Gastrointestinal

GASTROINTESTINAL Steven J. Parillo, DO, FACOEP, FACEP 1 1.0 ABDOMINAL AND GASTROINTESTINAL DISORDERS 1.1 ESOPHAGUS 1.1.1. Motor Abnormalities 1. Esophageal Spasm  Painful muscle contractions/colic  Etiology – Acid reflux, temperature extremes, large food bolus without obstruction  DDx: cardiac ischemia  Tx: nitro, calcium channel blockers, anticholinergic agents 2. Achalasia  Most common motility disorder producing dysphagia  Esophageal retention, regurgitation of retained food  Dx:  standard radiograph - dilated esophagus, distal beak  barium swallow - aperistalsis  DDx: Scleroderma – reflux symptoms 1.1.2. Structural Disorders 1. Varices  ETOH-induced cirrhosis most common cause  10-30% of all UGI bleeding; painless  80-90% of UGI bleeding in known cirrhotics  likely to rebleed  33% of UGI bleeding deaths  24-33% with known varices bleed from other site  Dx – endoscopy best  Tx:  oxygen  agent of choice - octreotide – 50 microgram bolus, 50mcg/hr (Main determinant of bleeding is variceal wall tension.)  beta-blockers (later) -  portal pressure,  rate of re-bleed  antibiotics – ceftriaxone, cefotaxime, ciprofloxacin (High rate of infection, especially in re-bleeds.)  Consider platelets  FFP – 2 units (10-15cc/kg)  Consider early intubation for airway protection  Balloon tamponade – Linton (best), Minnesota, SB  Intubate before using balloon  Avoid RSI drugs that may decrease BP  Tx - banding (better), sclerotherapy  *Remember ECG, chest film after tubes placed  Interventional radiology – TIPS  Transjugular intrahepatic portalsystemic shunt  Surgery PaACEP/CME/WB/GI final GASTROINTESTINAL Steven J. Parillo, DO, FACOEP, FACEP 2 2. Spontaneous Rupture - Boerhaave‟s Syndrome  Represents only 7-10% of all esophageal perforations  Full thickness tear, left posterolateral, distal rupture  Males, 40-60 y.o., after over-indulgence of food and EtOH  Classically occurs during vigorous vomiting (25% no Hx of vomiting)  Sudden, severe chest, back, abdominal, neck pain  shock, sepsis  *< ½ have classic triad of CP, vomiting, sub Q air  ~20% will not have CP  < ½ have dyspnea; < 40% have fever  Chemical, then infectious mediastinitis – grave prognosis  Air in mediastinum (Hamman‟s crunch)  Dx: Radiograph: wide/air in mediastinum, left pleural effusion, pneumothorax; Note – Several hours required for these signs.  Dx: gastrografin (water soluble) esophagram (~25% false negative), contrast CT (best overall test), endoscopy  Tx: Antibiotics (mediastinitis), +/- PPIs, surgery consult 3. Perforation  Most common site of GI perforation, largely because of delay in dx.  Delay in dx of 24 hours increases mortality by 50%.  Common causes – Iatrogenic (33-75%) - rigid endoscope, stricture dilatation, Ewald tube, intubation  Others – foreign body (40%) - pressure necrosis, trauma, chemical ingestion, aortic aneurysm, Barrett‟s esophagitis, infection (see below)  Signs, symptoms, dx, tx similar to Boerhaave‟s  Easily misdiagnosed as cardiac/ pulmonary 4. Tears (Mallory-Weiss Syndrome)  1-10% of all UGI bleeding  Violent vomiting in 50%; coughing & seizures have also been reported as etiologies.  Partial thickness tear, right posterolateral  Bleeding from esophageal laceration involving an artery 5. Foreign Body – most common in adults => food bolus most common in children => pills, coins, button batteries  Pain radiating to neck suggests perforation  Remove if - pointed, sharp, longer than 5 cm, wider than 2 cm  Sites of narrowing  Cervical most common, GE junction least common  Other narrow sites – arytenoid, thoracic junction  Button batteries  always remove from esophagus  remove from stomach only if impacted (uncommon) PaACEP/CME/WB/GI final GASTROINTESTINAL Steven J. Parillo, DO, FACOEP, FACEP Coins – on chest film - Anteroposterior - in trachea - Transverse - in esophagus - Relationship to air column?  Meat – usually signifies pre-existing esophageal pathology  Treatment: - Sublingual Nitro - Glucagon – relaxes lower esophageal sphincter - Nifedipine (po), diltiazem (IV) – reduce tone - Carbonated beverages - Endoscopy Diaphragmatic Hernia – intestinal tract into chest cavity  Bochdalek – left sided (more common)  Morgagni – retrosternal (mnemonic – M-midline) Diverticula  Zenker‟s - pharyngoesophageal Hiatal Hernia  Sliding – gastroesophageal junction moves into chest  Usually clinically insignificant by itself  Paraesophageal – stomach herniates into chest along esophagus Webs, strictures, stenosis, fistulas  Schatzki‟s ring – distal  3 6. 7. 8. 9. 1.1.3 Inflammatory Disorders 1. Reflux Esophagitis – aka gastroesophageal reflux - GERD  Pathophysiology – weak LES or transient LES relaxation  Pain – steady, substernal, worse with swallowing, sensation of fullness; worse in recumbent position  Treatment - antacids, elevate head of bed, avoid late night snacks - *proton pump inhibitors, H2 blockers - avoid fatty foods, chocolate, caffeine, ethanol  Association with reactive airway disease – aspiration  Complications – strictures, Barrett‟s esophagitis (10% premalignant) 2. Caustic Injury  Acids – coagulation necrosis, not ongoing  Alkali – liquefaction necrosis, ongoing (worse)  Clinical findings inconsistent with esophageal findings  All 2nd and 3rd degree burns symptomatic  Dx: endoscopy  Treatment water/milk controversial - no neutralizers (generate heat - exothermic reaction)  Complications – early => airway compromise - late => stricture, perforation PaACEP/CME/WB/GI final GASTROINTESTINAL Steven J. Parillo, DO, FACOEP, FACEP 1.1.4. Infectious Disorders 1. Herpetic / monilial / TB esophagitis:  Immunocompromised / suppressed patients - systemic diseases, steroids, antibiotics  Organisms – monilia (most common), herpes, CMV  Primary symptom – dysphagia  *High risk for perforation  Dx: indirect evidence on exam of mouth 4 1.2. LIVER 1.2.1 Hepatitis – constellation of: malaise, nausea, weakness, fever, anorexia, jaundice, RUQ pain, pruritus, dark urine, elevated SGOT (AST), SGPT (ALT), bili, PT 1. Viral a) Hepatitis A  RNA virus  Fecal/oral transmission; shellfish  Incubation 15-45 days  Children and young adults  Benign and self-limiting  Dx: anti HepA antigen (IgM) b) Hepatitis B  DNA virus (inner core HBcAg; outer coat HbsAg)  Blood, sweat, tears, breast milk, semen  300,000 cases/year; 12,000 in health care workers, most asymptomatic  Incubation 70-160 days  All age groups – percutaneous, parenteral, sexual  Hep B Markers:  HBsAg – active infection  HBAb – protective; develops after HBsAg resolves  E antigen – peak viral replication; pt highly infectious  Risk of transmission after needle stick:  2% if E Ag negative  *40% if E Ag positive  Chronic hepatitis 5-10%  Cirrhosis, death, cancer possible  Chronic carrier state 1%  Fulminant hepatic failure 1% (80% mortality)  Vaccine now recommended for all pediatric patients  *Protection 100% after recombinant vaccine if Ab reaches 10; boosters not required  Needle stick exposure – send HBAb (pt), hep profile on source PaACEP/CME/WB/GI final GASTROINTESTINAL Steven J. Parillo, DO, FACOEP, FACEP 5 c) Hepatitis C  4 million Americans infected; 40% unaware  RNA virus  Parenteral, sexual, perinatal spread  Major cause of post-transfusion hepatitis in past  Currently, risk after transfusion 1/60,000 – 200,000 (numbers changing)  Incubation 15-150 days  Milder symptoms, less severe than Hep B  Dx: antiHCV  *85% - chronic hepatitis  60-70% - elevated LFTs  10-20% cirrhosis, small number cancer  No vaccine or post exposure prophylaxis  *Interferon may help if used very early d) Hepatitis D  Virus replicated only in presence of HBV  Virus cleared if HBV cleared e) Hepatitis E  RNA virus  Similar presentation to Hep A, but more fulminant failure and death 2. Drug and Toxin a) Direct hepatotoxins - carbon tetrachloride, tannic acid, mushrooms (Amanita species) b) Toxic drug metabolites - Acetaminophen, INH c) Hypersensitivity with cholestasis - chlorpromazine, erythromycin estolate, chorpropamide, nitrofurantoin, methyltestosterone d) Hypersensitivity with necrosis - halothane, alphamethyldopa, oxacillin, phenytoin, allopurinol Alcoholic - Hepatitis develops in ~10% of all alcoholics - *SGOT (AST) higher than SGPT (ALT) - characteristic Post –exposure Prophylaxis a) Hep A: IG within 14 days exposure b) Hep B: Source unknown: Unvaccinated – single dose HBIG, initiate series Vaccinated – check titers Source known HbsAg positive: Unvaccinated – HBIG and initiate series Vaccinated – check titers, may need HBIG also 3. 4. PaACEP/CME/WB/GI final GASTROINTESTINAL Steven J. Parillo, DO, FACOEP, FACEP 5. 6 *Admission Criteria: Encephalopathy, PT > 3 seconds, dehydration, hypoglycemia, bilirubin > 20 mg/dl, age > 45 years, immunosuppression, uncertain diagnosis 1.2.2. Cirrhosis  Alcoholic – develops in ~10% of all alcoholics - continuous, low-grade fever; ascites, edema, jaundice - spider angiomata, palmar erythema, gynecomastia - Labs: anemia, leukopenia, thrombocytopenia, hypokalemia, hyponatremia, hypoxia, increased bilirubin, PT, alk phos, decreased albumin 1.2.3 Hepatic Failure / Portosystemic encephalopathy  *mental status change secondary to accumulation of toxins (esp. ammonia)  Precipitating factors: dehydration, infection, azotemia, GI bleeding, high protein diet, use of sedatives/analgesics  *Clinical findings: altered mental status, fetor hepaticus, asterixis  Differential dx: hypoglycemia  Treatment: a. maintain perfusion b. treat precipitating problems c. decrease ammonia levels – colonic cleansing enemas, neomycin, lactulose; decrease protein, avoid sedatives and bicarbonate d. flumazenil Hepatorenal syndrome – Acute renal failure in cirrhotic patient with histologcally normal kidneys. This syndrome occasionally occurs in hepatic failure patients. 1.3 GALL BLADDER AND BILIARY TRACT 1.3.1 Cholecystitis *White women, > age 50 *Most common cause of abdominal pain in the elderly *Most common surgical emergency in the elderly 1. Calculous a. *85-90% cholecystitis b. Obstruction of bladder neck or cystic duct (cholelithiais) with inflammation (cholecystitis) c. E.Coli, Klebsiella, Enterobacter, Grp D Strep, Proteus, Staph d. Epigastric or RUQ pain usually after fatty meals (2/3) radiating to back and scapula; pain colicky at first (obstruction), later becomes constant (inflammation), vomiting, fever, dark urine 2. Acalculous a. 5-10% cholecystitis, more rapid course b. Sepsis, trauma, burns, post-op, narcotics, postpartum c. Diabetics, the elderly d. Gangrene and perforation more likely e. Patients more ill, greater morbidity PaACEP/CME/WB/GI final GASTROINTESTINAL Steven J. Parillo, DO, FACOEP, FACEP 3. Cholecystitis - Clinical Features  History of fatty food intolerance is non-specific but helpful.  Epigastric or RUQ tenderness; mass with peritoneal signs.  Murphy‟s sign very sensitive; sonographic Murphy‟s  Perforation: diabetics, elderly, cardiac patients  Chemical and bacterial, 40% no stones 4. Labs: elevated bilirubin, amylase (with and without pancreatitis), SGOT, SGPT, alk phos Diagnosis: a. 7 5. b. c. d. Ultrasound – 90% sensitive (GB or CBD); stones, GB size and wall thickening (>5 mm), bile duct diameter; pericholecystic abscess HIDA / DISIDA scans – 100% sensitive; isotope collects in liver and flows into GB; + scan = nonvisualization of GB; HIDA okay if bilirubin < 5; DISIDA should be ordered for bilirubin up to 20. CT – good definition, not as sensitive as U/S, expensive; MR cholangiogram Endoscopic retrograde cholangiopancreatography (ERCP) – usually not indicated IV fluids, correct electrolyte imbalance NG suction for protracted vomiting Analgesia – meperidine, ketorolac Antispasmodics - glycopyrrolate Antibiotics ? if suppurative (prolonged, severe illness) Surgery 6. Tx: a. b. c. d. e. f. 1.3.2 Cholangitis 1. Charcot‟s triad  high fever, shaking chills, jaundice 2. Associated with choledocholithiasis 3. Majority bacterial; viral causes include hep A, B, C, E, HIV, herpes 4. Surgical emergency (ERCP, percutaneous, surgical) 5. ED treatment as in cholecystitis + antibiotics Cholelithiasis and Choledocholithiasis – Biliary colic 1. Most gallstones are cholesterol (12-25% radiopaque) 2. Risk Factors: obesity, estrogen use, ileal resection, cystic fibrosis, clofibrate therapy 3. Cholelithiasis – obstruction of gall bladder neck or cystic duct 4. Choledocholithiasis – obstruction of common bile duct 5. Dx: Bilirubin, alk phos, SGOT (AST), amylase Plain abdominal radiographs – radiopaque stones Ultrasound, CT 6. Tx: Analgesics, surgical referral 1.3.4 PaACEP/CME/WB/GI final GASTROINTESTINAL Steven J. Parillo, DO, FACOEP, FACEP 1.3.5. Gallstone Ileus 1. Elderly women with associated diseases (DM, CV) 2. Stone migrates down CBD, enters GI tract via cholecystoenteric fistula => cholecystitis, empyema, perforation 3. Vomiting, cramps, distention, obstipation 4. Pre-op diagnosis correct 15-30% 8 1.4 PANCREAS 1.4.1. Inflammatory 1. Acute Pancreatitis a. - 200K admissions / year; 5-10% mortality. - severe epigastric pain, sudden onset, radiates to back, worse recumbent, nausea, vomiting - 80-85% interstitial / edematous (0-5% mortality) - 15-20% severe acute pancreatitis (SAP) (aka hemorrhagic / necrotic) (35-50% mortality) - periumbilical ecchymosis (Cullen‟s sign) - flank ecchymosis (Grey Turner‟s sign) - dehydration may progress to shock - carpopedal spasm from hypocalcemia - left-sided pleural effusion b. Etiologies: - *alcohol most common, biliary tract disease in nonalcoholics - drugs: steroids, indomethacin, ASA, INH, cimetidine, thiazides, antibiotics, metronidazole, anti-AIDS drugs - hyperlipidemia, hypercalcemia, DKA, uremia - infections: mumps, hepatitis, mono, coxsackie, hemolytic strep, Salmonella, C. albicans - vasculitis (lupus, polyarteritis) c. Ransom‟s Criteria (for prognosis) On Admission Age > 55 Blood sugar > 200 White count > 16,000 ALT > 250 LDH > 350 48 Hours HCT falling > 10% Rise in BUN > 5mg.dl Ca ++ < 8mg/dl PO 2 < 60 Base deficit > 4meq/L Rapid fluid sequestration > 6L PaACEP/CME/WB/GI final GASTROINTESTINAL Steven J. Parillo, DO, FACOEP, FACEP 9 Number of Factors 1 –2 3–4 d. a 5-6 s Mortality 1% 15% 40% 100% 7 or more 2. d. D i Diagnosis: Physical exam insensitive; lipase – fairly diagnostic, more specific (? sensitive) than amylase; degree of enzyme elevation does not correlate with severity; other markers not practical. e. Radiographs - plain film may show calcifications, sentinel loop (small bowel air over pancreas), colon cutoff (dilation over pancreas) e. CT scan with contrast – insensitive in early or mild cases Recommendation – Sick patient, high Ransom – get CT. If CT shows necrosis, begin imipenem (see below) g. Tx: - Analgesia – narcotics; antiemetics - Calcium/insulin - Blood replacement as needed - No antibiotics except when SAP is suspected; one study suggested improved outcome with imipenem. No other antibiotic has been studied. - NG only in vomiting patients Pseudocyst / Abscess - Associated with chronic pancreatitis (5-25%) - Take 6-8 weeks to develop after acute episode - Persistent pain, fever, ileus, palpable mass 2-3 weeks after acute episode - Dx: CT/Echo 1.4.2 Tumors 1. Islet Cell Tumors – insulinoma - Women ages 40-70 - 80% - small, single, nonmalignant; 10% metastatic malignant, 10% multiple tumors - Sx: hypoglycemia = confusion, sweating, palpitations, diplopia, coma, seizure - Often mistaken for neurologic or psychiatric disorders - Differential Dx: insulin self-administration 2. Carcinoma - presentation – painless jaundice - common adult malignancy - high mortality PaACEP/CME/WB/GI final GASTROINTESTINAL Steven J. Parillo, DO, FACOEP, FACEP 10 1.5 STOMACH 1.5.2. Inflammatory Disorders 1. Acute Gastritis – acute / chronic inflammation of gastric mucosa a. Stress related causes: (within hours) CNS tumors, head trauma, fractures, burns, sepsis, shock b. Corrosive c. Drug-induced: ASA, steroids, alcohol, NSAIDs d. Features:  Ulcers are superficial; body or fundus  Common cause of GI bleeding (most common presentation)  Symptom – burning pain that worsens with eating  Nausea, vomiting, pain common e. Dx: endoscopy e. Rx: - medical – antacids, H2 blockers, NG suction/lavage - surgery - rarely indicated 1.5.3. Peptic Ulcer Disease 1. Duodenal (80%) and Gastric (20%) Ulcers a. Infection with Helicobacter pylori (present in 95% of duodenal, 80% of gastric) b. Effect of NSAIDs or ASA st c. Sites: lesser curvature of stomach, 1 part duodenum d. Burning, epigastric pain boring posteriorly - Gastric – immediately after eating - Duodenal – between meals, at night e. Dx: endoscopy, UGI; several tests available to confirm presence of H. pylori f. Tx: - antibiotics for H. pylori - H2 antagonists (cimetidine, ranitidine, famotidine) - Dietary management - Sucralfate - Antacids - Proton pump inhibitors (omeprazole) e. Complications  intractable pain – noncompliance  hemorrhage – see UGI bleed section  obstruction – healing by scarring, pylorus  perforation - pain sudden, severe, chemical peritonitis, benign > malignant, minimal bleeding  Posterior – into pancreas, pain radiates to back  Anterior – into peritoneal cavity  *The usual sudden onset of severe epigastric pain is present in only one-half of elderly patients with perforated ulcer. PaACEP/CME/WB/GI final GASTROINTESTINAL Steven J. Parillo, DO, FACOEP, FACEP 2. 11 Acute Gastrointestinal Hemorrhage (UGI bleeding) a. Incidence 100/100,000; mortality rises with age b. 300-350K admissions / yr, mortality 6-10% c. Etiology  *Duodenal ulcer most common cause (45-50%)  Gastric ulcer (10-15%)  Erosive gastritis, esophagitis, duodenitis (20%)  Esophageal varices (6-18%)  Mallory-Weiss tears (1-10%)  Esophagitis (1-10%)  Aortoenteric fistula - erosion of synthetic vascular graft into intestine d. Hx: misleading 25-30% (i.e. varices) e. Dx: Vomitus  Hematemesis = gross or swallowed blood; UGI proximal to ligament of Treitz; may not see if distal duodenal bleeding Stool  Hematochezia = dark, red, or maroon indicative of large upper GI bleed (4 hrs transit time) DDx: ingestion of beets  Melena = black, malodorous; 100-500 cc blood required (8 hrs transit time) *DDx: iron, bismuth, charcoal, dyes, swallowed blood  NG tube – “standard of care” but literature does not show clear value with obvious hematmesis.  *Endoscopy: 85-90% diagnostic, banding and sclerosing therapeutic for varices (*banding better – fewer complications)  Angiography: 0.5-2cc/min needed for dx; also therapeutic (octreotide, somatostatin for gastritis, stress ulcers, varices) f.   Tx ABCs, oxygen, T & C NG tube/lavage with saline or tap water; No ice water!  *Removing blood traditionally thought to be helpful, but literature does not bear this out.  *Diagnostic use of NG aspirate in patients without frank hematemesis has very low sensitivity (42%) and low NPV (64%).  *20% of patients with documented UGI bleed have a negative NG aspirate.  Why do this???? PaACEP/CME/WB/GI final GASTROINTESTINAL Steven J. Parillo, DO, FACOEP, FACEP  12         Octreotide now used as the primary agent (vasopressin of historical interest only) if known or suspected variceal bleeding, but also decreases rate of rebleeding in peptic ulcers.  Controls variceal wall tension.  50mcg bolus, 50mcg/hr infusion  Stops 70-80% of all variceal bleeding (decreases portal pressure) IV pantoprozole (Protonix) if bleeding of ulcer origin but also in variceal bleeding since source usually not known.  80mg bolus, 8mg/hr infusion for 3 days H2 blockers have not been shown to help in non-variceal bleeding. Consider FFP (2 units or 10-15cc/kg) *IV eythromycin (3mg/kg) is prokinetic and has been shown to be helpful in clearing stomach of blood and secretions. Consider platelets Surgery: relentless bleeding (i.e. 48 hrs continuous, 1500cc blood replacement 24 hrs, recurrent), obstruction, perforation Interventional radiology – TIPS (transjugular intrahepatic portalsystemic shunt) Linton tube: unresponsive varices - buys time, ALWAYS rebleed after tube is decompressed. (SB historical, may use Minnesota tube)  Complications: esophageal rupture, aspiration, asphyxiation 1.6. SMALL BOWEL 1.6.1. Motor Abnormalities 1. Obstruction / pseudo-obstruction (SBO) a. *most common cause adhesions, then *hernias/malignancies; *most common cause in children – congenital bowel wall lesions b. intermittent severe colicky pain at regular intervals; more vomiting, less distention than LBO; diarrhea c. signs of peritoneal irritation suggest vascular compromise d. Radiographs: dilated loops of small bowel, upright/decub airfluid levels, “string of beads” appearance; haustra across entire bowel width e. Tx: fluids, NG, electrolyte correction, surgery consult 1.6.2. Structural Disorders 1. Meckel‟s Diverticulum a. Causes bleeding, peritonitis, intussusception, obstruction b Gastric mucosa in diverticulum may bleed/perforate d. DDx: appendicitis PaACEP/CME/WB/GI final GASTROINTESTINAL Steven J. Parillo, DO, FACOEP, FACEP 1.6.3. 13 Inflammatory Disorders 1. Acute Appendicitis: a. Luminal obstruction leads to infection b. Typical – periumbilical to RLQ pain (McBurney‟s) anorexia, N/V/D, constipation, fever c. Flank pain – retrocecal , gravid uterus d. Testicular pain – retroileal e. Rosving‟s sign = RLQ pain with LLQ palpation f. Psoas sign = RLQ pain with thigh extension lying on left side g. Obturator sign = RLQ pain with internal rotation flexed right thigh h. Atypical – elderly, very young, pregnant i. Mortality – early (0.5%); after perforation (5%, elderly 15%) j. Perforations 50% in children, extreme ages more common Diagnosis a. early surgical consultation essential for lowest morbidity b. imaging studies:  KUB – appendicolith 1%  Ultrasound – dilated, non-compressible appendix (not as good as once believed)  CT scan – best overall test for abdominal pain; rectal contrast for appendicitis; *may be false negative c. Labs - increased WBCs in 75%; other tests to r/o other diseases, UA, preg test Differential Dx: PID, ovarian cyst, ectopic pregnancy, mesenteric adenitis, gastroenteritis, regional enteritis 2. Regional enteritis / Crohn‟s Disease: a. Granulomatous inflammatory process affecting all layers of GI tract; can involve any part of GI tract from mouth to anus. b. All ages, but mostly < age 25, Jewish descent c. Characterized by “skip lesions” of normal bowel d. Possible Etiologies – environmental, genetic (FH positive in 1015%), infectious, immune (note incidence of extraintestinal manifestations) e. Chronic, recurrent non-bloody diarrhea, cramps, fever, anorexia f. Rectum not commonly involved g. Perianal fistulas, abscesses common h. Dx: UGI (best when ileum is involved), air-contrast BE, sigmoidoscopy with biopsy, colonoscopy (best test for colon involvement) i. Systemic Complications:  Musculoskeletal: arthralgias, arthritis most common  Skin: erythema nodosum, pyoderma gangrenosum, stomatitis  Hepatobiliary: fatty liver, hepatitis, cholelithiasis, cholangitis  Pancreatic: pancreatitis or painless amylase elevation  Eye: uveitis, iritis, episcleritis  Venous thrombosis/thromobembolism PaACEP/CME/WB/GI final GASTROINTESTINAL Steven J. Parillo, DO, FACOEP, FACEP 3. Perforation – peritonitis  Jejunal = chemical from pancreatic enzyme spillage  Ileal = bacterial 1.6.6. 14 Vascular Disorders 1. Mesenteric Ischemia a. Classic triad - abdominal pain (out of proportion to physical findings), digitalis use, atrial fibrillation b. Elderly, heart disease (CHF), hypercoagulable states c. Etiology:  Arterial – occlusive; thrombotic / embolic  Arterial – nonocclusive (low-flow state)  Venous – mesenteric venous thrombosis (MVT) Digitalis as direct vasoconstrictor may be causative. d. High mortality – hypovolemia, systemic toxicity e. Distinctions among the types:  Embolic most abrupt in onset, MVT most indolent  Nonocclusive – low flow state (CHF, hypovolemia); may respond to improvement in hemodynamic status  MVT occurs in younger patients; CT good test; lower mortality; tx – anticoagulation  Angiography with papaverine may be helpful if splanchnic vasoconstriction is present. f. Risk Factors  SMA embolus– a-fib, recent MI  SMA thrombus – atherosclerosis, low-flow states  Nonocclusive infarction – low-flow states (CHF), digitalis use  MVT – hypercoagulable state; prior DVT, liver disease g. Sudden (if embolic), severe pain, N/V, occult bleeding, peritonitis, flank mottling h. Dx: CBC, electrolytes (metabolic acidosis), phos, amylase - Plain films – thickened bowel wall with air - Angiography – best overall study - CT scan – especially for MVT i. Tx: fluids, blood, antibiotics, NG tube, surgery consult, anticoagulants Ischemic Colitis a. Disease of older patients b. Majority (80%) have diffuse abdominal pain; many have diarrhea with or without blood c. Small vessel disease, angiography normal d. Presentation depends on degree of ischemia from mild to severe e. Bowel necrosis causes peritonitis 2. PaACEP/CME/WB/GI final GASTROINTESTINAL Steven J. Parillo, DO, FACOEP, FACEP 15 1.7. LARGE BOWEL 1.7.1. Motor Abnormalities 1. Irritable Bowel 2. Constipation 3. Aganglionic Megacolon/Hirschsprung‟s – pediatrics 4. Obstruction (LBO) a. *most common cause tumors (65%), then diverticulitis (15%) and volvulus (15%) *most common cause in children - intussusception b. pain diffuse, poorly localized, crampy or colicky c. obstruction series (still the best initial test) - colonic distension, haustra not across entire bowel width d. CT reportedly more sensitive, especially early 5. Pseudo-obstruction (Ogilvie‟s Syndrome) a. May mimic LBO b. Low colon most common site of involvement c. Film – dilated colon d. Common for patients to be using anti-motility drugs, tricyclic antidepressants. e. Colonoscopy is diagnostic and therapeutic f. Surgery not indicated 1.7.2. Structural Disorders 1. Diverticular Disease - Diverticulosis / Diverticulitis a. Predominantly a disease of the elderly, but increasingly reported in younger patients and women (10% of 40 year olds) b. *LLQ abdominal pain, alternating diarrhea and constipation c. Diverticulosis – false diverticulum (not all layers of bowel wall); mostly in sigmoid, greatest intraluminal pressure * Most common cause of massive LGI bleeding in elderly d. Diverticulitis – acute inflammatory process caused by bacterial proliferation within a diverticulum - perforation of diverticuli, local peritonitis - fever and leukocytosis; urinary symptoms - perforation, with diffuse peritonitis, rare - abscess and LBO may occur (common cause of LBO) - think about underlying cancer e. Painful diverticular disease – relatively mild pain in someone with known or suspected diverticulosis; no severe signs f. Complications of diverticular disease  bleeding  perforation – micro vs. major, abscess formation  obstruction  inflammation PaACEP/CME/WB/GI final GASTROINTESTINAL Steven J. Parillo, DO, FACOEP, FACEP g. 16 h. Dx:  Films: free air if perforation  BE: for diverticulosis, not if inflammation suspected  Angiography: may localize bleeding  Colonoscopy: good diagnostic tool  CT: best overall study Tx: Diverticulosis  High fiber diet  Analgesics – meperidine (morphine, codeine increase intraluminal pressure) Diverticulitis – above plus:  Antibiotics (coliforms, strep, clostridia, anaerobic)  IV, NG, Surgical consultation - drainage 2. Volvulus a. b. c. *Sigmoid 80-85% - elderly, debilitated - Tx: Sigmoidoscopy *Cecal 15-20% - younger (ages 35-55) - Dx: radiographs – distended loop in left, with tapered end; diameter > 8 cm likely to perforate (Current literature questions this). - Tx: Surgery *3rd most common cause of LBO after cancer and diverticulitis. 3. Lower Gastrointestinal (LGI) Bleeding a. Rule out UGI bleeding (“most common cause „LGI‟ bleeding”) with H&P, NG tube if uncertain (*Remember limitations of NG aspirate.) b. Rule out hemorrhoids (most common cause of rectal bleeding) c. Mortality 3-4%; 80% stop spontaneously; 10% require transfusion d. Causes: “Most common cause LGI bleeding is UGI bleeding” – technically not true  Carcinoma, left colon (33%) – age > 40 Most common overall cause bleeding in adults  Diverticulosis (25%) – age > 50, bleeding may be sudden, severe (arterial), often asymptomatic; most common cause of massive LGI bleeding in the elderly.  Angiodysplasia, right colon (25%) – age > 50, painless bleeding, hypertension, aortic stenosis  Inflammatory bowel disease (15%) – age 20-40, bloody diarrhea, weight loss, tenesmus *Most common overall cause of LGI bleeding in young patients  Polyps (10%) – any age, diarrhea, cramps, + FH *Most common overall cause of LGI bleeding in children; *Intussusception next most common cause PaACEP/CME/WB/GI final GASTROINTESTINAL Steven J. Parillo, DO, FACOEP, FACEP Carcinoma, right colon (5%) – age > 40 Painless, occult bleeding, dull RLQ pain  Others: Meckel‟s diverticulum, ischemic bowel, infectious colitis, radiation colitis, Henoch-Schoenlein Purpura, vascular e. Dx: Colonoscopy – Diagnostic accuracy better than angio. Tagged red cell radionuclide – 0.1-0.5cc.min; more senstive than angio, but does not give specific localization Angiography – 100% specific but only 30% sensitive; requires 1-1.5cc/minute bleeding; good localization; allows for embolization or coil therapy Surgery consultation f. Tx: Most patients are hemodynamically stable. Definitive treatment after diagnosis established. 1.7.3. Inflammatory Disorders 1. Ulcerative Colitis a. Age 30-50, white, Jewish descent b. *Continuous (no “skip areas”) mucosal inflammatory and ulcerative disease of colon and rectum c. Increased colon cancer risk d. *Rectum almost always involved; may be only area of involvement e. Bloody diarrhea, crampy abdominal pain, fever, tenesmus f. *Complication = Toxic Megacolon - transverse colon > 8 cm; st typically occurs after BE for 1 episode; patient is toxic g. Dx: sigmoidoscopy with biopsy, stool cultures to R/O invasive infection; avoid barium enema h. Tx: fluids, antibiotics, steroids 2. Radiation Colitis a. diarrhea during irradiation, stops at end of treatment b. persistent diarrhea suggests permanent bowel damage c. rectal bleeding d. stricture if rectal or distal colon obstruction e. complications: rectal/sigmoid stricture in 1-2 yrs f. Tx: anti-motility drugs, steroid enemas, iron/transfusions 3. Perforation – common causes: a. Diverticulitis (cecum) - most common site b. Cancer, colitis, foreign body, instrumentation c. Peritonitis is bacterial d. Signs and symptoms are septic  17 PaACEP/CME/WB/GI final GASTROINTESTINAL Steven J. Parillo, DO, FACOEP, FACEP 1.7.4. 18 Infectious (Diarrheal) Disorders 1. Bacterial a. Invasive = bloody, WBCs, gradually ill Tx: typically, antibiotics given ONLY if patient does not improve or if C & S is positive for an organism known to respond.  Shigella – very contagious, high fever - *most common cause of bloody diarrhea - *children – seizures, neuro findings - Tx: - Cipro, other quinolones - Amp or Bactrim (children empiric)  Salmonella – common, age < 9, summer - Loose, watery, mucous - 10-15% cause of food poisoning - Pet turtles, cats, dogs, poultry, eggs, - Susceptible: IVDA (IDU), AIDS, SSA, splenectomy osteomyelitis - *Typhoid Fever – high fever with bradycardia - *Enteric Fever – fever, pain, rose spots, meningismus, cramps - Tx: No antibiotics (prolongs carrier state) UNLESS… - Protracted clinical course - Culture-proven bacteremia - Enteric fever - Disseminated disease - Serious infection risk  Campylobacter – *most common bacterial cause - All ages, esp young children, summer - Poultry, raw milk, domestic animals - Rapid onset, loose, watery, (bloody 50%) Persistent diarrhea - Tx: Culture-proven with severe illness Not if pt is clinically improving Erythromycin x 7 days (children), Cipro 1-3 days  Vibrio parahemolyticus – gram negative - coastal sea waters, cruise ships, oysters, clams, shrimp - 2-12 hr onset - Tx: No antibiotics  Yersinia – gram negative, children - Contaminated food/drink - Prolonged abdominal pain, fever - Terminal ileus, mesenteric lymph nodes - Pseudoappendicitis – RLQ pain - Tx: Usually no antibiotics, Cipro if severe PaACEP/CME/WB/GI final GASTROINTESTINAL Steven J. Parillo, DO, FACOEP, FACEP b. 19 Preformed toxin = No WBCs in stool - No antibiotics  Staph food poisoning - most common cause - Ham, eggs, mayonnaise, potato salad - 1-2 hrs explosive onset, resolves 6-8 (24) hrs - Crampy abd pain, violent vomiting, afebrile  Bacillus cereus: gram positive rod - Emetic syndrome – staph-like enteritis - Fried rice - 2-3 hrs onset, resolves 6-14 hr - vomiting, cramps - Diarrhea syndrome – Clostridium-like picture - Meats, vegetables - 6-14 hr onset, resolves 20-36 hrs - diarrhea 100%, cramps, vomiting  Scombroid poisoning – mahi mahi, tuna, mackerel (dark meat fish) - Bacterial toxin causes histamine release – - facial flushing, diarrhea, cramps, palpitations, headache - DDx: allergic reaction - Tx: antihistamines - *Pearl – “allergic rxn” + cramps = scombroid  Ciguatera fish poisoning – grouper/snapper/kingfish 2-30 hrs onset, spring, summer - N/V, neuro symptoms – myalgias, perioral paresthesias, burning hands/feet - itching 2-3 days later, illness self-limiting - Tx: supportive, no specific treatment Toxins after colonization = No WBCs in stool  Clostridium perfringens – - food poisoning common cause (25%) - meats, poultry - 6-12 hr onset - watery diarrhea, cramps - fever, vomiting - *Necrotizing enteritis – rare form: shock; diffuse, hemorrhagic - Tx: No antibiotics (*Necrotizing form – antitoxin)  Vibrio cholera – rare in U.S.A. - symptoms 48 hrs after shellfish ingestion - “Rice-water stools,” watery diarrhea, dehydration, acidosis, hypokalemia - Tx: Fluids - WHO rehydration formula (primary therapy), tetracycline c. PaACEP/CME/WB/GI final GASTROINTESTINAL Steven J. Parillo, DO, FACOEP, FACEP  20 d. e. E. coli – major cause of diarrhea in world - 40-60% travelers - (+/-) unpeeled fruits, vegetables, unsanitary water, ice - Frequent, watery diarrhea - Tx: - antimotiles – effective but “dangerous” - Pepto Bismol – decreases fluid & electrolyte secretion - Fluids – primary therapy - TMP/SMX, doxycycline (with loperamide) - Prophylaxis: doxy, bactrim, cipro  Enterohemorrhagic E. coli - Poorly cooked meat (hamburger), raw milk - Abrupt onset, cramps, copious, watery, then bloody stools - Complications: HUS, TTP - Tx: Fluids; monitor coagulation / renal status Viral – most common cause of diarrhea - Rotavirus, enterovirus, Norwalk agent - Fecal-oral transmission, self-limiting - No WBCs, blood - Tx: Fluids, supportive, anti-motility agents Parasitic - General  Entamoeba histolytica (amebiasis): - fecal-oral, male homosexuals - most frequently asymptomatic - sudden or delayed onset, intermittent blood-streaked diarrhea - Complications: hepatic abscess, ameboma - Dx: - no WBCs - stool ova and parasites - Tx: Metronidazole  Giardiasis: *most common intestinal protozoa in U.S.A. - Fecal-oral, child > adult, backpackers, male homosexuals -Abdominal distension, bloating, flatulence, frequent, explosive, intermittent, malodorous, loose stools - Dx: Hx travel, cyst in feces, duodenal aspirate, jejunal biopsy - Tx: Metronidazole (carriers, too); Check sex partners g. AIDS related parasitic infections - Do not treat empirically.  Cryptosporidiosis - *most common cause - persistent diarrhea in AIDS patient; children, immunocompromised also - sustained, profuse diarrhea, abdominal pain - non-invasive in intestines, also occurs in lungs, gallbladder (biliary obstruction) - Dx: cyst in stool (O & P) - Tx: Fluids, bowel motility agents Antibiotics ?? PaACEP/CME/WB/GI final GASTROINTESTINAL Steven J. Parillo, DO, FACOEP, FACEP h. 21 Antibiotic-associated (pseudomembranous colitis) - Clostridium difficile necrolytic toxin - Most antibiotics esp amp/amoxicillin, cephalosporins, clindamycin, quinolones. (TCN, macrolides, sulfas have also been reported). - Antibiotics which have not been implicated include aminoglycosides, metronidazole, bacitracin and vancomycin. - Profuse, watery diarrhea 7-10 days after antibiotics - “pseudomembranous colitis” – yellow plaques heme positive stools - Dx: sigmoidoscopy, culture C. diff, toxin in stool - Tx: - Discontinue all antibiotics - vancomycin, metronidazole, cholestyramine (binds toxin), no anti-diarrheals 1.8. RECTUM AND ANUS 1.8.1. Structural Disorders 1. Anal Fissure – painful defecation - 90% posterior midline, assoc. with “sentinel pile” - sitz baths - topical nitro ointment - analgesic and lubricating ointments and suppositories - bulk laxatives 2. Anorectal Fistula – association with Crohn‟s - tract connects anal canal with skin - usually from perianal/ischiorectal abscess 3. Hemorrhoids – most common cause of rectal bleeding; these are not varicosities but normal veins that have lost supporting cushions. a. Internal - painless, mucosal surface - if prolapsed and irreducible, needs surgery b. External – painful, skin surface - may incise if thrombosed - sitz baths - stool softeners/laxatives - lubricating suppositories 4. Rectal Prolapse 5. Foreign Body 6. Perirectal/perianal Abscess – painful, may lead to fistulas - may form in any potential space - Tx: surgical I & D, OR drainage for diabetics 7. Pilonidal Abscess – acquired, not congenital - occurs at apex of natal cleft - ED Tx = I & D - Needs eventual surgical excision 1.8.2. Inflammatory Disorders - proctitis PaACEP/CME/WB/GI final GASTROINTESTINAL Steven J. Parillo, DO, FACOEP, FACEP 1.9. ABDOMINAL WALL 1.9.1. Hernias 1. Incarcerated – irreducible with simple manipulation 2. Strangulated – irreducible with vascular compromise 3. Inguinal – most common a. Indirect – most common in men, through inguinal canal, incarceration common b. Direct – through Hesselbach‟s triangle (not inguinal canal), incarceration uncommon 4. Femoral – most common in women, below inguinal ligament into femoral canal; may incarcerate or strangulate 5. Umbilical – through defect, may incarcerate, blacks, females 6. Most clinically asymptomatic, “lump” Incarceration – acute pain or obstruction Strangulation – toxic appearance, obstruction 7. Tx: Reduction after sedation if incarceration of short duration and strangulation not suspected (Trendelenburg position) Surgical consultation PERITONEUM 1.10.2 Spontaneous Bacterial Peritonitis  Portal hypertension leading to bowel edema  Cirrhosis, ascites, pain, fever, sepsis  Occurs in 20-30% of all acsitic patients  Mortality 20-40%  E.coli 50%, Enterococcus 25%  Incidence of gram (+) infection increasing  Risk factors – fever, new ascites, mental status change, leukocytosis  Risk factors – GI hemorrhage, UTI, worsening renal function  Dx: paracentesis, increased WBC (ANC >250), gram stain, culture  *Paracentesis safe in presence of coagulopathy  Tx: Antibiotics – cefotaxime, Timentin, Zosyn, Unasyn  10% resistance to quinolones 22 1.10 Revised 10/15/06 Parrills/lectures: PACEP-GI2006 PaACEP/CME/WB/GI final