ITE Review: GI

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  • Dysphagia vs odynophagia; Solids vs solid/liquid
  • Different causes of dyspahgia
  • No charcoal
  • Early HbcAb is IgMIgG
  • Mortality goes up to 15%
  • Suspensory muscle of the duodenum
  • First few days of life, late as one month
  • Still MCC in female is inguinal
  • LL decub
  • Although rare after 3 yearsHSP more often ileoileal
  • Large bowel loops
  • Cutoff
  • Coiled spring
  • Full thickeness
  • Superficial mucosal layer
  • Lactic acidWBC 30K
  • ITE Review: GI

    1. 1. Gastroenterology UNSOM Emergency Medicine Review 1/16/2007 UNSOM: EMR
    2. 2. 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  Esophagram  Endoscopy  Esophageal motility studies 1/16/2007 UNSOM: EMR
    3. 3. 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 neuropathy Achalasia (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
    4. 4. • 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
    5. 5. • 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
    6. 6. Dysphagia (3) Mechanical • Zenker’s diverticulum Pharyngoesophageal pouch Proximal: above the UES Elderly, regurgitation of undigested food • Cancer: MCC = squamous Risk factors: smoking, achalasia, caustic ingestion • Extraluminal obstruction / tumor 1/16/2007 UNSOM: EMR
    7. 7. Dysphagia (4) Mechanical • Strictures GERD, chronic inflammation, occur in distal esophagus • Schatzki’s ring Fibrous structure distal esophagus MCC of intermittent dysphagia, steakhouse syndrome • Webs (occurs intermittently) Circumferential mucosal outpouchings Congenital or acquired Plummer - Vinson Syndrome = symptomatic hypopharyngeal webs + iron deficiency anemia 1/16/2007 UNSOM: EMR
    8. 8. Odynophagia • Odynophagia - pain upon swallowing spasm - painful muscle contraction • Causes of esophagitis Reflux Infection: candida, herpes, immunosuppression: (HIV, DM, steroid use, CA) Inflammatory conditions: infection, radiation, trauma, foreign body • Admit dysphagia, odynophagia Bleeding Rupture Severe dehydration Malnutrition 1/16/2007 UNSOM: EMR
    9. 9. • 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
    10. 10. • 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
    11. 11. 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 • Organic  CNS: neoplasm, MS, ICP  PUD, tonsillitis, goiter, pericarditis, pacemaker, STEMI 1/16/2007 UNSOM: EMR
    12. 12. Esophageal Rupture (1) • MCC iatrogenic #1: Endoscopy #2: Dilation MCC in ED: NG tube Diagnosis by esophagram • Mallory - Weiss - partial thickness tear Location: GE junction 5-15 % of UGI bleeds Vomiting, retching Risk factors: ETOH, hiatal hernia Spontaneous resolution common 1/16/2007 UNSOM: EMR
    13. 13. Esophageal Rupture (2) • Boerhaave’s Syndrome - full thickness tear Males usually, age 40-60 Typically associated with alcohol (50%) Typically left posterior distal rupture Chemical, then infectious mediastinitis Severe chest pain, shock, sepsis Air in mediastinum (Hamman’s crunch) Pyopneumothorax Gastrografin (water soluble) UGI Fluids, Antibiotics, Surgical consult • X-ray: mediastinal air, left pleural effusion, pneumothorax, widened mediastinum 1/16/2007 UNSOM: EMR
    14. 14. Pneumomediastinum / Subcutaneous Emphysema 1/16/2007 UNSOM: EMR
    15. 15. 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
    16. 16. Foreign Body 1/16/2007 3 UNSOM: EMR
    17. 17. Esophageal Foreign Body 1/16/2007 UNSOM: EMR
    18. 18. 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
    19. 19. Esophageal Foreign Bodies (4) • Indications for endoscopy Sharp / elongated Button batteries Perforation Nickel / quarter at C6 (pediatric) In esophagus > 24 hours 1/16/2007 UNSOM: EMR
    20. 20. Esophageal Foreign Bodies (5) • Button batteries  Double density radiographically  Must always be removed from esophagus immediately  Rapid burns with perforation < 6 hours (Lithium worse)  Batteries do not need to be removed: Passed esophagus, asymptomatic Passed 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
    21. 21. Foreign Bodies (6) Sharp objects > 5cm long & 2cm wide Magnet + metal All others: serial exam / x-rays Fish/Chicken bones or plastic  CT 1/16/2007 UNSOM: EMR
    22. 22. Sharp Foreign Body Sharp Foreign Body 1/16/2007 UNSOM: EMR
    23. 23. Large-corrosive-impacted Foreign Body 1/16/2007 UNSOM: EMR
    24. 24. Esophageal Food Impaction • Most patients with food impaction have underlying esophageal pathology • Must evaluate for cause after dislodgement • Treatment options: Glucagon - relaxes distal esophageal sphincter Nifedipine - reduces lower esophageal tone Carbonated beverages - gaseous distention may push the bolus into the stomach Endoscopy No papain (meat tenderizer) 1/16/2007 UNSOM: EMR
    25. 25. Caustic Ingestions (1) • Acids (+/- bad) Coagulation necrosis No ongoing tissue necrosis • Alkali (bad) Liquefaction necrosis (pH 12.5) Ongoing tissue necrosis • Severity Nature, volume and concentration Tissue contact time Presence or absence of stomach contents Tonicity of pyloric sphincter 1/16/2007 5 UNSOM: EMR
    26. 26. 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 Endoscopy best diagnostic tool • Complications Early: acute airway compromise due to edema, perforation Late: stricture, perforation 1/16/2007 UNSOM: EMR
    27. 27. 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: - antibiotics against H. pylori (amox, clarithro, metro) - histamine blockers (histamines stimulate acid inhibitors) - parietal cell inhibitors (omeprazole) - ulcer surface protectants (sucralfate) • Complications: 1/16/2007 - smoking, alcohol - type O blood - NSAIDs and steroids - bleeding - perforation (can cause pancreatitis) (do upright CXR for free air) - obstruction UNSOM: EMR
    28. 28. 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 / obstruction Intrahepatic cholestasis Hepatocellular damage Damage to biliary endothelium Extrahepatic cholestasis 1/16/2007 Biliary outflow obstruction (stones, mass, congenital inflammation, CHF) UNSOM: EMR
    29. 29. 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
    30. 30. 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 livermetabolized drugs • Viral Type A 1/16/2007 Fecal - oral, onset 2 weeks post-exposure Prophylaxis - immune globulin within 2 weeks of exposure (travelers, household contacts) UNSOM: EMR
    31. 31. Hepatitis (2) • Viral Type B Percutaneous, parenteral or sexual exposure Onset 1-6 mo (mean = 75 days) post-exposure Complications = cirrhosis, liver cancer, carrier state (10%) • Markers HBsAg: HBsAb: HBcAb: HBeAg: + early (before enzymes increase) Infective + 2-6 mo after clearance of HBsAg Immune + 2 wks after + HBsAg * persists for life + implies high infectivity *May be the only positive marker during the window when HBsAg declining and HBsAb increasing 1/16/2007 UNSOM: EMR
    32. 32. Hepatitis (3) • Hepatitis B exposure - source known HBsAg positive • Unvaccinated HBIG ASAP + vaccination (0, 1 mo, 6 mo) • Vaccinated Incomplete series- vaccine booster Known responder- test for HBsAb if > 10, no rx; if < 10 HBIG and vaccine booster Known non - responder - HBIG x 2 (0, 30 days) 1/16/2007 UNSOM: EMR
    33. 33. Hepatitis (4) • Hepatitis B exposure - source unknown • Unvaccinated Initiate vaccination • Vaccinated Same as for HBsAg positive source • HBIG only recommended if source or situation maybe high risk for exposure 1/16/2007 UNSOM: EMR
    34. 34. Hepatitis (5) • Viral Type C Percutaneous, parenteral or sexual exposure Usual cause of non-A, non-B hepatitis High carrier rate, higher incidence in HIV Cirrhosis / 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
    35. 35. 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
    36. 36. 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 WBC PMN >250/ul • Tx: Ceftriaxone, ppx: Cipro or Bactrim 1/16/2007 UNSOM: EMR
    37. 37. • 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
    38. 38. • 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
    39. 39. 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 OR Obstruction distention pain / vomiting / inflammation infection (usually E. coli, Klebsiella) increased WBCs • Rupture of stone into small bowel with obstruction at ileocecal valve = GALLSTONE ILEUS Air in biliary tree (from bowel) = pneumobilia 1/16/2007 UNSOM: EMR
    40. 40. Gallbladder (2) • Acalculous cholecystitis No stones 5-10% of cases Usually a complication of another process (trauma, burn, postpartum, postop, narcotics) Patients often quite sick Likely cause of GB perforation Increased risk with diabetes and elderly Greater morbidity than calculous variety • Ascending cholangitis Infection spreading through biliary tree Charcot’s triad = jaundice, fever, RUQ pain 1/16/2007 UNSOM: EMR
    41. 41. 1/16/2007 UNSOM: EMR
    42. 42. Gallbladder (3) • Ultrasound initial diagnostic study of choice  Ultrasound 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 consult Air in biliary tree, fever, jaundice, diabetic, elderly, immuno-compromised 1/16/2007 UNSOM: EMR
    43. 43. Gallbladder Ultrasound 1/16/2007 UNSOM: EMR
    44. 44. Pancreatitis (1) • Causes Alcohol or gallstones the most common Drugs: 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
    45. 45. Pancreatitis (2) • Ranson’s criteria (prognostic) • On admission Age > 55 Glucose > 200 mg / dl WBC > 16,000 SGOT > 250 LDH > 350 • At 48 hours Decreased in HCT > 10% Increase in BUN > 5 mg / dl Ca++ below 8 mg / dl pAO2 < 60 mmHg Base deficit > 4 mEq / L Rapid fluid sequestration (over 6L) 3 positives = severe disease 1/16/2007 UNSOM: EMR
    46. 46. Pancreatitis (3) • Amylase Multiple non-pancreatic sources Height of amylase not necessarily related to severity • Lipase May be more sensitive than amylase More specific than amylase Closely follows clinical course • Plain x-ray 1/16/2007 Colon cutoff = dilation only over pancreas Pancreatic calcification Sentinel loop = small bowel air over pancreas Imaging study of choice - contrast CT UNSOM: EMR
    47. 47. Sentinel Loop (Pancreatitis) 1/16/2007 UNSOM: EMR
    48. 48. Pancreatitis complications • • • • • 1/16/2007 Pseudocyst, necrosis Hyperglycemia, hypocalcemia Volume loss, acidosis, GI bleed ARDS, DIC, renal failure Death UNSOM: EMR
    49. 49. GI Bleeding Definitions • Hematemesis - UGI proximal to ligament of Treitz • Hematochezia Maroon 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
    50. 50. 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 sites MCC PUD (45-50%) usually duodenal Gastritis (15-30%) (alcohol, NSAIDS) Varices (10-15%) 1/3 of UGI bleed deaths Mallory - Weiss esophageal tears (5-10%) Esophagitis (5-10%) (MCC in pregnancy Duodenitis (less than 5%) 1/16/2007 UNSOM: EMR
    51. 51. Upper GI Bleeding Risk Factors for Increased Mortality • • • • • • • 1/16/2007 Advancing age SBP < 100 + hr > 100 Hematochezia Varices Jaundice Hemoglobin < 10 g/dl Co-morbid conditions UNSOM: EMR
    52. 52. • 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
    53. 53. • 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
    54. 54. 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
    55. 55. 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
    56. 56. Low risk LGIB – send home? • • • • • • • 1/16/2007 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 UNSOM: EMR
    57. 57. 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
    58. 58. Pediatric GI Bleeding (1) Under 2 Months • Upper Bleeding diathesis Swallowed maternal blood Vascular malformation • Lower MCC is Meckel’s diverticulum (50%) Congenital GI duplications Intussusception Necrotizing enterocolitis Swallowed maternal blood Vascular malformation Volvulus 1/16/2007 UNSOM: EMR
    59. 59. Pediatric GI Bleeding (2) Necrotizing Enterocolitis • Predisposed Premature neonates Hypoxia Hypothermia Polycythemia Umbilical 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
    60. 60. Neonatal Necrotizing Enterocolitis 1/16/2007 Med-Challenger • EM UNSOM: EMR
    61. 61. Pediatric GI Bleeding (3) Under 2 Years • Upper Bleeding diathesis Foreign body Gastroenteritis Traumatic hemobilia Vascular malformation Mallory-Weiss tear 1/16/2007 • Lower Anal fissure Congenital dupl. Gastroenteritis HUS HS purpura Inflammatory bowel disease Intussusception Meckel’s diverticulum Milk allergy Polyps UNSOM: EMR
    62. 62. Pediatric GI Bleeding (4) Lower GI Bleeding Sites (1) • Meckel’s diverticulum  Congenital anomaly, 2% of population  Typically diagnosed age < 2  Located 40 cm from ileocecal jnx, free or attached to umbilicus  Ectopic production of gastric acid (30-50%)  Peptic ulceration causes bleed  Most common cause of significant LGI bleeding in children  Can mimic appy, may initiate intussusception, or volvulus Painless “bright red” bleeding (most common clinical presentation) 1/16/2007 UNSOM: EMR
    63. 63. • 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
    64. 64. • 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
    65. 65. Pediatric GI Bleeding (5) Lower GI Bleeding Sites (2) • Intussusception Sudden, intermittent pain, vertical sausage mass in 50% “Currant jelly” stool Second most common cause of lower GI bleeding in children Most common cause of bowel obstruction in first 2 yrs. BE = diagnostic and therapeutic 1/16/2007 Lead points Adults = polyp, cancer Child = Meckel’s, lymphoid patch UNSOM: EMR
    66. 66. 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
    67. 67. 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
    68. 68. 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, fluidfilled loops 1/16/2007 UNSOM: EMR
    69. 69. Bowel Obstruction • Small bowel (1) adhesions, (2) hernias, (3) malignancy Generally more intense pain and more vomiting and less distention than large bowel obstruction X-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 = perforation Can occur in colon if ileocecal valve is competent 1/16/2007 UNSOM: EMR
    70. 70. Small Bowel Obstruction 14 1/16/2007 UNSOM: EMR
    71. 71. Small Bowel Obstruction 1/16/2007 UNSOM: EMR
    72. 72. 1/16/2007 UNSOM: EMR
    73. 73. Volvulus • Sigmoid volvulus Elderly, debilitated • Chronic motility disorder Insidious onset, most recur X-ray: inverted u, loops project obliquely to RUQ  Sigmoidoscopy may be therapeutic Third most common cause of large bowel obstruction behind (diverticular, tumor) 1/16/2007 Cecal (15 -20%) Young (35 -55), runner Congenital freely mobile cecum Acute onset X-ray: kidney shaped loop, LUQ, Requires surgery The most common cause in pregnancy UNSOM: EMR
    74. 74. Sigmoid Volvulus 1/16/2007 UNSOM: EMR
    75. 75. Cecal Volvulus 1/16/2007 17 UNSOM: EMR
    76. 76. 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
    77. 77. Free Air; Thickened Bowel Wall 1/16/2007 UNSOM: EMR
    78. 78. Pediatric GI Emergencies • Obstructive GI lesions 1st year Gut atresia Inguinal hernia Malrotation, +/- volvulus Volvulus around congenital band Intussusception Meconium ileus (associated with CF) Hirschsprung’s disease Duplication cysts of intestine BE is diagnostic study of choice after plain x-ray 1/16/2007 UNSOM: EMR
    79. 79. Pediatric GI Emergencies Obstructive Newborn GI Lesions 1st Year • Intussusception MCC surgical abdomen/obstruction 3mo – 6yr Ileocolic most common (85%) Peak incidence - age 5 to 9 months / most occur before 2 Classic triad only in 30% (colicky pain, vomiting, currant jelly stool) Paroxysms of colicky pain is the most specific symptom KUB: “coiled spring” Infants less than one can have profound listlessness as well Children with Henoch-Schönlein purpura are at increased risk Ultrasound can be diagnostic as well as BE 1/16/2007 UNSOM: EMR
    80. 80. Intussusception 1/16/2007 UNSOM: EMR
    81. 81. Intussusception - Barium Enema 1/16/2007 15 UNSOM: EMR
    82. 82. Intussusception - Barium Enema 1/16/2007 UNSOM: EMR
    83. 83. Pediatric GI Emergencies Obstructive Newborn GI lesions 1st year • Malrotation +/- volvulus First year of life > first month Early diagnosis is crucial to prevent gangrene of midgut Abnormal rotation & fixation X-ray: loop of bowel over-riding the liver is suggestive (double bubble) Acute abdomen, shock, rigid / distended abdomen, bilious vomiting Bilious vomiting / signs of obstruction = prompt surgical consultation 1/16/2007 UNSOM: EMR
    84. 84. Pediatric GI Emergencies Obstructive Newborn GI Lesions 1st Year • Pyloric stenosis Non-bilious projectile vomiting Hypochloremic metabolic alkalosis First born males, familial propensity 50% Third week to third month of life Palpable “olive”: mass lateral margin right rectus muscle at liver edge Ultrasound (20%) false negative UGI: delayed gastric emptying, string sign 1/16/2007 UNSOM: EMR
    85. 85. • 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
    86. 86. • 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
    87. 87. 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 1/16/2007 MUST RULE OUT OBSTRUCTION UNSOM: EMR
    88. 88. 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
    89. 89. 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
    90. 90. Ulcerative Colitis • Chronic inflammatory disease - colon • Similar GI symptoms to Crohn’s disease Major finding = bloody diarrhea Toxic 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
    91. 91. 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%) *Sudden onset with pain out of proportion to physical findings • Leukocytosis (present in most cases), acidosis, hyperphosphatemia, hyperamylasemia - all inconsistently present • Avoid digoxin, beta-blockers, vasopressors (decrease splanchnic blood-flow) 1/16/2007 UNSOM: EMR
    92. 92. 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
    93. 93. 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
    94. 94. Appendicolith 1/16/2007 19 UNSOM: EMR
    95. 95. Appendicitis (2) • Confounders = situs inversus, retrocecal, pregnancy malrotation, very long appendix  Result-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 position Obturator 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
    96. 96. Diverticular disease 1/16/2007 UNSOM: EMR
    97. 97. 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
    98. 98. 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
    99. 99. Diarrhea • Viral  Most common cause of diarrhea 50-70% of cases  Mostly winter / spring / children / day care  Rotavirus, 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
    100. 100. 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 water  Can cause HUS (children) and TTP (elderly)  No ABX recommended may increase risk of HUS 1/16/2007 UNSOM: EMR
    101. 101. Diarrhea - Invasive (2) • Shigella Very infectious, high fever, febrile seizures, watery bloody Most common cause of bloody diarrhea 1/16/2007 • Salmonella  Very common bacterial diarrhea (U.S.)  Watery / mucoid  Pet turtles, amphibians, eggs, chickens  Osteomyelitis can occur in sicklers (autosplenectomy) and those with splenectomy Systemic toxicity = typhoid fever (low WBC and relative carrier state  Antibiotics increase bradycardia, abdominal septic) (give if sick /pain, no diarrhea) UNSOM: EMR
    102. 102. Diarrhea - Invasive (3) • Campylobacter Most common cause of bacterial diarrhea Hard to culture / water-borne (raw milk) Invasive enterotoxin 60-70% 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
    103. 103. Diarrhea - Invasive (4) • Yersinia enterocolitica Invasive gram pos bacteria Increasing evidence, most common in childhood Can mimic appendicitis Fever Colicky abdominal pain (may be prolonged) Diarrhea May 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
    104. 104. 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
    105. 105. Diarrhea - Protozoan (2) • Amebiasis (entamoeba histolyticus) Spread between family members and sexual partners Fecal / oral - anal intercourse Diarrhea can be bloody Extra-intestinal manifestations (5%) Liver abscess most common (“chocolate cysts”) Pericarditis, pleuropulm disease, cerebral amebiasis Wide variety of presentations Asymptomatic cyst passer Colitis Cerebral amebiasis 1/16/2007 UNSOM: EMR
    106. 106. Diarrhea Protozoan (3) • Cryptosporidium Intestinal protozoan parasites MCC of chronic diarrhea in AIDS Contaminated water supply; recent outbreaks Children, animal handlers; immunocompromised Ingestion of oocysts; trophozoites attack intestinal membrane 1 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
    107. 107. Diarrhea - Toxigenic (1) • • • • • 1/16/2007 Bacteria producing enterotoxin Food-borne Diarrhea: watery, voluminous Minor fever, no septicemia No WBC or RBC in stool UNSOM: EMR
    108. 108. Diarrhea - Toxigenic (2) • Staph (toxin) Contaminated foods GI overgrowth from antibiotics Ham, poultry, dairy products, potato salad MCC of food-borne disease Symptoms within 6 hours of ingestion Usually afebrile, no abx • E. coli Water contaminated by feces MCC Traveler’s diarrhea No readily available diagnostic tests TMP / SMX, cipro 1/16/2007 UNSOM: EMR
    109. 109. Diarrhea - Toxigenic (3) • Clostridium perfringens Common, large outbreaks Meat and poultry source Enterotoxin mediated 6 hours (longer onset) Watery diarrhea Severe abdominal cramps Fecal WBC / RBC negative Treatment: fluids; no abx • Vibrio – cholera Copious watery diarrhea= “rice water stools” Severe fluid & electrolyte problems Treatment: fluids, ciprofloxacin, TMP-SMX 1/16/2007 UNSOM: EMR
    110. 110. 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
    111. 111. 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 blockers Suspect when multiple patients have “allergic reaction” 1/16/2007 UNSOM: EMR
    112. 112. Diarrhea - Toxigenic (5) • Ciguatera S.E. US, tropical and subtropical waters Grouper, snapper, king fish Fish 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 alcohol No specific treatment, symptoms can be permanent 1/16/2007 UNSOM: EMR
    113. 113. Pseudomembranous Enterocolitis • • • • • • • • • 1/16/2007 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 UNSOM: EMR
    114. 114. Botulism • Characteristics Heat-labile neurotoxin, short onset (half hour) Inadequately processed canned foods Bulbar symptoms / descending paralysis / anticholinergic findings • Infantile Floppy baby, constipation, feeble cry Honey can be source Most 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
    115. 115. Rectal Prolapse • Full thickness protrusion of rectum through anal canal • Sensation of rectal mass • In children, intussusception more likely • Differentiation from internal hemorrhoids & intussusception Intussusception – can place finger between protruding rectum and anus Internal hemorrhoids – fold of mucosa radiates out like spoke on a wheel Rectal prolapse – folds of mucosa circular 1/16/2007 UNSOM: EMR
    116. 116. Rectal Prolapse 1/16/2007 UNSOM: EMR
    117. 117. 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
    118. 118. Anal Fissure • Most common causes of painful rectal bleeding in adults and children • 90% posterior midline • Non-midline fissures should suggest more serious conditions IBD, CA, sexual abuse • Sharp cutting pain, especially with bowel movement, blood-streaked stool • Perianal hygiene, sitz baths Fistula in Ano Tract between rectum and skin Causes drainage and itching Consider Crohn’s Disease 1/16/2007 UNSOM: EMR
    119. 119. Perianal Fissure 1/16/2007 UNSOM: EMR
    120. 120. Rectal Trauma • Causes: Penetrating 80% Blunt 10% Iatrogenic Foreign body • Must consider GU & colon injuries • Rectal foreign body 60% removed in ED High-riding or sharp require general anesthesia Sigmoidoscopy after removal 1/16/2007 UNSOM: EMR
    121. 121. Rectal Foreign Body 1/16/2007 UNSOM: EMR
    122. 122. 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
    123. 123. 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
    124. 124. 1/16/2007 UNSOM: EMR

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