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Gastrointestinal Emergencies

Gastrointestinal Emergencies. Topics. Acute appendicitis Acute pancreatitis Diverticulitis Instestinal obstruction Upper/lower GI bleeding/hemorrhoids Gastroenteritis Cholelithiasis/cholecystitis/cholangitis Hepatitis (alcoholic and viral) Booerhave’s syndrome. ABDOMINAL PAIN.

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Gastrointestinal Emergencies

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  1. Gastrointestinal Emergencies

  2. Topics • Acute appendicitis • Acute pancreatitis • Diverticulitis • Instestinal obstruction • Upper/lower GI bleeding/hemorrhoids • Gastroenteritis • Cholelithiasis/cholecystitis/cholangitis • Hepatitis (alcoholic and viral) • Booerhave’s syndrome

  3. ABDOMINAL PAIN Acute abdominal pain accounts for 5% of all ED visits. • Three categories • Intra-abdominal • 3G’s • GI. • GU. • GYN. • Vascular emergencies. • Extra-abdominal • Cardiopulmonary • Abdominal wall. • Toxic-metabolic • Neurogenic • Undifferentiated

  4. ABDOMINAL PAIN Common Causes of Abdominal Pain in the ED for All Age Groups Cause Percentage Abdominal pain of unknown cause 41.3 Gastroenteritis 6.9 Pelvic inflammatory disease 6.7 Urinary tract infection 5.2 Ureteral stone 4.3 Appendicitis 4.3 Acute cholecystitis 2.5 Intestinal obstruction 2.5 Constipation 2.3 Duodenal ulcer 2.0 Other causes 22.0 From Brewer RJ et al: Am J Surg 131:219, 1976.

  5. ABDOMINAL PAIN Causes of Abdominal Pain in Patients Over 70 Years of Age Cause Percentage Acute cholecystitis 26.0 Malignant disease 13.2 Bowel obstruction 10.7 Nonspecific abdominal pain 9.6 Gastroduodenal ulcer 8.4 Acute diverticular Dz 7.0 Incarcerated hernia 4.8 Acute pancreatitis 4.1 Acute appendicitis 3.5 Other causes 12.7

  6. ACUTE ABDOMINALPAIN

  7. ACUTE ABDOMINAL PAIN • Three categories: • Visceral • Often poorly localized. • Steady ache or dull. • Vague discomfort or gaseous. • Colicky or crampy. • Can be excruciating. • Parietal • Sharper and more localized. • Tenderness and guarding. • Rigidity and rebound. • Referred

  8. ABDOMINAL PAIN • Visceral pain • Often the earliest symptom . • Caused by inflammation, distention, or ischemia of nerve fibers innervating the walls or capsules of hollow or solid organs. • Parietal or Somatic pain • Irritation of fibers that innervate the parietal peritoneum. • Often initiated by chemical or bacterial inflammation. • Referred Pain • Any pain felt in a cutaneous site distant from a diseased organ.

  9. Pareital peritoneum • Lines internal surface of the walls of the abdomen and pelvic cavity

  10. Epigastric pain Forgut organs Stomach Duodenum Biliary tract Periumbilical pain Midgut Most of small intestines Appendix Cecum Suprapubic or hypogastric pain Hindgut organs Most of colon including sigmoid. Intra-peritoneal portions of GU system. Kidney, Ureters and Bladder. Pelvic organs. ABDOMINAL PAIN Location hypochondriac lumbar hypogastric iliac

  11. CLINICAL ASSESSMENT • History. • Onset and Duration of Pain. • Location, radiation and migration of Pain. • Quality and Severity of Pain. • Aggravating and relieving factors. • Associated Symptoms. • Past and Current Medical History. • ____________________________(very important) • Social History. • Physical Exam. • General Appearance and Vital Signs. • Inspection, Auscultation, and Percussion. • Palpation and Localization of Tenderness. • Rectal and Pelvic Examination. • Extra-abdominal Examination.

  12. Lab & imaging • White Blood Cell Count. • Urinalysis. • Electrolytes. • Renal function test. • Tests for Pregnancy. • Amylase and Lipase. • LFTs. • Plain abdominal films. • Abdominal ultrasound. • Abdominal CT scan.

  13. Appendicitis

  14. cecum appendix

  15. Acute AppendicitisIncidence • Approximate yearly incidence of 1 per 1,000 population • Affects all ages • Highest incidence in second and third decades of life. • Slight male predominance. • Approximately 200,000 appendectomies annually in the US. • Most common surgical condition in children. • the most common surgical problem requiring emergency intervention during pregnancy. • Less than 1% mortality rate. • Mortality is higher with children <2yrs.

  16. Acute AppendicitisClinical presentation(Classic) • Abdominal pain Initially periumbilical  RLQ  Severe diffuse abdominal pain

  17. Acute AppendicitisClinical presentation(atypical) Abdominal pain • Retrocecal appendix • Back, flank, testicular pain • Pelvic appendix • Suprapubic pain • Long appendix • The inflamed tip may cause pain in RUQ or LLQ

  18. Acute AppendicitisClinical presentation • Anorexia • Fever (low grade) • Vomiting • Diarrhea (33%) • Constipation (9–33%)

  19. Acute AppendicitisClinical exam • Abdominal exam • RLQ tenderness. • McBurney's point • Guarding • Rebound • Bowel sounds • Rectal exam

  20. Acute AppendicitisClinical exam(Special tests) • Abdominal exam • Psoas sign • Obturator sign • Rovsing's sign

  21. Acute AppendicitisDDx • Adults • undiagnosable abdominal pain, diverticulitis, urinary tract infection, ileitis, cholelithiasis, pancreatitis, bowel obstruction, and gastroenteritis. • Women • abdominal pain of unknown cause, PID, ovarian cysts, endometriosis, and ectopic pregnancy. • Children, • abdominal pain of unknown cause, mesenteric adenitis, ileocolitis, Meckel’s diverticulum, testicular torsion, urinary tract infection, Henoch-Schönlein purpura, pancreatitis, and gastroenteritis. • Elderly. • gallstones, diverticulitis, and intraabdominal tumors.

  22. Acute AppendicitisLab & imaging • CBC. • Electrolytes. • Renal function test. • Urinalysis. • Urine pregnancy test (if woman of childbearing age). • Abdominal series. • RLQ ultrasound. • CT scan of abdomen and pelvis.

  23. Appendicolith

  24. Acute AppendicitisManagement • Nothing by mouth (NPO) • Saline lock (IV hydration if dehydrated) • Surgical consultation • Antibiotic • e.g., cefotetan or cefoxitin • Flagyl (or clindamycin) with ampicillin and gentamicin.

  25. Acute AppendicitisManagement High clinical probability • Surgical consultation • Antibiotic (e.g., cefotetan or cefoxitin) • Appendectomy Moderate clinical probability • Surgical consultation • Ultrasound • If positive, appendectomy • If negative, observation and serial examinations. Low clinical probability • Ultrasound if symptoms persist at time of follow-up • Surgical consultation • Follow-up in 12 to 24 hours for repeat examination, earlier if increased symptoms.

  26. Remember This  • Standard of care for acute appendicitis • Appendectomy

  27. Acute Pancreatitis

  28. Acute pancreatitis • In the U.S. Cholelithiasis or alcohol abuse accounts for 90% of all cases of acute pancreatitis

  29. Pathophysiology • The central cause is believed to be the intracellular activation of digestive enzymes and autodigestion of the pancreas • Pancreatic digestion from activated proteolytic enzymes leads to edema, interstitial hemorrhage, vascular damage, coagulation, and cellular enzymes.

  30. Pathophysiology • It can also cause a generalized systemic inflammatory response that may lead to shock, ARDS, and multisystem organ failure.

  31. Clinical features • Boring epigastric pain that radiates to the back. • Tachycardia • Nausea and vomiting • Abdominal distension • Cullen’s sign • Grey Turner’s sign • Blood loss, refractory hypotension, and respiratory failure may accompany more severe forms.

  32. Diagnosis and differential • Diagnosis is made by a suggestive history and physical exam, associated with elevated pancreatic enzymes. • Amylase greater than 3x the upper limit of normal has a specificity of 75% and a sensitivity of 80-90% • Lipase is more specific than amylase and is the preferred test. At a cutoff of 2x the upper limit of normal, lipase is 90% sensitive and specific.

  33. Diagnosis and differential • Leukocytosis may be present, and an elevated alkaline phosphatase suggests biliary disease. • Hypotension, tachycardia >130bpm, Po2<60mmhg, oliguria, increasing (BUN) or creatinine or hypocalcemia are indicators of a potentially complicated course. • Sentinel loop or colon cut-off sign suggesting ileus may be present, but are not diagnostic.

  34. Diagnosis and differential • Ultrasound is helpful in the identification of gallstones or dilatation of the biliary tree. • CT is the study of choice for visualizing the pancreas, confirmation of inflammation, and the identification of phlegmons, abscesses, or pseudocyts. It cannot be used to rule out Acute Pancreatitis.

  35. Diagnosis and differential • Endoscopic retrograde cholangiopancreatography (ECRP) can be useful the the etilology remains unclear after initial evaluation • DDX: LLL pneumonia, rupture of a pseudocyst, gallbladder disease, peritonitis, PUD, SBO, renal colic, dissecting aortic aneurysm, DKA, and gastroenteritis.

  36. Treatment • Pancreatic rest (NPO) • Fluid resuscitation with normal saline • Pain control; parenteral analgesia prn IV narcotics e.g. Morphine • Prevention of vomiting; antiemetics e.g. Promethazine IV • Pressors such as dopamine are indicated for persistent hypotension despite fluid resuscitation

  37. Treatment • O2 to maintain a pulse ox of <95% • Nasogastric tube if the patient is distended with persistent vomiting • Urgent decompression is indicated in persistent biliary obstruction • Patients with mild pancreatitis maybe managed on a outpatient basis if they are able to tolerate oral fluids and their pain is well controlled.

  38. Treatment • Patients with significant systemic complications, shock or extensive pancreatic necrosis will need to be place in an ICU setting.

  39. Diverticulitis

  40. Diverticulitis • Is caused by bacterial proliferation within an existing colonic diverticulum, leading to microperforation and inflammation or pericolonic tissue.

  41. Diverticulitis • Clinical diverticulitis occurs in 10-25% of patients with diverticulosis. • One-third of the population will have acquired the disease by age 50, and two-thirds by age 85. • Only 2-4% of patients with diverticulitis are under age 40 and tend to have a more virulent form of the disease, with frequent complications requiring earlier surgical intervention.

  42. Pathophysiology • Most commonly, clinical diverticulitis results form high colonic pressures, resulting in erosion and microperforation of the diverticular wall, leading to inflammation of pericolonic tissue.

  43. Clinical features • The most common symptom is LLQ pain. • Other symptoms include tenesmus, diarrhea or increasing constipation. • The involved diverticulum may irritate the urinary tract and cause frequency, dysuria or pyuria. • If a fistula develps between the colon and bladder patient may present with recurrent UTIs or pneumaturia

  44. Clinical features • Paralytic ileus w/abd distension. • Nausea and vomiting • Small bowel obstruction and perforation can also occur. • RLQ pain • Low-grade fever but the temperature may be higher in patients with generalized peritonitis and in those with and abscess.

  45. Clinical features • Abdominal exam reveals localized tenderness oftern w/voluntary guarding and rebound tenderness. • A fullness or mass may be appreciated over the affected area of colon. • Occult blood may be present in the stool.

  46. Diagnosis and differential • DDX: appendicitis, PUD, PID, endometriosis, ischemic colitis, aortic aneurysm, renal calculus, IBS, lactate intolerance, colon carcinoma, intestinal lymphoma, Kaposi's sarcoma, sarcoidosis, collagen vascular disease, irradiation colitis or proctosigmoiditis, fecal impaction, foreign body granuloma, and any bacterial, parasitic, or viral infectious cause.

  47. Diagnosis and differential • Routine screening blood tests, UA, and an abdominal radiographic series. • Leukocytosis is present in only 36% of patients with diverticulitis. • CT scan of the abdomen is the diagnostic procedure of choice.

  48. Treatment • If patient has systemic signs and symptoms of infection, has failed outpatient management, or demonstrates signs of peritonitis, hospitalization and surgical consultation is necessary. • Inpatient treatment consists of IV antibx, usually an aminoglycoside e.g. Gentamicin or tobramycin and either flagyl or clindamycin for aerobic and anerobic coverage.

  49. Treatment • Ticarcillin-clavulanic acid or imipenem have been used as alternative agents. • Bowel rest, NPO, IV fluids are administered. • Nasogastric suction may be indicated in patients with bowel obstruction or adynamic illeus.

  50. Treatment • Outpatient management is acceptable for patients with localized pain without signs and symptoms of local peritonitis or systemic infection. • Treatments consists of bowel rest, broad-spectrum or antibx therapy. • Ampicillin, bactrim, ciprofloxacin, or keflex. One of these meds is taken in combination with an agent with anaerobic coverage e.g. Flagyl, clindamycin

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