Gastrointestinal Emergencies

TopicsAcute appendicitisAcute pancreatitisDiverticulitisInstestinal obstructionUpper/lower GI bleeding/hemorrhoidsGastroenteritisCholelithiasis/cholecystitis/cholangitisHepatitis (alcoholic and viral)Booerhaves syndrome

ABDOMINAL PAINAcute abdominal pain accounts for 5% of all ED visits.Three categoriesIntra-abdominal3GsGI.GU.GYN.Vascular emergencies.Extra-abdominalCardiopulmonaryAbdominal wall.Toxic-metabolicNeurogenicUndifferentiated

Common Causes of Abdominal Pain in the ED for All Age Groups

Cause Percentage Abdominal pain of unknown cause41.3Gastroenteritis6.9Pelvic inflammatory disease6.7Urinary tract infection5.2Ureteral stone4.3Appendicitis4.3Acute cholecystitis2.5Intestinal obstruction2.5Constipation2.3Duodenal ulcer2.0Other causes22.0

From Brewer RJ et al: Am J Surg 131:219, 1976.

Causes of Abdominal Pain in Patients Over 70 Years of Age

Cause Percentage Acute cholecystitis26.0 Malignant disease13.2 Bowel obstruction10.7 Nonspecific abdominal pain 9.6 Gastroduodenal ulcer 8.4 Acute diverticular Dz 7.0 Incarcerated hernia4.8 Acute pancreatitis4.1 Acute appendicitis3.5 Other causes12.7

ACUTE ABDOMINALPAIN

ACUTE ABDOMINAL PAINThree categories: VisceralOften poorly localized. Steady ache or dull.Vague discomfort or gaseous.Colicky or crampy.Can be excruciating.ParietalSharper and more localized. Tenderness and guarding.Rigidity and rebound.Referred

ABDOMINAL PAIN

Visceral pain Often the earliest symptom .Caused by inflammation, distention, or ischemia of nerve fibers innervating the walls or capsules of hollow or solid organs.Parietal or Somatic painIrritation of fibers that innervate the parietal peritoneum.Often initiated by chemical or bacterial inflammation.Referred PainAny pain felt in a cutaneous site distant from a diseased organ.

Pareital peritoneumLines internal surface of the walls of the abdomen and pelvic cavity

ABDOMINAL PAIN

Epigastric painForgut organsStomachDuodenumBiliary tractPeriumbilical painMidgutMost of small intestines AppendixCecumSuprapubic or hypogastric painHindgut organsMost of colon including sigmoid.Intra-peritoneal portions of GU system.Kidney, Ureters and Bladder.Pelvic organs.

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History.Onset and Duration of Pain.Location, radiation and migration of Pain.Quality and Severity of Pain.Aggravating and relieving factors.Associated Symptoms. Past and Current Medical History.____________________________(very important)Social History.Physical Exam.General Appearance and Vital Signs. Inspection, Auscultation, and Percussion.Palpation and Localization of Tenderness.Rectal and Pelvic Examination. Extra-abdominal Examination.

Lab & imagingWhite Blood Cell Count.Urinalysis.Electrolytes.Renal function test.Tests for Pregnancy.Amylase and Lipase.LFTs.Plain abdominal films.Abdominal ultrasound.Abdominal CT scan.

Appendicitis

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Acute Appendicitis Incidence

Approximate yearly incidence of 1 per 1,000 populationAffects all agesHighest incidence in second and third decades of life.Slight male predominance. Approximately 200,000 appendectomies annually in the US.Most common surgical condition in children.the most common surgical problem requiring emergency intervention during pregnancy.Less than 1% mortality rate.Mortality is higher with children

Acute AppendicitisClinical presentation (Classic)Abdominal pain Initially periumbilical RLQSevere diffuse abdominal pain

Acute AppendicitisClinical presentation (atypical)Abdominal painRetrocecal appendixBack, flank, testicular pain Pelvic appendixSuprapubic pain Long appendixThe inflamed tip may cause pain in RUQ or LLQ

Acute AppendicitisClinical presentation

Anorexia Fever (low grade)Vomiting Diarrhea (33%) Constipation (933%)

Acute AppendicitisClinical exam

Abdominal exam RLQ tenderness.McBurney's point Guarding ReboundBowel sounds Rectal exam

Acute AppendicitisClinical exam

(Special tests)Abdominal exam Psoas signObturator signRovsing's sign

Acute AppendicitisDDxAdultsundiagnosable abdominal pain, diverticulitis, urinary tract infection, ileitis, cholelithiasis, pancreatitis, bowel obstruction, and gastroenteritis.Womenabdominal pain of unknown cause, PID, ovarian cysts, endometriosis, and ectopic pregnancy.Children, abdominal pain of unknown cause, mesenteric adenitis, ileocolitis, Meckels diverticulum, testicular torsion, urinary tract infection, Henoch-Schnlein purpura, pancreatitis, and gastroenteritis.Elderly.gallstones, diverticulitis, and intraabdominal tumors.

Acute AppendicitisLab & imagingCBC.Electrolytes.Renal function test.Urinalysis. Urine pregnancy test (if woman of childbearing age). Abdominal series.RLQ ultrasound.CT scan of abdomen and pelvis.

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Acute AppendicitisManagement

Nothing by mouth (NPO)Saline lock (IV hydration if dehydrated) Surgical consultation Antibiotic e.g., cefotetan or cefoxitinFlagyl (or clindamycin) with ampicillin and gentamicin.

Acute AppendicitisManagement

High clinical probabilitySurgical consultationAntibiotic (e.g., cefotetan or cefoxitin)AppendectomyModerate clinical probabilitySurgical consultation UltrasoundIf positive, appendectomyIf negative, observation and serial examinations.Low clinical probabilityUltrasound if symptoms persist at time of follow-up Surgical consultation Follow-up in 12 to 24 hours for repeat examination, earlier if increased symptoms.

Standard of care for acute appendicitisAppendectomyRemember This

Acute Pancreatitis

Acute pancreatitisIn the U.S. Cholelithiasis or alcohol abuse accounts for 90% of all cases of acute pancreatitis

PathophysiologyThe central cause is believed to be the intracellular activation of digestive enzymes and autodigestion of the pancreasPancreatic digestion from activated proteolytic enzymes leads to edema, interstitial hemorrhage, vascular damage, coagulation, and cellular enzymes.

PathophysiologyIt can also cause a generalized systemic inflammatory response that may lead to shock, ARDS, and multisystem organ failure.

Clinical featuresBoring epigastric pain that radiates to the back.TachycardiaNausea and vomitingAbdominal distensionCullens signGrey Turners signBlood loss, refractory hypotension, and respiratory failure may accompany more severe forms.

Diagnosis and differentialDiagnosis is made by a suggestive history and physical exam, associated with elevated pancreatic enzymes.Amylase greater than 3x the upper limit of normal has a specificity of 75% and a sensitivity of 80-90%Lipase is more specific than amylase and is the preferred test. At a cutoff of 2x the upper limit of normal, lipase is 90% sensitive and specific.

Diagnosis and differentialLeukocytosis may be present, and an elevated alkaline phosphatase suggests biliary disease.Hypotension, tachycardia >130bpm, Po2

Diagnosis and differentialUltrasound is helpful in the identification of gallstones or dilatation of the biliary tree.CT is the study of choice for visualizing the pancreas, confirmation of inflammation, and the identification of phlegmons, abscesses, or pseudocyts. It cannot be used to rule out Acute Pancreatitis.

Diagnosis and differentialEndoscopic retrograde cholangiopancreatography (ECRP) can be useful the the etilology remains unclear after initial evaluationDDX: LLL pneumonia, rupture of a pseudocyst, gallbladder disease, peritonitis, PUD, SBO, renal colic, dissecting aortic aneurysm, DKA, and gastroenteritis.

TreatmentPancreatic rest (NPO)Fluid resuscitation with normal salinePain control; parenteral analgesia prn IV narcotics e.g. MorphinePrevention of vomiting; antiemetics e.g. Promethazine IVPressors such as dopamine are indicated for persistent hypotension despite fluid resuscitation

TreatmentO2 to maintain a pulse ox of

TreatmentPatients with significant systemic complications, shock or extensive pancreatic necrosis will need to be place in an ICU setting.

Diverticulitis

DiverticulitisIs caused by bacterial proliferation within an existing colonic diverticulum, leading to microperforation and inflammation or pericolonic tissue.

DiverticulitisClinical diverticulitis occurs in 10-25% of patients with diverticulosis.One-third of the population will have acquired the disease by age 50, and two-thirds by age 85.Only 2-4% of patients with diverticulitis are under age 40 and tend to have a more virulent form of the disease, with frequent complications requiring earlier surgical intervention.

PathophysiologyMost commonly, clinical diverticulitis results form high colonic pressures, resulting in erosion and microperforation of the diverticular wall, leading to inflammation of pericolonic tissue.

Clinical featuresThe most common symptom is LLQ pain.Other symptoms include tenesmus, diarrhea or increasing constipation.The involved diverticulum may irritate the urinary tract and cause frequency, dysuria or pyuria.If a fistula develps between the colon and bladder patient may present with recurrent UTIs or pneumaturia

Clinical featuresParalytic ileus w/abd distension.Nausea and vomitingSmall bowel obstruction and perforation can also occur.RLQ painLow-grade fever but the temperature may be higher in patients with generalized peritonitis and in those with and abscess.

Clinical featuresAbdominal exam reveals localized tenderness oftern w/voluntary guarding and rebound tenderness.A fullness or mass may be appreciated over the affected area of colon.Occult blood may be present in the stool.

Diagnosis and differentialDDX: appendicitis, PUD, PID, endometriosis, ischemic colitis, aortic aneurysm, renal calculus, IBS, lactate intolerance, colon carcinoma, intestinal lymphoma, Kaposi's sarcoma, sarcoidosis, collagen vascular disease, irradiation colitis or proctosigmoiditis, fecal impaction, foreign body granuloma, and any bacterial, parasitic, or viral infectious cause.

Diagnosis and differentialRoutine screening blood tests, UA, and an abdominal radiographic series.Leukocytosis is present in only 36% of patients with diverticulitis.CT scan of the abdomen is the diagnostic procedure of choice.

TreatmentIf patient has systemic signs and symptoms of infection, has failed outpatient management, or demonstrates signs of peritonitis, hospitalization and surgical consultation is necessary.Inpatient treatment consists of IV antibx, usually an aminoglycoside e.g. Gentamicin or tobramycin and either flagyl or clindamycin for aerobic and anerobic coverage.

TreatmentTicarcillin-clavulanic acid or imipenem have been used as alternative agents.Bowel rest, NPO, IV fluids are administered.Nasogastric suction may be indicated in patients with bowel obstruction or adynamic illeus.

TreatmentOutpatient management is acceptable for patients with localized pain without signs and symptoms of local peritonitis or systemic infection.Treatments consists of bowel rest, broad-spectrum or antibx therapy.Ampicillin, bactrim, ciprofloxacin, or keflex. One of these meds is taken in combination with an agent with anaerobic coverage e.g. Flagyl, clindamycin

TreatmentPatients should limit activity and maintain a liquid diet for 48 hours.If symptoms, improve low-residue diet then begun.Patients should seek medical care if they develop increasing abdominal pain, fever, or are unable to tolerate oral intake.

HemorrhoidsAre associated with constipation and straining at stool, pregnancy, obesity, chronic liver disease, portal hypertension, and rarely tumors of the rectum and sigmoid colon.

PathophysiologyInternal hemorrhoidal veins are located above the dentate line and drain into the portal venous system.External hemorrhoidal veins are located below the dentate line and drain through the pudendal and iliac venous system.

Clinical featuresInternal hemorrhoids are only visible through and anoscope and cause painless bright-red rectal bleeding with defecation.External hemorrhoids may be visualized on external exam and commonly cause pain and discomfort, most severe at the time of defecation.

Clinical featuresThrombosis of external hemorrhoids is the usual cause of pain.Prolapse may occur with larger hemorrhoids, spontaneously reducing or requiring periodic manual reduction.Prolapse may cause mucous discharge and pruritus ani.Common complications are strangulation, thrombosis, and severe bleeding.

Diagnosis and differentialClinical signs cannot differential colonic lesions from hemorrhoidsDDX of rectal pain: malignancy, abscess, cryptitis, anal fissure, trauma, foreign bodies, rectal prolapse, and venereal proctitis.

TreatmentFor most patients treatment is nonsurgical and includes: hot sitz baths and good hygiene. Bulk laxatives( Metamucil, stool softeners)Topical analgesics or steroids may provide temporary relief.Thrombosed external hemorrhoids require excision of clot for relief. Initial conservative treatment may be tried for less severe cases.

TreatmentSurgical referral and intervention is indicated for continued bleeding, intractable pain, incarceration, or strangulation.

Intestinal obstructionSmall bowel obstruction(SBO) is more common the large bowel obstruction (LBO)Intestinal obstruction is due to mechanical or function obstruction, with ileus being more common.Adhesions following surgery are the most common cause of SBOLBO is most commonly due to neoplasm.

Intestinal obstructionFecal impaction is common is elderly and debilitated patients.

PathophysiologyBlockage prevents passage of luminal contents and result in dilatation due to accumulation of gastric, biliary, and pancreatic secretions.With distention, intraluminal pressure rises, decreasing bowel wall blood flow. When pressure exceeds capillary pressure, absorption ceases and leakage of fluids (third-spacing) may occur.

PathophysiologyMicrovascular changes may allow entry of gut flora into the circulation, resulting in bacteremia and sepsis. Necrosis and bowel perforation may follow.With obstruction, oral fluid intake stops and vomiting occurs. This fluid loss, coupled with the third space losses, leads to hypovolemia and shock.Closed loop obstruction has a more rapid progression.

Clinical featuresClassic history includes vomiting, abd distention, and pain, with a past history of abdominal surgery or hernia.Abdominal pain is crampy and intermittent.SBO primarily periumbilical painLBO hypogastric painPain with ileus may be constant.

Clinical featuresEmesis is often bilious early and may be feculent with late SBO or with LBO.Early symptoms may include high-pitched bowel sounds, and this may decrease with time.Physical exam may be show surgical scars, hernias, or intraabdominal mass.Peritoneal signs suggest perforation.

Clinical featuresTachycardia, hypotensionRectal exam may reveal impaction,occult blood, or carcinoma.Women may have palpable gynecologic neoplasms on pelvic exam.Passage of stool does not rule out obstruction.

Diagnosis and differentialDDX: pseudo-obstruction(Ogilvies syndrome), intestinal motility due to TCAs or anticholinergic agents.Radiographs help localize SBO vs. LBO.Laboratory tests include: CBC, BUN, serum electrolytes, serum amalyse and UA. LFTs as well as cross-match and coagulation studies may also be needed.

Diagnosis and differentialSigmoidoscopy or barium enema may be useful in localizing the site of LBO.CT of the abdomen.

TreatmentWith mechanical bowel obstruction, prompt surgical consultation is required!Nasogastric tube is used to decompress the bowel.Fluid resuscitation using crystalloid.Monitor vital signs and urine output.

TreatmentAppropriate antibiotic therapy e.g. Piperacillin-tazobactam, or ampicillin-sulbactam should be started if perforation is suspected or surgery is anticipated.For adynamic ileus, conservative tx including: nasogastric decompression, fluid replacemdtn, and observation

CHOLELITHIASISCholecystitisCholangitis

PERFORATED VISCUS

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TopicsCholelithiasis/Cholecystitis/Cholangitis.Acute Pancreatitis.Hepatitis (alcoholic and viral).Acute Appendicitis. Diverticulitis.Intestinal obstruction. Upper and lower GI bleeding/hemorroids. Gastroenteritis.Boerhaaves syndrome.Mallory-Weiss Syndrome.

Cholelithiasis

Kehrs signIrritation of the diaphragm perceived as pain in the side of the neck and proximal shoulder area. iliopsoas sign obturator sign Murphys sign Rovsings sign,pain is caused in the RLQ while palpating the opposite side of the abdomen, is another indicator of appendicitis.

*Acute abd pain is pain of