Download 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.