPR,common presentation• Treatment
Non complicated (nonsurgical): sitz bath, laxatives, topical steroids, fiber
Complicated: large, incarcerated, strangulated, intractable pain require surgery
Thrombosed: elliptical incision to remove clot
1/16/2007 UNSOM: EMR
Anal Fissure• Most common causes of painful rectal bleeding in
adults and children• 90% posterior midline• Non-midline fissures should suggest more serious
conditionsIBD, CA, sexual abuse
• Sharp cutting pain, especially with bowel movement, blood-streaked stool
• Perianal hygiene, sitz bathsFistula in Ano
Tract between rectum and skin Causes drainage and itchingConsider Crohn’s Disease
1/16/2007 UNSOM: EMR
Perianal Fissure
1/16/2007 UNSOM: EMR
Rectal Trauma• Causes:
Penetrating 80%Blunt 10%IatrogenicForeign body
• Must consider GU & colon injuries• Rectal foreign body
60% removed in EDHigh-riding or sharp require general anesthesiaSigmoidoscopy after removal
1/16/2007 UNSOM: EMR
Rectal Foreign Body
1/16/2007 UNSOM: EMR
GI Miscellaneous (1)• BE and colonoscopy are relatively
contraindicated in diverticulitis (fear of perforation)
• Hypoglycemia in alcoholics may not respond to glucagon because liver glycogen stores are depleted
• AIDS patients with diarrhea usually have stool specimens positive for pathogens; due to the numerous causes, empiric therapy is not advised
1/16/2007 UNSOM: EMR
GI Miscellaneous (2)• Extension of a perirectal abscess = ischiorectal
abscess
• Prolapsed, irreducible internal hemorrhoids require urgent surgery
• In most alcoholics with low-grade amylase elevations, the source is non-pancreatic
• Most common serious complication of a Sengstaken - Blakemore tube = aspiration / suffocation
1/16/2007 UNSOM: EMR
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