CMPP -- Upper GI Bleeding and Foreign Body Ingestion

gastritis/PUD

esophagitis

mallory weiss tear

portal HTN/esophageal varices/gastropathy

most common causes of upper GI bleeding

hematemesis, coffee ground emesis, melena

clinical presentation of upper GI bleeding

proximal to the ligament of treitz

one presenting with hematemesis most likely has bleeding...

proximal to the ligament of treitz

one presenting with melena most likely has bleeding...

lower GI bleed -- but CAN result from brisk upper GI bleed

one presenting with hematochezia most likely has bleeding...

prior epsiodes

hx of PUD, smoking, liver disease, malignancy, AAA/aortic graft

important PMH in one with upper GI bleeding

aspirin and NSAIDs

Bisphosponates, tetracyclines (pill esophagitis)

anticoagulants

bismuth/oral iron supplementation

important medication hx in one with upper GI bleeding

peptic ulcer disease

epigastric/RUQ pain associated with upper GI bleeding can point us to...

esophagitis or esophageal ulcer

odynophagia, GERD, dysphagia associated with upper GI bleeding can point us to...

Mallory Weiss Tear

emesis, cough, or retching prior to episode associated with upper GI bleeding can point us to...

vatical bleeding or other liver etiology

jaundice hematemesis, and hemodynamic instability associated with upper GI bleeding can point us to...

brisk bleeds from PUD/varcies

hemodynamic instability is often seen with what cause of upper GI bleeding?

varices/portal hypertensive gastropathy

stigmata of liver disease are often seen with what cause of upper GI bleeding?

perforation

abdominal pain with rebound tenderness/guarding should lead one to consider what cause of upper GI bleeding?

CBC (Hgb/Hct and platelets)

CMP (electrolytes, renal/liver function tests)

Coagulation studies

what labs should you get for one with an upper GI bleed?

generally not warranted

but get CXR for suspected esophageal perforation and abdominal x ray for suspected gastric/duodenal perforation

what imaging should you get for one with an upper GI bleed?

initiate IV fluids +/- blood products

IV PPI

hold anticoagulation therapy

while figuring out the cause of one's upper GI bleed, what should you do?

upper endoscopy

what is the test of choice for discovering source of upper GI bleeding?

barium will interfere with future endoscopy, angiography, and surgery -- can be caustic

why is a barium swallow contraindicated in those with an upper GI bleed?

electrocautery

epinephrine injection

endoclip

banding for variceal bleeding

endotherapy options for acute GI bleeding

Mallory-Weiss tear

tear that occurs in the esophageal mucosa at the junction of the esophagus and stomach caused by severe retching and vomiting and results in severe bleeding.

forceful retching

most common mechanism of Mallory-Weiss tear

acute Gi bleeding

usually give history of non-bloody emesis preceding the hematemesis

+/- chest, back pain, melena/hematochezia

clinical manifestations of Mallory Weiss tear

single, longitudinal mucosal laceration

endoscopic appearance of a Mallory Weiss tear

distal esophagus/proximal stomach -- red crack in mucosa

most common location of a Mallory-Weiss tear

most will heal uneventfully within 24-48 hours

if active bleeding -- epi injection of thermal cautery

generally treated with 2-4 wks of acid suppression therapy

treatment for Mallory Weiss tear

portal HTN

esophageal varices develop in response to...

GEJ

esophageal varices most commonly develop at...

hematemesis

melena OR hematochezia

hemodynamic instability (hypotension, tachycardia, tachypnea, dizziness, syncope)

clinical manifestations of esophageal variceal bleeding

endoscopy

how to diagnose esophageal variceal bleeding

Octreotide (Sandostatin)

drug of choice for esophageal variceal bleeding

vasoconstriction diminishes blood flow to the portal system which will decrease variceal bleeding

Octreotide (Sandostatin) MOA

Blakemore Tube

Tube inserted through the nose down the esophagus and into the stomach (w/ balloons) that can be inflated to stop bleeding esophageal varices; puts pressure on bleeding varices

Ligation/Banding during endoscopy

prophylactic Abx

after initial treatment, what is commonly given to patients with esophageal varices?

Non-selective BB (Nadolol, Propanolol)

after the esophageal variceal bleeding episode what drug is commonly prescribed to patients?

stigmata of liver disease

elevated LFTS (AST:ALT in a 2:1 ratio)

thrombocytopenia

hypoalbuminemia

elevated INR

look for any previous imaging/labs

hints a pt might have cirrhosis

upper esophageal sphincter

the level of the aortic arch

diaphragmatic hiatus

most common sites of physiologic narrowing in the GI tract

fish/chicken bones

common accidental food ingestion

medication packing, dentures, coins, pens, batteries, magnets, razors, drugs

common non-food ingestion

ulcer formation, lacerations

esophageal perforation

intestinal obstruction or perforation

aortoesophageal or tracheoesophageal fistula formation

bacteremia/sepsis

complications associated with foreign body ingestion

retrosternal pain or a sense that something is "stuck in the throat"

in one with intellectual/developmental disability, may show refusal to eat, hypersalivation/drooling, regurgitation of undigested food

clinical presentation of one with foreign body ingestion

plain radiographs

if high suspicion, endoscopic evaluation is required

how to diagnose foreign body ingestion

24 hours

all esophageal FBs should be removed within...

button/disc batteries

long, pointed objects

magnets

risk for erosion and creation of esophageal-aortic fistula

high risk items in Fb ingestion and why

most pass on their now, but some may need endoscopic/surgical intervention

treatment for FB ingestion

chest discomfort -- retrosternal "fullness"

inability to handle secretions (spitting/drooling)

clinical presentation of food bolus impaction

esophageal web/ring

peptic stricture

eosinophilic esohagitis

other structural/motility abnormalities

poorly formed bolus art natural area of constriction

causes of food bolus impaction

meat (chicken, steak, hot dogs)

bread, pasta, rice

common food bolus impactions

administration of glucagon to relax esophagus

EGD for persistent food bolus impaction and FB removal

may need repeat endoscopy in 4-6 weeks to address underlying cause

treatment for food bolus impaction

Perforation

prolonged food bolus exerting constant pressure can result in ischemia-induced necrosis

retrosternal pain SOB, fever, subcutaneous crepitus

clinical presentation of acute perforation

features of free air -- mediastinal widening, pneumomediastinum, pleural effusion, hydropneumothorax

in perforation, a CXR would show...

surgical management

how to treat perforation