EM E1: GI

Where does an upper GI bleed originate from?

proximal to the ligament of Treitz

Where does a lower GI bleed originate from?

distal to the ligament of Treitz

What is the MCC of upper GI bleed?

Peptic ulcer disease

What is the MCC of lower GI bleed?

Diverticulosis

*followed by hemorrhoids

What is the diagnostic & therapeutic diagnostic study used for GI bleeds?

Colonoscopy (lower)/Endoscopy (upper)

The use of barium contrast studies limits the use of what subsequent imaging?

endoscopy or angiography

What should be placed in the treatment of GI bleed?

NG tube

What is used in the tx of anorectal bleeding?

Proctoscopy

What class of meds is used to reduce GI bleeding, reduce transfusion requirements, and reduce the need for surgery for PUD?

PPIs (-prazole)

What is transport dysphagia?

impaired movement down the esophagus and through the LES, → feeling of food "getting stuck"

What is transfer dysphagia?

difficulty in initiating a swallow -occurs early in the swallowing process, as the food bolus moves from the oropharynx through the UES

What are the MC structural abnormalities of the esophagus?

Esophageal webs/rings

What is the MC location of esophageal rings?

distal esophagus

What is the MC locations of esophageal webs?

anterior postcricoid area of proximal esophagus

What is an esophageal stricture?

esophageal scarring from GERD

What is an esophageal ring?

concentric, smooth thin (3-5mm) extension of normal esophageal tissue consisting of mucosa, submucosa, and muscle

What is an esophageal web?

eccentric, smooth, thinner (2-3mm) extension of normal esophageal tissue composed of only mucosa & submucosa

What is a diffuse esophageal spasm?

normal peristalsis that is periodically interrupted by simultaneous contraction, commonly complain of chest pain

What is the tx for diffuse esophageal spasm?

tx reflux, smooth muscle relaxants, antidepressants

What is the tx for achalasia?

botox, dilatations, surgical myotomy

What is the tx for GERD?

H2 blockers or PPIs

avoid EtOH, caffeine, nicotine, chocolate, fatty foods

What is the MCC of infectious esophagitis?

candida

“Nutcracker esophagus” on XR indicates what?

esophageal motility disorder → peristaltic contractions

How does an esophageal perforation present?

acute severe pain in neck/chest, hypotension, fever, tachy, Hamman’s crunch

What test is used to confirm dx of esophageal perforation?

CT or endoscopy

What is Boerhaave syndrome?

full thickness esophageal perforation following a sudden rise in intra-esophageal pressure

What is the tx for variceal esophageal bleeding?

majority resolve spontaneously

What is the 1st line tx for esophageal bleeding?

endoscopy

What is Mallory-Weiss syndrome?

esophageal bleeding from longitudinal mucosal laceration (can cause melena OR hematochezia)

Where do a majority of pediatric esophageal foreign bodies create obstruction?

proximal esophagus

Where do a majority of adult esophageal foreign bodies create obstruction?

distal esophagus

Pt states feeling sticking sensation in the esophagus or has ingested a bone, what imaging study would you want to do?

Laryngoscopy

What is the tx for a swallowed FB?

endoscopy -removal w/o complications

What is the method of removal for coin ingestion?

Foley catheter technique- Katz Extractor

What can help clear a lower esophageal FB?

IV glucagon

*DO NOT use for suspected sharp edge FBs

What is the tx for upper esophageal FB?

Refer to GI

What is a true emergency if ingested?

button battery (alkaline burns mucosa)

What do you do if a button battery has passed the esophagus?

doesn't need to be retrieved unless not passing through the pylorus after 48 hrs

What is the MC impacted objects in esophageal emergencies in peds?

Coin

What is the MC impacted objects in esophageal emergencies in adults?

meat & bones

What is "Cafe coronary"?

proximal esophageal obstruction -characterized by sudden cyanosis and collapse caused by food obstruction

What is "Steakhouse syndrome"?

distal esophageal obstruction -improperly chewed food obstruction

What patients are at the highest risk for cafe & steakhouse?

alcoholics & those with missing teeth

What is the tx for sharp FB ingestion?

endoscopy or laparotomy

must be removed before they pass through the stomach

How does acute appendicitis present?

pain begins in epigastrium/periumbilical, followed by anorexia, N/V, and pain becomes more localized to RLQ (McBurney’s point)

What is the best initial imaging study for acute appendicitis?

CT

What is the standard of care tx for appendicitis?

Appendectomy

What is the MCC of small bowel obstruction?

adhesions from abdominal surgery (months-years later)

*followed by Incarceration of groin hernia

What is the MCC of large bowel obstruction?

Neoplasms

How do proximal SBOs present?

bilious vomiting

How do distal SBOs present?

feculent vomiting

What tests confirms SBO dx?

flat/upright ABX or upright CXR

-identify free air or masses, localize the site

What is the tx for a true mechanical SBO?

NG tube to remove excess bowel contents and then surgical intervention

What it the tx for a closed-loop obstruction, bowel necrosis, or cecal volvulus?

immediate surgical intervention

What is the tx for volvulus of sigmoid colon?

decompress via sigmoidoscopy & insertion of rectal tube

What does "Parrot beak" appearance of the sigmoid colon indicate?

Colonic volvulus

What is Ogilvie syndrome?

large amounts of gas present in the large intestine caused by anticholinergic or TCAs → delay in peristalsis (may mimic bowel obstruction)

What is the tx for Ogilvie syndrome?

colonoscopy after DRE, also therapeutic for decompression

Neostigmine infusion

What should be AVOIDED in Ogilvie syndrome?

Barium studies

What type of hernia is common in males on the right side?

Indirect inguinal hernia

What type of hernia protrudes directly through the transversalis fascia and the external inguinal ring (acquired)?

Direct inguinal hernia

What type of hernia protrusion below the inguinal ligament & is more common in women?

Femoral hernia

What type of hernia protrudes through the linea alba, above the umbilicus?

Epigastric hernia

What type of hernia is lateral to the rectus muscle (often intraparietal)?

Spigelian hernia

What type of hernia goes through the inferior or superior lumbar triangles?

Lumbar hernia

What type of hernia goes through a surgical incision (frequent complication)?

Incisional hernia

What type of hernias require immediate attention/treatment?

Incarcerated hernia

What is the best imaging study for hernia?

CT

What is Crohn's disease?

chronic granulomatous inflammatory disease involving any part of the GI tract from mouth to anus (rectum spared)

What is the best imaging study for Crohn's & UC?

Colonoscopy

What is the tx for Crohn's?

Sulfasalazine (or PO steroids)

What is Ulcerative colitis?

chronic inflammatory disease of colon which almost always involves the rectum

What are extraintestinal manifestations of ulcerative colitis?

peripheral arthritis, ankylosing spondylitis, episcleritis/uveitis, pyoderma gangrenosum, erythema nodosum, higher carcinoma rates

What is a complication of severe UC?

toxic megacolon

What is the tx for severe UC?

IV steroids, IV fluids, broad-spectrum Abx

What is the tx for mild-moderate UC?

Glucocorticoids, Sulfasalazine

What is pseudomembranous enterocolitis (C. diff)?

membrane like yellowish plaques of exudate overlie and replace necrotic intestinal mucosa; typically follows abx use

What confirms pseudomembranous enterocolitis dx?

stool examination -confirm toxin

What is the tx for Pseudomembranous enterocolitis?

d/c Abx, supportive tx, Metronidazole (or vanco if failed metro)

What is diverticulitis?

acute inflammation of the wall of a diverticulum and surrounding tissue caused by either a micro- or macroperforation

How does diverticulitis present?

steady, deep discomfort in LLQ, change in bowel habits, tenesmus, SBO, low grade fever, occult blood may be present

What is the diagnostic imaging of choice for diverticulitis?

CT

What is the outpatient tx for diverticulitis?

Cipro + Flagyl, Bowel rest

What is the inpatient tx for severe diverticulitis?

IV Beta-lactam OR Flagyl + 3rd gen ceph/FQ; NPO

What degree hemorrhoid:

do not prolapse

1st degree

What degree hemorrhoid:

prolapse and spontaneously reduce

2nd degree

What degree hemorrhoid:

prolapse and require manual reduction

3rd degree

What degree hemorrhoid:

prolapse, are not reducible (can strangulate)

4th degree

How do external thrombosed hemorrhoids present?

Bluish-purple growth on anus with pain on palpation & defecation

What type of hemorrhoids require surgical consultation in the ED?

4th degree incarcerated internal hemorrhoids

What is the tx for an anal fissure?

sx relief -hot sitz baths, add bran to diet, local analgesic

What is an anorectal abscess?

obstruction of an anal gland that opens in the base of an anal crypt resulting in infection and abscess formation, typically polymicrobial; pain w/ be worse before defecation

What is the tx for an anorectal abscess?

surgical drainage; abx not necessary but can be useful

What is an anal fistula?

abnormal tract that connects the anal canal with the skin, usually results from perianal abscess

How do anal fistulas present?

persistent, blood-stained, malodorous discharge; local, recurrent abscess formation that is relieved by spontaneous rupture

What is the imaging study of choice for detecting anal fistulaes?

MRI

What is the only definitive tx for anal fistula?

Surgical excision

*improperly done → permanent fecal incontinence

How does a rectal prolapse present?

presence of a mass, especially following defecation, mucous discharge with some associated bleeding and fecal incontinence

Where are most rectal foreign bodies located?

Rectal ampulla

How do you remove a rectal large foreign body?

sphincter relaxation: anesthesia/IV sedation, passing a catheter beyond the object and injecting air, Katz extractor