Inpatient GI Flashcards
Lower GI Bleed
-hematochezia vs melena, pain with defecation, abd pain, weight loss, bowel changes, fever
-diverticular, vascular (AVM, ischemia, radiation-induced), neoplasm, inflammatory (IBD, infectious), anorectal (hem, fissure), postpolypectomy
Lower GIB Workup
-Labs (CBC, BMP, PT/INR)
-Colonoscopy
-Radionucleotide studies
(Technetium, tagged RBC scan *These are helpful if actively bleeding
-CT angiography vs angiography
Tx Lower GIB
-Depends on cause
-Clip, Cauterize, or APC
postpolypectomy bleed, AVM
*Treat infection
*Manage IBD
*Surgery for malignancy (+/- chemoradiation)
*Treat hemorrhoids, fissure
*Radiation proctitis: APC, hyperbaric chamber
*Coil during angiography (this is completed by IR)
Mechanical Bowel Obstruction
-Severe abd pain, N/V, dehydration, cessation of stool/gas
Small Bowel Obstruction Tx
-Fluids
-Pain management
-NPO, NG to decompress, TPN if palliative
-Tincture of time, usually improve 4-5 days
-Gastrograffin challenge if partial can be therapeutic
100 ml gastrografin in 50 ml water via NG tube, clamp for 2 hours. Should have BM or colon contrast in 8 hours
-Surgery consultation if high concerns of ischemia, necrosis on physical exam or perforation or transition point on imaging
SBO on Imaging
-Will see dilated bowel, wall thickening, free air, transition point, closed loop obstruction, air-fluid level, mesentery swirling.
-If strangulated may see portal venous gas, pneumatosis intestinalis, extraluminal contrast
-Enteroclysis (xray, CT, MR)
-Capsule enteroscopy
Appendicitis
-RLQ pain (initially periumbilical in > 50% of patients)
-Anorexia
-Nausea and vomiting
-Low grade fever
-May have change in BM, malaise
Appendicitis Eval and Tx
–McBurney’s: point tenderness 1.5-2 cm iliac spine
—Rovsing’s sign: pain RLQ with palpation of LLQ
—Psoas sign: RLQ pain with passive R hip extension
—Obturator sign: Pain with flexion/internal rotation of R hip
–Labs: ↑ WBC with left shift in 80%
–Radiographic studies: CT abd/pelvis if uncertain
–Management: Surgery (delayed if perforation req drainage)
Diverticular Disease
-Presents as low abd pain, ± LG fever, diarrhea.
-May have LLQ mass or tenderness on exam.
Diverticular Evaluation
-CT scan if complications suspected.
—soft tissue density increased
—bowel wall thickened, possible phlegmon (abscess)
—free air (peritonitis)
—or extraluminal air collections in bladder, vagina (fistula).
-Flex sigmoidoscopy if cancer or colitis suspected
Diverticulitis Tx
-Uncomplicated: Antibiotic x 10-14 days
-Complicated (bowel perforation, abscess, fistula, obstruction): hospitalize
Hospitalize also if:
Significant medical morbidity, Older age, Unable to tolerate oral intake, Immunocompromised
Fever, Significant leukocytosis
-Clear liquids, bowel rest. High fiber diet once acute phase resolved.
Toxic Megacolon
-Total or segmental dilation of colon due to IBD infectious or ischemic colitis
-Severe bloody diarrhea most common symptom
-Plain film X-ray shows dilatation >6 cm
-Management:
Fluids, bowel rest and/or decompression, abx, steroids
-Flex sig ok but avoid colonoscopy
-GI and CRS consult for emergent subtotal colectomy
—–If cecum is greater than 11 cm very high risk of perforation
Acute Mesentery Ischemia Etiology
-Superior mesenteric artery emboli (most common)
-SMA vasoconstriction
-SMA thrombosis
-low-flow states
-Mesentery vein thrombosis
Acute Mesentery Ischemia Presentation and Eval
-Severe mid abdominal pain, persistent, unrelenting, with bowel urgency
-Often fatal without early surgical intervention (>80%)
-Pain out of proportion to abd exam findings (small intestine)
-Lab studies often normal until infarction has occurred
-CT abdomen or MR angiography
-Emergent Surgical consult
-Aggressive IV fluid resuscitation
-NG tube
Acute Mesentery Ischemia Imaging
Pneumatosis intestinalis or portal venous gas suggest infarction
