uppergiemergencies - Global Emergency Health Medicine
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Transcript uppergiemergencies - Global Emergency Health Medicine
Upper Gastrointestinal
Emergencies
Author: Andrew McDonald MD,
FRCP, Assistant Professor
Date Created: January 2012
Global Health Emergency Medicine Teaching Modules by GHEM is licensed under
a Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported License.
Learning Objectives
Understand the approach to GI bleeding
Understand the approach to esophageal
injuries from caustics and foreign bodies
Understand the approach to peptic ulcer
disease and gastritis
Case example
A 31 year old man is brought by his family
after vomiting black material for two days
He appears unwell and lethargic
HR 130 BP 90/50 RR 30 T 35°C
Family says he has a history of chronic
liver disease
GI bleeding – How patients present
History of vomiting blood or rectal blood
Shock +/- passing blood
Decreased LOC +/- passing blood
Challenges in these patients
Management of hypovolemic shock
Vomiting and aspiration
Hepatic encephalopathy
Coagulation disorder
Causes of Upper GI bleeding
Peptic ulcer disease
Gastritis
Varices
Mallory – Weiss tear rare
Malignancies
Causes of Lower GI bleeding
Hemorrhoids
Diverticulosis
Malignancies/polyps
Angiodysplasia (AVM) of aging
Inflammatory bowel disease
Complications of Typhoid fever
Upper GI bleeding
Bloody diarrhea
Epidemiology
Little is documented on the epidemiology of
GI bleeding in developing countries
Clinical features
Hematemesis = upper GI source
Hematochezia = lower GI source
Melena = don’t know source
Clinical features (continued)
Weight loss -- Think of malignancy
Bleeding following vomiting -- Think of
Mallory Weiss tear
Medications can cause bleeding:
NSAID/ASA
Steroids
Anticoagulants
Alcohol use/abuse associated with various
types of bleeding
Clinical features (continued)
Establish vascular volume status
Confirm bleeding by site
Do a rectal exam to look for bright red blood or
melena; perform a guaiac test if available
Role for NG tube?
Look for signs of liver disease
Look for generalized bleeding problem
Management
Assess for airway management
Prompt large bore iv access
Volume resuscitation if necessary as
patients can deteriorate rapidly
CBC, cross match, LFT, coagulation, renal
Reverse any coagulopthy if possible
Access to endoscopy as diagnostic and
therapeutic procedure (Ideal <24 hours)
Management (cont.) - Medications
Reducing gastric acidity via H2 blockers or
PPI meds
Reducing portal pressure for varices
Antibiotics may improve survival
Use of Sengstaken-Blakemore tube not
recommended due to complications
Need for surgery uncommon
Case continued
Patient’s airway reflexes were intact
Given Oxygen for shock state
Monitored vascular/respiratory status
closely
Administered fluids to improve perfusion
Cross matched for blood and plasma to
restore hemoglobin and coagulation
PPI and antibiotics given while waiting for
endoscopy
Esophageal Emergencies
Esophageal emergencies
Causes:
Varices
Ingestion of corrosives
Foreign bodies
Caustics – how patients present
Pain
Difficulty swallowing
Airway compromise
Challenges in these patients
Protecting healthcare workers
Pain masking complications
Systemic effects of chemical/co-ingestion
Mental health issues
Causes
Intentional self harm versus accidental
Sources of chemical information
Causes (continued)
Alkali – liquefaction necrosis, thrombosis
Acids – coagulation necrosis, eschar,
systemic absorption
Clinical features
Pain – range of severity
Respiratory/airway symptoms
GI symptoms
Absence of oral injury does not preclude
GI injury!
Management
Protect yourself
Airway assessment – direct vision
technique
Treat shock = GI bleed, perforation,
delayed sepsis, metabolic
Decontaminate eyes and skin as needed
Surgical consult if perforation
Esophageal FB – How patients
present
Usually based on history
Chest pain, retching, can’t swallow
Beware of children, mental health,
“prisoners”
Clinical features
Problems with handling secretions
Location in esophagus
Pediatric typically proximal
Adults typically distal
Perforation is uncommon
Endoscopy is diagnostic and therapeutic
procedure
Diagnosis
X-ray can show the
location of a foreign
body
Management
Endoscopy preferred
Time +/- sedation often works
Meds:
Glucagon 1 mg IV
Nifedipine 10 mg SL
Nitroglycerine SL
Management (continued)
Button batteries and coins:
Remove if in esophagus if endoscopy available
Remove if still in stomach after 24 h
Sharp objects
Endoscopy preferred if available
Ulcers and Gastritis
Ulcers and gastritis – How patients
present
Pain
GI bleeding
Perforation (shock)
Causes
H. pylori infection
Meds:
NSAID/ASA
Alcohol
Spices
Severe physiological stress
Clinical features
Pain
Often epigastric tenderness without
peritonitis
Tests not really useful except to rule out
other things
Management
Perforation, bleeding discussed elsewhere
Antacids
H2 blockers, PPI
Antibiotic therapy
Avoidance of NSAID and alcohol
Quiz
Quiz Question 1
Which is the most common cause of upper
GI bleeding?
A.
B.
C.
D.
Malignancy
Intestinal perforation
Peptic ulcers/gastritis
Mallory Weis tear
Quiz Question 2
GI bleeding can present as:
A.
B.
C.
D.
E.
Melena
Hematemesis
Shock without obvious blood loss
Hematochezia
All of the above are correct
Quiz Question 3
In managing patient after a caustic
ingestion:
A.
B.
C.
D.
They usually present with shock
Those without any pain are the sickest
Their vomit can be harmful to care givers
An NG tube should always be placed
Quiz Question 4
Regarding esophageal obstruction:
A. Endoscopy is never indicated
B. If batteries are not obstructing the esophagus,
they can be left there for up to three days
C. Adults and children usually obstruct proximally
D. All patients with obstruction should be
intubated
E. Medications may sometimes prevent the need
for endoscopy
Quiz Question 5
Regarding patients with peptic ulcer
disease:
A.
B.
C.
D.
Abdominal pain is usually constant
Alcohol use is one of the causes of ulcers
Acetaminophen is a common cause of ulcers
The usual treatment is surgical repair
Summary
GI bleeding can be a cause of lifethreatening shock requiring resuscitation
Esophageal injuries should be managed in
conjunction with endoscopy experts
Peptic ulcer disease and gastritis can
present as life-threatening complications
General References
Tintinalli, JE et al (2011) Chapters 78, 79,
80, 81, 194. McGraw Hill Publishers
Emergency Medicine – A study guide 7th
Edition, USA
Manson’s Tropical Diseases, Chapter 10.
Saunders Elsevier, 22nd edition.