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Flashcards in GI bleeds and emergencies DSA Deck (26):
1

acute upper GI bleeding- essential of diagnosis

-hematemesis (bright red blood or "Coffee grounds")
-melena in most cases; hematochezia in massive bleeds
-volume status to determine severity of blood loss; hematocrit is a poor early indicator of blood loss
-endoscopy diagnostic and may be therapeutic

2

Esophageal varices- essentials of diagnosis

-develop secondary to portal HTN
-found in 50% of pts with cirrhosis
-1/3 will develop upper GI bleeding!
-dx- upper endoscopy

3

bleeding esophageal varices- sx

-acute GI hemorrhage
-severe!- hypovolemia`

4

Acute LGIB- essentials of diagnosis

-hematochezia usually present
-10% of hematochezia cases due to upper GI source
-evaluation with colonoscopy in stable pts
-massive active bleeding calls for evaluation with sigmoidoscopy, upper endoscopy, angiography, or nuclear bleeding scan

5

Acute LGIB- where? etiology?

-below ligament of Treitz (small intestine or colon)
-95% arise from colon
-<50 yo- infectious colitis, anorectal dz, IBD
->50- diverticulosis, angiectasias, malignancy, ischemia

6

Acute LGIB- diverticulosis

-in 3-5% of pts with diverticulosis
-most common cause of major lower tract bleeding!!- 50% of cases
-painless, large volume bright red hematochezia in pts over 50 yo

7

Acute LGIB- angioectasias

-painless bleeding
-flat, red lesions with ectatic peripheral vessels radiating from a central vessel
-most common- >70 yo, chronic renal failure

8

Acute LGIB- color of stool

-brown mixed/streaked with blood- rectosigmoid or anus
-large volumes of bright red blood- colon
-maroon- right colon or small intestine
-black (melena)- proximal to ligament of Treitz

9

Acute LGIB- diagnostic tests

-exclusion of upper tract source
-anoscopy and sigmoidoscopy- if <40 yo- look for anorectal dz, IBD, infectious colitis; if >40 yo, look for tumor (colonoscopy)
-colonoscopy- preferred when large volume bleeding!!
-nuclear bleeding scans and anigography
-small intestine push enteroscopy or capsule imaging

10

Familial Mediterranean Fever

-rare, AD disorder, unknown pathogenesis
-Mediterranean ancestry
-lack a protease in serosal fluids that normally inact IL-8 and chemotactic complement factor 5A
-sx- b/f 20 yo- episodic bouts of acute peritonitis, that may be assoc with serositis involving joints and pleura
-peritoneal attacks- fever, abd pain, abd tenderness
-tx- colchicine!

11

Appendicitis- essentials of diagnosis

-early- periumbilical pain
-later- RLQ pain and tenderness
-anorexia, N/V, obstipation
-tenderness, rigidity at McBurney point
-low-grade fever and leukocytosis

12

Appendicitis- imaging

-abd US and CT scanning

13

Appendicitis- complications

-perforation- 20% of pts

14

Appendicitis- treatment

-surgical appendectomy!- early, uncomplicated appendicitis
-emergency appendectomy- perforated appendicitis with generalized peritonitis

15

Acute Pancreatitis- essentials of diagnosis

-abrupt onset of deep epigastric pain, often with radiation to back
-Hx of previous episodes, often related to alcohol intake
-N/V, sweating, weakness
-abd tenderness, distention, fever
-leukocytosis, elevated serum amylase and lipase

16

Acute Pancreatitis- assessment of severity

Ranson Criteria:
3 or more predict a severe course complicated by pancreatic necrosis with a sensitivity 60-80%):
->55 yo
-WBC > 16,000
-blood glucose> 200
-serum lactic dehydrogenase > 350
-aspartate aminotransferase > 250
Development of the following in the first 48 hrs indicates a worsening prognosis:
-Hematocrit drop 10% points
-BUN rise > 5
-arterial PO2 < 60
-serum calcium < 8
-base deficit over 4 mEq/L
-fluid sequestration of > 6 L
*0-2 (1%); 3-4 (16%), 5-6 (40%), 7-8 (100%)- mortality rate

17

Acute Pancreatitis- CT Grade Severity Index

-normal pancreas- 0
-pancreatic enlargement- 1
-pancreatic infl and/or peripancreatic fat- 2
-single acute peripancreatic fluid collection- 3
-2 or more acute peripancreatic fluid collections or retroperitoneal air- 4

18

revised atlanta classification of severity of acute pancreatitis

-mild dz- absence of organ failure and local (pancreatic necrosis or fluid collections) or systemic complications
-moderate- transient organ failure or local or systemic complications
-severe- persistent (>48 hrs) organ failure

19

Acute Pancreatitis- imaging

-gallstones
-"Sentinel loop"- segment of air-filled small intestine
-"colon cutoff sign"- gas-filled transverse colon, abruptly ending at area of pancreatic infl

20

serum amylase also elevated in?

high intestinal obstruction, gastroenteritis, mumps, ectopic pregnancy, opioids, abdominal surgery

21

Acute Pancreatitis- complications

-intravascular volume depletion
-necrotizing pancreatitis- 5-10%- assoc with fever, leukocytosis, shock, organ failure
-ARDS
-pancreatic abscess
-pseudocysts

22

Acute Pancreatitis- mild dz- treatment

-in most pts- subsides spontaneously
-pancreas "rested"- withhold food and liquids by mouth, bed rest
-fluid resuscitation
-pain controlled with meperidine

23

Acute pancreatitis- severe dz- treatment

-leakage of fluids- need IV fluids!!
-hemodynamic monitoring in ICU!

24

Chronic pancreatitis- essentials of diagnosis

-chronic or intermittent epigastric pain, steatorrhea, weight loss, abnormal pancreatic imaging
-predisposing factors- TIGARO- toxic-metabolic, idiopathic, genetic, autoimmune, recurrent and severe acute pancreatitis, or obstructive

25

Chronic pancreatitis- lab findings

-amylase and lipase- elevated during acute attacks
-pancreatic insufficiency- response to therapy with pancreatic enzyme supplements; secretin stimuation test

26

Chronic pancreatitis- imaging

plain films- calcifications due to pancreaticolithiasis- in 30%
-CT- calcifications, ductal dilatation, atrophy
-ERCP- most sensitive
-MRCP And EUS- less invasive
-EUS- hyperechoic foci with shadowing (calculi in main pancreatic duct) and lobularity with honeycombing of pancreatic parenchyma