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CMT-dos > Esophageal FB/GI bleeds > Flashcards

Esophageal FB/GI bleeds Flashcards

1
Q

Esophageal Foreign Bodies

Esophagus

pic is abcess from embedded fish bone.

A

Esophagus
Most common site of foreign body impaction
Lodge in areas of physiologic or pathologic luminal narrowing
Sphincters (UES and LES)
Strictures
Tumors
Previous surgery (adhesions)
Underlying disorder/disease (achalasia, eosinophilic esophagitis)

Causes of impaction
Food (steak, hot dogs, grapes, peanuts, candies)
Bones (fish bones)
Inedible objects (coins, batteries, magnets)

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2
Q

FB

complications

A

complete much more serious

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3
Q

FB

S/Sx

A

Dysphagia: Main presenting symptom
Unable to swallow oral secretions (complete obstruction)
Hypersalivation
Retrosternal fullness
Regurgitation
Anxiety → hyperventilation

Dyspnea and auscultatory findings of stridor or wheezing → foreign body in the airway and not the esophagus

pain behind the sternum

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4
Q

FB

imaging

A

Imaging studies
Plain film x-rays (2 views)
Detect metallic foreign objects and bones
Detect signs of perforation (free air in the mediastinum or peritoneum)

CT scan
Objects not identifiable on plain film x-ray (wood, plastic, glass)
Dangerous ingestions (packets of illicit drugs)
Confirm and localize the foreign body prior to endoscopy
Oral contrast should be avoided due to risk of aspiration and possible leakage of contrast with perforation

History & physical examination
History suggesting ingestion and symptoms consistent with esophageal foreign body

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5
Q

Common Anatomic Locations for Foreign Bodies

A

Proximal esophagus at the level of the cricopharyngeus muscle (thoracic inlet) → in line with the clavicles on x-ray
(most common in kids)

Mid-esophagus at the level of the aortic arch → at the carina on x-ray

Lower esophageal sphincter → 2-4 vertebral levels above the gastric bubble on x-ray

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6
Q

FB

Emergency situations

A

Complete esophageal obstruction - inability to handle oral secretions
Disk batteries in the esophagus
Sharp-pointed objects in the esophagus

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7
Q

FB

Urgent (within 12 to 24 hours) situations

A

Esophageal objects that are not sharp-pointed
Food impactions without complete obstruction
Sharp-pointed objects in the stomach or duodenum
Objects greater than 6 cm in length above the duodenum
Multiple magnets (or single magnet plus another ferromagnetic object within endoscopic reach)
Coins in esophagus

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8
Q

FB

Nonurgent

A

Objects in the stomach greater than 2.5 cm diameter
Disk battery in stomach up to 48 hours if asymptomatic
Blunt objects that fail to pass stomach in 3 to 4 weeks

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9
Q

Treatment for Food Impaction (3)

A
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10
Q

GI bleeds

Upper and lower are divided by

A

Ligament of Treitz: suspensory ligament and important surgical landmark; runs from the left diaphragm to the junction of the duodenum and jejunum (structure is green in the photo)

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11
Q

GI bleeds

classifications of bleeds
Acute vs chronic

A

Classified as:
Acute (<3 days) or chronic (>3 days) bleeding
Overt or occult bleeding
Overt: visible bleeding
Occult: only detectable by chemical testing of a stool specimen

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12
Q

GI bleeds

Risk Factors

A

History of GI bleeding
Helicobacterpyloriinfection
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Anticoagulant use
Alcohol use
Cirrhosis
Vascular disease
Older age

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13
Q

GI bleeds and NSAIDS

A

PGE2 provides gastroprotection by increasing mucus secretion and inhibiting gastric acid secretion
NSAIDs inhibited production of prostaglandins (PGs) through the inhibition of two cyclooxygenase enzymes, COX-1 and COX-2

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14
Q

Upper GI bleed

etiology

A

Peptic ulcer disease
Gastric ulcer
Duodenal ulcer
Erosive gastritis
Erosive esophagitis
Esophageal or gastric varices
Esophageal cancer
Mallory-Weiss tears

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15
Q

lower GI bleeding

etiology

A

Diverticular disease -Diverticulosis and Diverticulitis
Hemorrhoids
Infectious colitis
Anal fissures
Inflammatory bowel diseases
Crohn’s disease
Ulcerative colitis
Colorectal cancer
Iatrogenic – after biopsy or radiation

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16
Q

GI bleeding

S/Sx
Patients with occult bleeding

A

Patients with occult bleeding may be asymptomatic

Symptoms of anemia:
Fatigue/weakness
Dyspnea
Pallor
Lightheaded

Heartburn
Abdominal pain
Weight loss…should make you think?

17
Q

GI Bleeds

Hematemesis

A

Indicates an upper GI bleed
Vomiting of red blood or “coffee-ground” material

Coffee-ground emesis
Vomit that is dark brown and resembling coffee
Conversion of red hemoglobin to brown hematin by gastric acid

18
Q

GI bleeds

Hematochezia

A

Indicates a lower GI bleed or a vigorous upper GI bleed with rapid transit through the intestines
Passage of gross blood from the rectum
Bright red

19
Q

GI bleeds

Melena

A

Typically indicates an upper GI bleed, but can occur with a small intstinal or proximal colonic bleed
Black, tarry stool

20
Q

GI Bleeds

Hemodynamic Instability
Primary and advanced parameters

A

Occurs when there is a decrease in blood pressure leading to lowered blood flow to the body’s organs

Primary hemodynamic parameters include:
heart rate (HR) and blood pressure (BP)

Advanced hemodynamic parameters include:
stroke volume (SV), cardiac output (CO), and total peripheral resistance (TPR)

21
Q
A
22
Q

Evaluation of GI Bleeding - History

medications

A

Medications that can increase risk of bleeding: NSAIDs, aspirin, clopidogrel, anticoagulants, SSRIs

23
Q

GI bleeds

HPI questions for Heamtemiesis

A

Distinguish hematemesis from hemoptysis
Blood passed with initial vomiting or after an initial (or several) non-bloody bouts of emesis?

24
Q

GI bleed

HPI questions for rectal bleeding

A

Pure blood passed? Blood mixed with stool, pus, or mucus?
Blood on the toilet tissue or coated the toilet water?
Bloody diarrhea – recent travel or possible exposure to GI pathogens?

25
Q

GI bleed

HPI associated Sx questions

A

Associated symptoms
Abdominal discomfort, weight loss, easy bleeding or bruising, symptoms of anemia?

26
Q

GI bleeds

PE

A

Vital signs including orthostatic measurements
Indicators of shock or hypovolemia
Tachycardia, tachypnea, pallor, diaphoresis, confusion, oliguria
Why would a patient with a GI bleed present with oliguria?

Signs of anemia
External stigmata of bleeding disorders
Petechiae or ecchymosis

Signs of chronic liver disease
Spider angiomas, ascites, palmar erythema, dilated abdominal wall veins, splenomegaly

Digital rectal exam
Stool color, masses, or fissures
Stool specimen for occult blood

27
Q

GI bleeds

Labs

A

History and physical exam will suggest a diagnosis in >50% of patients
Confirmatory testing is required
Labs
CBC with differential
Type and cross-match *
Coagulation profile
Fecal occult blood testing
Liver tests (bilirubin, alkaline phosphatase, albumin, AST, ALT)
Basic metabolic panel
Iron and ferritin

28
Q

GI bleed

Nasogastric aspiration and lavage

A

Patients with suspected upper GI bleeding

29
Q

GI bleeds

Upper endoscopy/EGD – modality of choice for upper GI bleed

A

Examination of the esophagus, stomach, and duodenum
Diagnostic and therapeutic

30
Q

GI blood

Flexible sigmoidoscopy and anoscopy

A

Typical symptoms hemorrhoidal bleeding

31
Q

GI bleeds

Colonoscopy indications

A

modality of choice for lower GI bleed
Often done electively after routine preparation

Significant bleeding – rapid prep delivered via NG tube for patients with hematochezia

32
Q

GI Bleeds

CT angiography indications
Bleeding rate

A

Bleeding rate of at least 0.5–1 mL/min is required for detection.

Reserved forpatients who cannot undergoendoscopydue to hemodynamic instability

33
Q
A
34
Q

GI bleeds

non pharm Tx

A

Secure airway – intubation may be required
2 large-gauge peripheral IVs and/or central line

IV fluid resuscitation

Blood transfusion (hemoglobin < 7)
Packed RBCs, platelets, fresh frozen plasma
NPO

GI and/or surgical consultation

35
Q

GI Bleeds

Pharm Tx

A

IV Proton pump inhibitor (PPI) for all upper GI bleeding
Octreotide for suspected variceal bleeding
Prophylactic antibiotics for suspected variceal bleeding in patient with cirrhosis (prevention of spontaneous bacterial peritonitis)

36
Q

GI bleeds

Hemostasis Tx

A

GI bleeding stops spontaneously in ~80% of patients
Specific hemostatic therapy depends on the bleeding site

37
Q
A

CMT-dos (95 decks)

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