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 Pain History . 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 Pain Physical 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 . Radiology . Plain abdominal series . U/S . CT scan Acute Abdominal Pain Special Circumstances (1)

Elderly – History and physical exam may be unreliable – Labs may be normal even with severe intra- abdominal process – disease, malignancy, obstruction, complicated PUD, incarcerated Pregnancy – , , 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 , , 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, /obstruction, acalculous cholecystitis, stress ulcer, ischemia Acute Abdominal Pain – Common Causes (1)

CONDITION ONSET SITE CHARACTER TYPE RADIATION INTENSITY

Appendicitis Gradual Periumbil- Diffuse Ache None + icalRLQ localized Cholecystitis Rapid RUQ Localized Constricting Scapula ++ Rapid Epigastric, Localized Boring Midback ++ to +++ back Gradual LLQ Localized Ache None + to ++ Perforated Sudden Epigastric Localized Burning None +++ peptic ulcer diffuse Small bowel Gradual Periumbil- Diffuse Crampy None ++ obstruction ical Gastro- Gradual Periumbil- Diffuse Spasmodic None + to ++ ical

+ = Mild, ++ = Moderate, +++ = Severe Acute Abdominal Pain – Common Causes (2)

CONDITION ONSET SITE CHARACTER TYPE RADIATION INTENSITY

Mesenteric Sudden Periumbil- Diffuse Agonizing None +++ ischemia ical

Ruptured Sudden Abdominal, Diffuse Tearing Back, flank +++ AAA back, flank

Pelvic Gradual RLQ, LLQ, Localized Ache Upper thigh ++ inflammatory or pelvic disease Ruptured Sudden RLQ, LLQ, Localized Light- None ++ ectopic or pelvic headed pregnancy

+ = Mild, ++ = Moderate, +++ = Severe Acute Appendicitis . Younger patients (teens, 20s) . Pain, anorexia, , . 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 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 /septic , 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 . Most commonly due to 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 . , tachycardia . Hypotension, rigid abdomen . X-ray: free air 75% of the time . Immediate surgery Small . 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

CARDIAC THORACIC INFECTIONS Myocardial ischemia/infarction Pneumonitis Herpes zoster Myocarditis Pleurodynia Osteomyelitis Endocarditis Typhoid fever Congestive heart failure Empyema HEMATOLOGIC METABOLIC Esophageal spasm Sickle cell anemia Uremia Hemolytic anemia Diabetes mellitus Henoch-Schönlein Porphyria MISCELLANEOUS Acute leukemia Acute adrenal insufficiency Muscular Hyperlipidemia Narcotic withdrawal Hyperparathyroidism Familial Mediterranean fever NEUROLOGIC Psychiatric 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 Bleeding . Vomiting of fresh red blood or old blood (“coffee grounds”) . Black, tarry, foul-smelling stools . Degradation of blood to hematin by bacteria . DDX: bismuth (Pepto-Bismol), iron . Passage of bright red or maroon blood per . 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 Bleeding Vital Signs VITAL BLOOD BLEED SIGNS LOSS (%) SEVERITY Shock (Resting 20-25 Massive hypotension) Postural (Orthostatic 10-20 Moderate tachycardia/ hypotension) Normal < 10 Minor Upper GI Bleeding - Causes Common - Gastric ulcer - Duodenal ulcer - - Mallory-Weiss tear

Less frequent - Dieulafoy’s lesions - Vascular ectasia - Portal hypertensive gastropathy - - Gastric antral vascular ectasia - Esophagitis - Gastric erosions - Neoplasia

Rare - Esophageal ulcer - Pancreatic source - Erosive - Crohn’s disease - Aortoenteric fistula - Hemobilia Causes of Upper GI bleeding

Active ulcer bleeding Esophageal Varices Duodenal ulcer

Portal Hypertensive Mallory Weiss Tear GAVE 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 Variceal Upper GI Bleeding – Risks for Recurrent Bleeding

Early Rebleeding Late Rebleeding (<6 weeks) (>6 weeks) - Age >60 years - Severity of - Severity of initial bleed - Red signs on varicies - Ascites - Ascites - Renal failure - Hepatoma - Active bleeding on - Active alcoholism - Red signs on varicies 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 Bleeding Causes Common

Uncommon Neoplasia, Postpolypectomy Inflammatory Bowel Disease (IBD) (Infection, Ischemic, Radiation) 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 Bleeding Causes

Diverticular bleeding Angiodysplasia

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), , 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 Bleeding Surgery . 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 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.