GASTROINTESTINAL

EMERGENCIES

Ganesh R. Veerappan, MD, FACG AGAF

Akron Digestive Disease Consultants, Inc.

July 12th, 2019

Outline

Acute abdominal pain

Acute upper GI bleeding

- Non-variceal upper GI bleeding

- Variceal upper GI bleeding

Acute lower GI bleeding

Food Impaction

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

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

Acute Abdominal PainPhysical Exam

Vital signs

Systemic exam

Abdominal exam

Genital, rectal, pelvic exam

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

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

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

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

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

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

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

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

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

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

Perforated Peptic Ulcer

Epigastric, sudden, sharp severe pain

Tachypnea, tachycardia

Hypotension, rigid abdomen

X-ray: free air 75% of the time

Immediate surgery

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

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

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

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

GI Bleeding

GI Bleeding

Upper GI Bleeding

Bleeding proximal to the ligament of Trietz

Lower GI Bleeding

Bleeding distal to the ligament of Trietz

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

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

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

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

Causes of Upper GI bleeding

Active ulcer bleeding Esophageal Varices Duodenal ulcer

Mallory Weiss Tear GAVEPortal Hypertensive

Gastropathy

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

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

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?

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

Upper GI Bleeding: An Algorithm

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

Acute Lower GI BleedingCauses

Diverticular bleeding Angiodysplasia Ischemic Colitis

Malignancy Post polypectomy bleed

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

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

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

Lower GI Bleeding: An Algorithm

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

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.

Endoscopy

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

Causes of Food Impaction

Esophageal Ring Concentric Rings in

Eosinophilic EsophagitisEsophageal Stricture

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.

Chew on this

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.

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

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

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).

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.

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.

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).

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.

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.