Peritonitis, Ascites, GI Bleeds, Obesity

Ligament of treitz

What anatomical structure determines if a GI bleed is upper or lower

Upper GI Bleeding (UGIB)

Bleeding proximal to the ligament of trietz that can present as Hematemesis (moderate/severe) or coffee-ground emesis (limited) → self limited in 80%

Over 1000 mL (melena can be as little as 50-100)

If there is an UGIB with hematochezia what is the estimated blood loss

Peptic ulcer disease (40%), Portal hypertension (10-20%), Mallory-Weiss tears (5-10%), vascular abnormalities, erosive gastritis/esophagitis, gastric neoplasms

Etiology of UGIB

CBC (anemia if chronic, don’t watch Hgb/Hct it takes to 2-3 hrs), CMP (LFTs), H. pylori, 2 16 G IVs, Type and screen, Coags (correct if necessary), EGD (varice ligation, within 12 hours)

45 y/o patient presents to the ER for “throwing up blood” and abdominal pain. He also reports melena and fatigue as well. On a physical exam you note pallor and diaphoresis. Vitals are stable with the exception of 90/50 (sitting) and 134 bpm. What do you want to order?

EGD

What is the definitive diagnostic and treatment for GI bleeds?

Admit to hospital, PPIs, Antibiotics (patients with bleeding varices), Octreotide (only recommended for varices), TXA (no benefit)

Treatment plan for UGIB

Systolic under 100, Postural hypotension, tachycardia

Indications of severe blood loss during a GI Bleed (remember don’t watch Hbg/Hct it ain’t fast enough)

evacuating the stomach pre-EGD

When are NG tubes used for UGIBs

Lower GI Bleed (LGIB)

A bleed distal to the ligament of treitz (colon 95%) usually presenting with hematochezia (blood on toilet paper, in stool, dripping) → spontaneous cessation in 75%

Diverticulosis (50% most common), neoplasms (polyps, cancers, chronic occult blood loss), IBD (ulcerative colitis), hemorrhoids, fissures, ulcers, Ischemic colitis (think this post-MI)

Causes of lower GI bleed

Reported bright red blood from rectum, Rectal exam with frank blood, positive fecal occult blood test, Anoscope visualization of hemorrhoid/rectal vault bleeding

Diagnostic criteria for LGIB

Start with colonoscopy if you don’t find the source → EGD

When treating stable patients with hematochezia

Resuscitate/consider surgery, EGD once stable if you don’t find the source → colonoscopy

When treating unstable patients with hematochezia

PPIs (omeprazole) for risk of ulcers due to NSAID use, Beta blockers for esophageal varices, Preventative EVL in patients with C/I for beta blockers

Prevention measures for GI bleeds

Ascites

An abnormal accumulation of fluid in the peritoneal cavity (more than 20 mL) most commonly caused by portal HTN

Infectious, intra-abdominal malignancy, inflammatory disorders of the peritoneum, ductal disruptions

Etiologies for Ascites (other than portal HTN)

liver disease, EtOH, blood transfusions, tattoos, IV drug use, hepatitis/jaundice at birth

Risk factors for ascites

Paracentesis with cell count/differential, inspection, SAAG, culture, gram stain, cytology; Blood work may show evidence of liver failure or CHF, cirrhosis may show elevated INR, hypoalbuminemia, thrombocytopenia, anemia, and leukopenia

55 y/o male patient presents to the ER for SOB and abdominal fullness. PMHx is positive for alcoholic liver cirrhosis. On a physical exam you note a distended abdomen that has a positive fluid wave. See abdominal U/s. What do you want to order?

NORMAL

Clear, yellowish, honey-colored para fluid is associated with

infection

Cloudy para fluid is associated with

chylous

Milky para fluid is associated with

trauma, malignancy

Bloody para fluid is associated with

Iatrogenic bacterial peritonitis, organ damage/perforation

While an abdominal paracentesis can be indicated for initial onset of ascites, Sx relief, or diagnosing bacterial periotnitis → what are the complications

Less than 500 WBCs, less than 250 PMNs (if lymph > PMN think viral)

What is a normal cell count/Diff for para fluid

Portal hypertension (anything over 1.1 g/dL)

The Serum Albumin Ascites Albumin Gradient has a 95% specificity for determining

Abdominal U/S (find drainage spots), CT (finding masses), Laparoscopy (visualization and biopsy of suspected malignancy)

What else should be included in the diagnostic eval for acites?

Sodium restriction, Diuresis (spironolactone, furosemide), para (symptomatic relief), TIPS (trans-jugular intraheptic portosystemic shunt) or liver transplant for refractory cases

Treatment plan for ascites → 1st line for peeps with cirrhosis

Spontaneous Bacterial peritonitis

A infection of ascitic fluid with no apparent intra-abdominal source (usually translocation from the gut so think gram neg pathogens)

IV 3G CPH for 5-10 days, IV albumin (protects kidneys, decrease mortality), discontinue non-selective beta blockers

55 y/o male patient presents to the ER for AMS and abdominal pain. Vitals are stable with the exception of a temp of 101.7. On a physical exam you note a red, distended, tender abdomen that has a positive fluid wave, rebound tenderness, and a positive heel tap. See abdominal U/s. Labs are as follows serum WBCs at 13,000, Ascitic fluid PMN of 400, WBCs of 750. What is your treatment plan?

temp over 100, PMNs over 250, abdominal pain/tenderness, AMS

Which bacterial peritonitis patients get empiric therapy → treat early (over 30% mortality if you don’t)?

secondary intra-abdominal infections, perforation, malignancy

DDX for bacterial peritonitis

Long-term prophylatic antibiotics to all survivors (70% relapse)

Prevention plan for Bacterial peritonitis

obesity

An excessive accumulation of body fat, typically a BMI over 30 that is associated with numerous health complications

caloric intake exceeds expenditure, genetic/environement/behavioral, leptin resistance, insulin resistance, altered gut microbiome, chronic low-grade inflammation

Pathophys for obesity

BMI, waist circumference, assess for central obesity

Ways to diagnose obesity

HTN, coronary artery disease

CV effects of obesity

Type 2 DM, dyslipidemia

Metabolic effects of obesity

OSA

Respiratory effects of obesity

osteoarthritis, certain cancers, depression

Other effects of obesity

Caloric deficit with balanced nutrition, 150 min/week of activity, CBT, Bariatric surgery (BMI 35+. 30+ with comorbidities)

Non-pharm management of Obesity

S.C. tirzepatide, semaglutide, liraglutide

1st line Pharm management of Obesity - indicated for BMI 30+ or 27+ with comorbidities

Phenteramine-topiramate (C/I with CVD and uncontrolled HTN), Naltrexone-bupropion, Orlistat, Lorcaserin with liraglutide

Alternative Pharm management of Obesity - indicated for BMI 30+ or 27+ with comorbidities

6 y/o and up

When are we screening for obesity?