4. • A 32-year-old woman presents with chest pain that has
worsened over the past 2 months. She says it gets worse
when she lies flat or exercises and after she eats or drinks
quickly. She has no significant past medical history, but
her husband says she has lost about 10 pounds recently
and has been throwing up undigested food. What are the
expected diagnostic findings?
• A. Diffuse ST-segment elevation and PR-interval
depression
• B. Dilated esophagus proximal to a beaklike lower
esophageal sphincter
• C. Gastric inflammatory changes
• D. White matter plaques in the brainstem
1/16/2007
UNSOM: EMR
5. • A 32-year-old woman presents with chest pain that has
worsened over the past 2 months. She says it gets worse
when she lies flat or exercises and after she eats or drinks
quickly. She has no significant past medical history, but
her husband says she has lost about 10 pounds recently
and has been throwing up undigested food. What are the
expected diagnostic findings?
• A. Diffuse ST-segment elevation and PR-interval
depression
• B. Dilated esophagus proximal to a beaklike lower
esophageal sphincter
• C. Gastric inflammatory changes
• D. White matter plaques in the brainstem
1/16/2007
UNSOM: EMR
9. • Which of the following patients requires oral fluconazole
treatment?
• A. 17-year-old girl with both dysphagia and odynophagia
refractory to acid suppression therapy who also has
multiple allergies
• B. 27-year-old man with chest pain and severe
odynophagia who also has asthma and is HIV positive
• C. 47-year-old man with transport dysphagia for solids
initially and now liquids who also smokes
• D. 55-year-old man with halitosis, transfer dysphagia, and
neck fullness
1/16/2007
UNSOM: EMR
10. • Which of the following patients requires oral fluconazole
treatment?
• A. 17-year-old girl with both dysphagia and odynophagia
refractory to acid suppression therapy who also has
multiple allergies
• B. 27-year-old man with chest pain and severe
odynophagia who also has asthma and is HIV positive
• C. 47-year-old man with transport dysphagia for solids
initially and now liquids who also smokes
• D. 55-year-old man with halitosis, transfer dysphagia, and
neck fullness
1/16/2007
UNSOM: EMR
11. Hiccups (Singultus)
• Involuntary stimulation of the respiratory reflex
with spastic contraction of inspiratory muscles
on closed glottis
• Benign causes: gastric distention, smoking,
ETOH, change is environmental temperature
• Persistent: damage to vagus/phrenic
nerve/CNS
Continue with sleep: organic
Relieved with sleep: psychogenic
• Organic
CNS: neoplasm, MS, ICP
PUD, tonsillitis, goiter, pericarditis, pacemaker, STEMI
1/16/2007
UNSOM: EMR
12. Esophageal Rupture (1)
• MCC iatrogenic
#1: Endoscopy
#2: Dilation
MCC in ED: NG tube
Diagnosis by esophagram
• Mallory - Weiss - partial thickness tear
Location: GE junction
5-15 % of UGI bleeds
Vomiting, retching
Risk factors: ETOH, hiatal hernia
Spontaneous resolution common
1/16/2007
UNSOM: EMR
13. Esophageal Rupture (2)
• Boerhaave’s Syndrome - full thickness tear
Males usually, age 40-60
Typically associated with alcohol (50%)
Typically left posterior distal rupture
Chemical, then infectious mediastinitis
Severe chest pain, shock, sepsis
Air in mediastinum (Hamman’s crunch)
Pyopneumothorax
Gastrografin (water soluble) UGI
Fluids, Antibiotics, Surgical consult
• X-ray: mediastinal air, left pleural effusion,
pneumothorax, widened mediastinum
1/16/2007
UNSOM: EMR
18. Esophageal Foreign Bodies (3)
• 10-20% require some intervention
• 1% demand surgical treatment
• Most foreign bodies will pass if they traverse
the pylorus
• Soft drink pull tabs - may not show up on x-ray
1/16/2007
UNSOM: EMR
20. Esophageal Foreign Bodies (5)
• Button batteries
Double density radiographically
Must always be removed from esophagus immediately
Rapid burns with perforation < 6 hours (Lithium worse)
Batteries do not need to be removed:
Passed esophagus, asymptomatic
Passed the pylorus <48 hours
Most will pass completely in 48-72 hours, serial radiography
• Treatment: broad-spectrum ABX, surgical consultation
1/16/2007
UNSOM: EMR
21. Foreign Bodies (6)
Sharp objects
> 5cm long & 2cm wide
Magnet + metal
All others: serial exam / x-rays
Fish/Chicken bones or plastic CT
1/16/2007
UNSOM: EMR
24. Esophageal Food Impaction
• Most patients with food impaction have
underlying esophageal pathology
• Must evaluate for cause after dislodgement
• Treatment options:
Glucagon - relaxes distal esophageal sphincter
Nifedipine - reduces lower esophageal tone
Carbonated beverages - gaseous distention
may push the bolus into the stomach
Endoscopy
No papain (meat tenderizer)
1/16/2007
UNSOM: EMR
25. Caustic Ingestions (1)
• Acids (+/- bad)
Coagulation necrosis
No ongoing tissue necrosis
• Alkali (bad)
Liquefaction necrosis (pH 12.5)
Ongoing tissue necrosis
• Severity
Nature, volume and concentration
Tissue contact time
Presence or absence of stomach contents
Tonicity of pyloric sphincter
1/16/2007
5
UNSOM: EMR
26. Caustic Ingestions (2)
• Inconsistent relationship between oral signs /
symptoms and esophageal findings
• All patients with 2-3° burns are symptomatic
• Diluents - water / milk only for solid alkali
• No neutralizers = exothermic generation of heat
Endoscopy best diagnostic tool
• Complications
Early: acute airway compromise due to edema,
perforation
Late: stricture, perforation
1/16/2007
UNSOM: EMR
27. Peptic Ulcer Disease
• Incidence decreasing in general population and
increasing in the elderly (liberal use of NSAIDs)
• MCC Duodenal (80%), gastric (20%)
• Helicobacter pylori responsible for most
• Predisposing factors:
• Treatment:
- antibiotics against H. pylori (amox, clarithro, metro)
- histamine blockers (histamines stimulate acid inhibitors)
- parietal cell inhibitors (omeprazole)
- ulcer surface protectants (sucralfate)
• Complications:
1/16/2007
- smoking, alcohol
- type O blood
- NSAIDs and steroids
- bleeding
- perforation (can cause pancreatitis)
(do upright CXR for free air)
- obstruction
UNSOM: EMR
29. Bilirubin (2)
• Conjugated bilirubin in bowel is converted by
gut bacteria to urobilinogen
• Urobilinogen is absorbed from the gut into the
circulation and excreted in urine
• If jaundice is present but urine urobilinogen is
negative = excess unconjugated
hyperbilirubinemia
• If jaundice is present but excess positive urine
urobilinogen = excess conjugated bilirubin
1/16/2007
UNSOM: EMR
30. Hepatitis (1)
• Causes - viral and toxic
Malaise, jaundice, increased SGOT, increased
bilirubin
Alcoholic hepatitis
Abnormal protime is a marker indicating
significant liver dysfunction
if elevated,
consider altering or holding doses of livermetabolized drugs
• Viral Type A
1/16/2007
Fecal - oral, onset 2 weeks post-exposure
Prophylaxis - immune globulin within 2 weeks of
exposure (travelers, household contacts)
UNSOM: EMR
31. Hepatitis (2)
• Viral Type B
Percutaneous, parenteral or sexual exposure
Onset 1-6 mo (mean = 75 days) post-exposure
Complications = cirrhosis, liver cancer, carrier
state (10%)
• Markers
HBsAg:
HBsAb:
HBcAb:
HBeAg:
+ early (before enzymes increase) Infective
+ 2-6 mo after clearance of HBsAg Immune
+ 2 wks after + HBsAg * persists for life
+ implies high infectivity
*May be the only positive marker during the window
when HBsAg declining and HBsAb increasing
1/16/2007
UNSOM: EMR
32. Hepatitis (3)
• Hepatitis B exposure - source known HBsAg
positive
• Unvaccinated
HBIG ASAP + vaccination (0, 1 mo, 6 mo)
• Vaccinated
Incomplete series- vaccine booster
Known responder- test for HBsAb if > 10,
no rx; if < 10 HBIG and vaccine booster
Known non - responder - HBIG x 2 (0, 30 days)
1/16/2007
UNSOM: EMR
33. Hepatitis (4)
• Hepatitis B exposure - source unknown
• Unvaccinated
Initiate vaccination
• Vaccinated
Same as for HBsAg positive source
• HBIG only recommended if source or situation
maybe high risk for exposure
1/16/2007
UNSOM: EMR
34. Hepatitis (5)
• Viral Type C
Percutaneous, parenteral or sexual exposure
Usual cause of non-A, non-B hepatitis
High carrier rate, higher incidence in HIV
Cirrhosis / liver cancer (50%)
2% seroconversion
• Indications for hospitalization (any hepatitis)
Encephalopathy, PT/INR significantly increased,
dehydration, hypoglycemia, bilirubin over 20, age
over 45, immunosuppression, diagnosis uncertain
1/16/2007
UNSOM: EMR
35. Hepatic Encephalopathy
• Precipitants = “LIVER” (Librium [sedatives],
Infection, Volume loss, Electrolytes disorders, Red
blood cells in the gut [a major cause])
• Others: dietary protein excess, worsening
hepatocellular function
• Early sign = “sleep inversion” - sleeping during the
day / awake at night
• Asterixis (“liver flap”)
• Ammonia levels: arterial more helpful than venous
• Check for hypoglycemia!!!
• Treatment: Oral or rectal neomycin / lactulose /
decrease dietary protein / avoid sedatives / avoid
bicarbonate (alkalosis can worsen encephalopathy)
1/16/2007
UNSOM: EMR
36. Spontaneous Bacterial Peritonitis
• Occurs with chronic liver disease
Portal hypertension
bowel edema
migration and leakage of enteric organisms (E.
coli 50%, enterococcus 25%)
• Abdominal tenderness, worsening ascites,
encephalopathy, fever, sepsis, shock
• Diagnosis: paracentesis with increased WBC
PMN >250/ul
• Tx: Ceftriaxone, ppx: Cipro or Bactrim
1/16/2007
UNSOM: EMR
37. • A 57-year-old man with a history of cirrhosis
presents with acute renal failure. He denies
recent illness and is not taking any nephrotoxic
medications. He is well hydrated; his urinalysis
is negative. Which of the following is the
definitive treatment?
• A. Hydration
• B. Liver transplant
• C. Renal transplant
• D. Transjugular intrahepatic portosystemic
shunt
1/16/2007
UNSOM: EMR
38. • A 57-year-old man with a history of cirrhosis
presents with acute renal failure. He denies
recent illness and is not taking any nephrotoxic
medications. He is well hydrated; his urinalysis
is negative. Which of the following is the
definitive treatment?
• A. Hydration
• B. Liver transplant
• C. Renal transplant
• D. Transjugular intrahepatic portosystemic
shunt
1/16/2007
UNSOM: EMR
39. Gallbladder (1)
• Stones = mostly bilirubin / cholesterol (radiolucent)
• Biliary colic = pain, vomiting, due to obstruction
by stones without inflammation
• Cholecystitis (stone-related = calculous)
MCC of abdominal pain in the elderly
OR
Obstruction
distention pain / vomiting /
inflammation
infection (usually E. coli,
Klebsiella)
increased WBCs
• Rupture of stone into small bowel with obstruction at
ileocecal valve = GALLSTONE ILEUS
Air in biliary tree (from bowel) = pneumobilia
1/16/2007
UNSOM: EMR
40. Gallbladder (2)
• Acalculous cholecystitis
No stones
5-10% of cases
Usually a complication of another process
(trauma, burn, postpartum, postop, narcotics)
Patients often quite sick
Likely cause of GB perforation
Increased risk with diabetes and elderly
Greater morbidity than calculous variety
• Ascending cholangitis
Infection spreading through biliary tree
Charcot’s triad = jaundice, fever, RUQ pain
1/16/2007
UNSOM: EMR
42. Gallbladder (3)
• Ultrasound initial diagnostic study of choice
Ultrasound shows stones, wall thickening, duct dilatation
(not inflammation)
HIDA has sensitivity/specificity 97% / 90%
HIDA or PIPIDA scan is positive if GB is not visualized =
cystic duct obstruction, best test for cholecystitis
Immediate surgical consult
Air in biliary tree, fever, jaundice,
diabetic, elderly, immuno-compromised
1/16/2007
UNSOM: EMR
46. Pancreatitis (3)
• Amylase
Multiple non-pancreatic sources
Height of amylase not necessarily related to
severity
• Lipase
May be more sensitive than amylase
More specific than amylase
Closely follows clinical course
• Plain x-ray
1/16/2007
Colon cutoff = dilation only over pancreas
Pancreatic calcification
Sentinel loop = small bowel air over pancreas
Imaging study of choice - contrast CT
UNSOM: EMR
49. GI Bleeding
Definitions
• Hematemesis - UGI proximal to ligament of
Treitz
• Hematochezia
Maroon stools
Very rapid UGI bleed (uncommon)
Usually colon or small bowel bleed
• Melena - black tarry stools - usually UGI bleed,
color from effects of acid and digestion on
blood (GI protein breakdown of blood causes
increased BUN)
1/16/2007
UNSOM: EMR
50. Upper GI Bleeding Sites
• A prior site of GI bleeding is often not the site
of subsequent bleeds (best example = variceal
bleed, half of subsequent bleeds are from
another site)
• UGI sites
MCC PUD (45-50%) usually duodenal
Gastritis (15-30%) (alcohol, NSAIDS)
Varices (10-15%) 1/3 of UGI bleed deaths
Mallory - Weiss esophageal tears (5-10%)
Esophagitis (5-10%) (MCC in pregnancy
Duodenitis (less than 5%)
1/16/2007
UNSOM: EMR
52. • A 67-year-old woman presents after three episodes of
hematemesis. She denies significant past medical history
and is taking only an over-the-counter medication for
osteoarthritis. She appears anxious and diaphoretic.
During the interview, she vomits 250 mL of bright red
blood. Physical examination is notable for blood pressure
79/58, pulse 122, moderate epigastric abdominal
tenderness and bloody stool. Which of the following is
most likely to control the bleeding?
• A. Bedside esophagogastroduodenoscopy
• B. Nasogastric tube placement with lavage
• C. Omeprazole infusion followed by vasopressin drip
• D. Sengstaken-Blakemore tube
1/16/2007
UNSOM: EMR
53. • A 67-year-old woman presents after three episodes of
hematemesis. She denies significant past medical history
and is taking only an over-the-counter medication for
osteoarthritis. She appears anxious and diaphoretic.
During the interview, she vomits 250 mL of bright red
blood. Physical examination is notable for blood pressure
79/58, pulse 122, moderate epigastric abdominal
tenderness and bloody stool. Which of the following is
most likely to control the bleeding?
• A. Bedside esophagogastroduodenoscopy
• B. Nasogastric tube placement with lavage
• C. Omeprazole infusion followed by vasopressin drip
• D. Sengstaken-Blakemore tube
1/16/2007
UNSOM: EMR
54. UGIB Management
• PPI (No benefit?)
• Octreotide for variceal bleed, decreases
splanchnic flow (No benefit?)
• Vasopressin for variceal if delay to endoscopy
• Only clear benefit from antibiotics in cirrhotics
• Sengstaken-Blakemore/Minnesota tube last
resort for esophageal varices
1/16/2007
UNSOM: EMR
55. Lower GI Bleeding (1)
Sites
• MCC Upper GI bleed
• Diverticulosis
• Angiodysplasia (AV malformations), associated
with HTN and aortic stenosis - usually right colon
• Aortoenteric fistula, esp if previous AAA repair
Erosion of synthetic vascular graft into gut
(often preceded by premonitory bleed)
• Cancer / polyps, IBD, rectal disease
• Hemorrhoids: MCC of rectal bleeding
• Anal fissure – MCC of minor LGI bleeding in infants
to age 5
1/16/2007
UNSOM: EMR
56. Low risk LGIB – send home?
•
•
•
•
•
•
•
1/16/2007
No comorbid disease
Normal vitals
Negative or trace positive stool guiac
Negative NG lavage (if performed)
Normal H/H
Good support/reliable
24 hour follow up
UNSOM: EMR
57. Osler-Weber-Rendu Syndrome
• Autosomal dominant vascular anomaly
• Multiple small telangiectases of the skin,
mucous membranes, GI tract
• Recurrent episodes of GI bleeding, gross and
occult
1/16/2007
UNSOM: EMR
58. Pediatric GI Bleeding (1)
Under 2 Months
• Upper
Bleeding diathesis
Swallowed maternal blood
Vascular malformation
• Lower
MCC is Meckel’s diverticulum (50%)
Congenital GI duplications
Intussusception
Necrotizing enterocolitis
Swallowed maternal blood
Vascular malformation
Volvulus
1/16/2007
UNSOM: EMR
62. Pediatric GI Bleeding (4)
Lower GI Bleeding Sites (1)
• Meckel’s diverticulum
Congenital anomaly, 2% of population
Typically diagnosed age < 2
Located 40 cm from ileocecal jnx, free or attached to
umbilicus
Ectopic production of gastric acid (30-50%)
Peptic ulceration causes bleed
Most common cause of significant LGI bleeding in
children
Can mimic appy, may initiate intussusception, or
volvulus
Painless “bright red” bleeding
(most common clinical presentation)
1/16/2007
UNSOM: EMR
63. • A 11-month-old boy is brought in by his mother
after she noticed a large amount of dark red blood
in his diaper. He appears well and has normal
vital signs and a benign abdominal examination.
Rectal examination is remarkable for blood
without an obvious source. Which of the following
is needed to confirm the suspected diagnosis?
• A. Abdominal ultrasound examination
• B. Additional history on diet
• C. Apt test
• D. Nuclear medicine scan
1/16/2007
UNSOM: EMR
64. • A 11-month-old boy is brought in by his mother
after she noticed a large amount of dark red blood
in his diaper. He appears well and has normal
vital signs and a benign abdominal examination.
Rectal examination is remarkable for blood
without an obvious source. Which of the following
is needed to confirm the suspected diagnosis?
• A. Abdominal ultrasound examination
• B. Additional history on diet
• C. Apt test
• D. Nuclear medicine scan
1/16/2007
UNSOM: EMR
65. Pediatric GI Bleeding (5)
Lower GI Bleeding Sites (2)
• Intussusception
Sudden, intermittent pain, vertical sausage
mass in 50%
“Currant jelly” stool
Second most common cause of lower GI
bleeding in children
Most common cause of bowel obstruction in
first 2 yrs.
BE = diagnostic and therapeutic
1/16/2007
Lead points
Adults = polyp, cancer
Child = Meckel’s, lymphoid patch
UNSOM: EMR
66. Hernias (1)
• Inguinal - most common
Direct - does not
involve passage
through the inguinal
canal
Indirect - involves
inguinal canal (most
common)
• Femoral – femoral
canal, usually female,
below the inguinal
ligament, strangulation /
incarceration common
1/16/2007
UNSOM: EMR
67. Hernias (2)
• Umbilical
Congenital: newborns - blacks > whites; females >
males, strangulation / incarceration rare
Acquired: women, obesity, pregnancy & ascites,
strangulation / incarceration common
• Pantaloon : Indirect + direct at same time
• Spigelian (lateral ventral): level of arcuate line lateral
to rectus abdominus, difficult to diagnose, CT / US
• Richter - incarceration of a single wall of a
hollow viscus
• Incarcerated = irreducible (highest incidence of
inguinal incarceration = 1st year)
• Strangulated = irreducible with vascular compromise
(don’t manually reduce)
1/16/2007
UNSOM: EMR
68. Ileus
• Ileus = cessation of normal peristalsis without
mechanical obstruction
• Continuous pain, distention, decreased bowel
sounds, minimal or no tenderness, no flatus or
BM, usually self limiting
• Ileus is more common than mechanical bowel
obstruction
• X-rays show entire bowel with dilated, fluidfilled loops
1/16/2007
UNSOM: EMR
69. Bowel Obstruction
• Small bowel
(1) adhesions, (2) hernias, (3) malignancy
Generally more intense pain and more vomiting
and less distention than large bowel obstruction
X-ray - “step ladder” plicae circulares - traverse
bowel width
• Large bowel
(1) cancer, (2) diverticulitis, (3) sigmoid volvulus
X-ray: haustral pattern (doesn’t traverse entire
bowel width)
• “Closed-loop” obstruction dangerous = perforation
Can occur in colon if ileocecal valve is
competent
1/16/2007
UNSOM: EMR
73. Volvulus
• Sigmoid volvulus
Elderly, debilitated
•
Chronic motility
disorder
Insidious onset, most
recur
X-ray: inverted u, loops
project obliquely to
RUQ
Sigmoidoscopy may
be therapeutic
Third most common cause of
large bowel obstruction behind
(diverticular, tumor)
1/16/2007
Cecal (15 -20%)
Young (35 -55), runner
Congenital freely
mobile cecum
Acute onset
X-ray: kidney shaped
loop, LUQ,
Requires surgery
The most common cause in
pregnancy
UNSOM: EMR
76. Bowel Perforation
• Large bowel > small bowel
• Mechanism: inflammation, ulceration, trauma,
obstruction
• Causes - diverticular disease (the most common
cause), appendicitis (especially at extremes of
age), colitis / IBD, ischemia, cancer, foreign
body, PUD, radiation
• Cecum the most common site
• X-rays – may miss small amount of free air or
retroperitoneal, best view = upright chest x-ray
Ulcers are the most common cause of a visceral perforation
1/16/2007
UNSOM: EMR
78. Pediatric GI Emergencies
• Obstructive GI lesions 1st year
Gut atresia
Inguinal hernia
Malrotation, +/- volvulus
Volvulus around congenital band
Intussusception
Meconium ileus (associated with CF)
Hirschsprung’s disease
Duplication cysts of intestine
BE is diagnostic study
of choice after plain x-ray
1/16/2007
UNSOM: EMR
79. Pediatric GI Emergencies
Obstructive Newborn GI Lesions 1st Year
• Intussusception
MCC surgical abdomen/obstruction 3mo – 6yr
Ileocolic most common (85%)
Peak incidence - age 5 to 9 months / most occur
before 2
Classic triad only in 30% (colicky pain, vomiting,
currant jelly stool)
Paroxysms of colicky pain is the most specific
symptom
KUB: “coiled spring”
Infants less than one can have profound
listlessness as well
Children with Henoch-Schönlein purpura are at
increased risk
Ultrasound can be diagnostic as well as BE
1/16/2007
UNSOM: EMR
83. Pediatric GI Emergencies
Obstructive Newborn GI lesions 1st year
• Malrotation +/- volvulus
First year of life > first month
Early diagnosis is crucial to prevent gangrene
of midgut
Abnormal rotation & fixation
X-ray: loop of bowel over-riding the liver is
suggestive (double bubble)
Acute abdomen, shock, rigid / distended
abdomen, bilious vomiting
Bilious vomiting / signs of obstruction = prompt
surgical consultation
1/16/2007
UNSOM: EMR
84. Pediatric GI Emergencies
Obstructive Newborn GI Lesions 1st Year
• Pyloric stenosis
Non-bilious projectile vomiting
Hypochloremic metabolic alkalosis
First born males, familial propensity 50%
Third week to third month of life
Palpable “olive”: mass lateral margin right
rectus muscle at liver edge
Ultrasound (20%) false negative
UGI: delayed gastric emptying, string sign
1/16/2007
UNSOM: EMR
85. • What is the most common cause of small
bowel obstruction in children?
• A. Adhesions
• B. Hernia
• C. Intussusception
• D. Midgut volvulus
1/16/2007
UNSOM: EMR
86. • What is the most common cause of small
bowel obstruction in children?
• A. Adhesions
• B. Hernia
• C. Intussusception
• D. Midgut volvulus
1/16/2007
UNSOM: EMR
87. Constipation
• Most common digestive complaint in United States,
2.5 million visits
• 30-40% > 65 years old
• Acute causes: obstruction, medication (narcotics, Ca2+
blockers, psych. meds, Fe, antacids)
• Common cause: fiber + fluid intake + exercise
• Chronic causes: slow growing tumor, thyroid,
parathyroid, lead, neurologic dysfunction
• Rectal exam for: fecal impaction, rectal mass, heme +
stool, anal fissure
• Treatment: diet/behavior changes, medical adjuncts,
underlying cause
1/16/2007
MUST RULE OUT OBSTRUCTION
UNSOM: EMR
88. Inflammatory Bowel Disease
•
•
•
•
•
Crohn’s disease & ulcerative colitis
Idiopathic, chronic
High rate of colon CA with disease > 10 years
Exacerbation / remission pattern
Bimodal age distribution peaks between 20’s
and 60’s
• Extracutaneous manifestations - arthritis
(20%), dermatologic (4%), hepatobiliary (4%),
vascular (1.3%) - also uveitis
• Tx: sulfasalazine, mesalamine, prednisone,
metronidazole, ciprofloxacin
1/16/2007
UNSOM: EMR
89. Regional Enteritis - Crohn’s Disease
• Chronic inflammatory disease of the entire GI
tract
• Segmental involvement is characteristic =
“skip lesions”
• Abdominal pain, cramps, diarrhea (sometimes
bloody), fever, perianal fissures, fistulas or
abscesses or rectal prolapse (90%), toxic
megacolon
• Gross blood uncommon
• ↑ oxalate absorption of terminal ilium leads to
nephrolithiasis
1/16/2007
UNSOM: EMR
90. Ulcerative Colitis
• Chronic inflammatory disease - colon
• Similar GI symptoms to Crohn’s disease
Major finding = bloody diarrhea
Toxic megacolon
Gross distention (over 8 cm)
Transverse colon
Systemic toxicity
Peritonitis
• Rectum, small bowel not affect (unlike Crohn’s)
• Colon cancer = 10 - 30 times greater risk
1/16/2007
UNSOM: EMR
91. Mesenteric Ischemia
• Risk factors - dysrhythmias (a. fib), low flow &
hypercoagulable states, vascular disease
• Deadly / generally elderly / early angiography
• Causes:
Embolic *(30%)
Arterial thrombus *(10%)
Venous thrombus (10%)
Nonocclusive (50%)
*Sudden onset with
pain out of proportion
to physical findings
• Leukocytosis (present in most cases), acidosis,
hyperphosphatemia, hyperamylasemia - all
inconsistently present
• Avoid digoxin, beta-blockers, vasopressors
(decrease splanchnic blood-flow)
1/16/2007
UNSOM: EMR
92. Mesenteric Ischemia Imaging
•
•
•
•
Thickened bowel wall
Pneumointestinalis (air in bowel wall)
Air in portal vein
“Thumb printing” = submucosal hemorrhage
All infrequently seen
Mainstay of diagnosis = arteriography
1/16/2007
UNSOM: EMR
93. Appendicitis (1)
• Luminal obstruction
inflammation
infection
• Anorexia often present
•
•
•
•
•
•
•
Increased perforation in elderly and small children
Pain migrating periumbilical to RLQ is specific
Late pregnancy - moves lateral and superior
BE - mass effect and non-filling
KUB - appendicolith (1%)
Ultrasound - dilated, non-compressible >6mm
Spiral CT – usually diagnostic
Most common cause of surgical abdomen
1/16/2007
UNSOM: EMR
95. Appendicitis (2)
• Confounders = situs inversus, retrocecal, pregnancy
malrotation, very long appendix
Result-uncommon pain location: right upper quadrant,
back, flank, testicular, suprapubic
• Rovsing’s sign = LLQ palpation
RLQ pain
Psoas sign = RLQ pain on thigh extension while lying in
left lateral decubitus position
Obturator sign = RLQ pain with internal rotation of the
flexed right thigh
• Most common symptom: anorexia, nausea and vomiting
• R sided tenderness most common sign
• Rebound, rectal and referred tenderness common
• Psoas/obturator sign uncommon
1/16/2007
UNSOM: EMR
97. Diverticulitis (1)
• Pain is the most common symptom
Steady, deep, LLQ
• Bowel habits may be altered - diarrhea or
constipation
• May mimic appendicitis if copious redundant
sigmoid colon
• Intraluminal pressure is greatest in the sigmoid
(most diverticula there)
1/16/2007
UNSOM: EMR
98. Diverticulitis (2)
• Manifestations = pain (inflammation / infection)
and bleeding; pain left side, bleeding right side
• Free perforation is rare / most are contained to
the mesentery
• May cause urinary frequency / urgency due to
irritation of underlying GU structures
• Colon cancer may be in the differential
• Tx: fiber, abx (Cipro/Metro), analgesics
1/16/2007
UNSOM: EMR
99. Diarrhea
• Viral
Most common cause of diarrhea 50-70% of cases
Mostly winter / spring / children / day care
Rotavirus, adenovirus calicivirus, enterovirus, Norwalk agent
“RACE to Norwalk”
Rotavirus MCC pediatric cause of diarrhea 50%
Self-limiting / fecal-oral / community outbreak
1/16/2007
UNSOM: EMR
100. Diarrhea - Invasive
• Invades mucosa
inflammation (stool WBCs)
and bleeding (degree varies by pathogen),
fever, rash, arthritis, septicemia
• E. coli 0157:HS
Hamburger, petting zoo, raw milk, untreated water
Can cause HUS (children) and TTP (elderly)
No ABX recommended may increase risk of HUS
1/16/2007
UNSOM: EMR
101. Diarrhea - Invasive (2)
• Shigella
Very infectious,
high fever, febrile
seizures, watery bloody
Most common
cause of bloody
diarrhea
1/16/2007
• Salmonella
Very common bacterial diarrhea
(U.S.)
Watery / mucoid
Pet turtles, amphibians, eggs,
chickens
Osteomyelitis can occur in sicklers
(autosplenectomy) and those with
splenectomy
Systemic toxicity =
typhoid fever
(low WBC and relative carrier state
Antibiotics increase bradycardia,
abdominal septic)
(give if sick /pain, no diarrhea)
UNSOM: EMR
102. Diarrhea - Invasive (3)
• Campylobacter
Most common cause of bacterial diarrhea
Hard to culture / water-borne (raw milk)
Invasive enterotoxin
60-70% with bloody diarrhea (gross or occult)
Erythromycin (children), fluoroquinolone (adults)
Acute infection associated with development of
Guillain-Barré syndrome
• Vibrio
Parahaemolyticus - oysters, clams, crabs,
2 -12 hour latency
Vulnificus - oysters, shellfish increased morbidity /
mortality with pre-existent liver disease
1/16/2007
UNSOM: EMR
103. Diarrhea - Invasive (4)
• Yersinia enterocolitica
Invasive gram pos bacteria
Increasing evidence, most common in
childhood
Can mimic appendicitis
Fever
Colicky abdominal pain (may be prolonged)
Diarrhea
May be persist 10-14 days
• Diagnosis: fecal WBC stain positive, stool
C&S
• Treatment: uncomplicated - supportive only
complicated - TMP-SMX, quinolones
1/16/2007
UNSOM: EMR
104. Diarrhea - Protozoan (1)
• Giardia
Most common US intestinal parasite
Beavers, deer, stream contamination
Stools floating, frothy, foul-smelling, flatulence
Multiple stool specimens may be needed to
identify cysts and / or trophozoites
Metronidazole
Homosexuals, campers, pregnancy
1/16/2007
UNSOM: EMR
105. Diarrhea - Protozoan (2)
• Amebiasis (entamoeba histolyticus)
Spread between family members and sexual
partners
Fecal / oral - anal intercourse
Diarrhea can be bloody
Extra-intestinal manifestations (5%)
Liver abscess most common (“chocolate cysts”)
Pericarditis, pleuropulm disease, cerebral amebiasis
Wide variety of presentations
Asymptomatic cyst passer
Colitis
Cerebral amebiasis
1/16/2007
UNSOM: EMR
106. Diarrhea Protozoan (3)
• Cryptosporidium
Intestinal protozoan parasites
MCC of chronic diarrhea in AIDS
Contaminated water supply; recent outbreaks
Children, animal handlers; immunocompromised
Ingestion of oocysts; trophozoites attack intestinal
membrane
1 week incubation, severe watery diarrhea,
abdominal pain
• Diagnosis: Oocyst in stool
• Treatment: Fluid replacement, CDC rec’s
nitazoxanide, or parmomycin plus azithro
1/16/2007
UNSOM: EMR
107. Diarrhea - Toxigenic (1)
•
•
•
•
•
1/16/2007
Bacteria producing enterotoxin
Food-borne
Diarrhea: watery, voluminous
Minor fever, no septicemia
No WBC or RBC in stool
UNSOM: EMR
108. Diarrhea - Toxigenic (2)
• Staph (toxin)
Contaminated foods
GI overgrowth from antibiotics
Ham, poultry, dairy products, potato salad
MCC of food-borne disease
Symptoms within 6 hours of ingestion
Usually afebrile, no abx
• E. coli
Water contaminated by feces
MCC Traveler’s diarrhea
No readily available diagnostic tests
TMP / SMX, cipro
1/16/2007
UNSOM: EMR
110. Diarrhea – Toxigenic
• Bacillus Cereus
• Aerobic spore forming pod
• Common in rice, especially Chinese
restaurants
• Spores germinate when boiled rice is not
refrigerated
• Two forms:
Emetic: 2 – 3 hours post ingestion (much like Staph)
Diarrheal: 6 – 14 hours (much like Clostridia)
• Also from vegetables and meat
• Self limited; no specific therapy or test
1/16/2007
UNSOM: EMR
111. Diarrhea - Toxigenic (4)
• Scombroid poisoning
Named for fish (suborder) = tuna, mackerel,
mahimahi (most frequent cause), related species
Heat - stable toxin from bacterial action on dark meat fish
Histamine - like toxin / rapid symptom onset (30
min)
Fish - tastes “peppery”
Facial flushing, diarrhea, throbbing headache,
abdominal cramps, palpitations
Give antihistamines and H2 blockers
Suspect when multiple patients have “allergic
reaction”
1/16/2007
UNSOM: EMR
112. Diarrhea - Toxigenic (5)
• Ciguatera
S.E. US, tropical and subtropical waters
Grouper, snapper, king fish
Fish eat certain dinoflagellates in spring /
summer, that contain toxins harmful to those
eating the fish
Muscle weakness, paresthesias (perioral,
burning hand / feet), distorted or reversed
temperature sensation, vomiting, diarrhea
Neuro symptoms worsened with alcohol
No specific treatment, symptoms can be
permanent
1/16/2007
UNSOM: EMR
113. Pseudomembranous Enterocolitis
•
•
•
•
•
•
•
•
•
1/16/2007
Varieties = neonatal, postop, antibiotic-related
Due to overgrowth of toxin-producing C. difficile
Begins 7 - 10 days after beginning antibiotics
Patients may be quite sick - fever, toxic, profuse
diarrhea, dehydration
Diagnosis via immunoassay for toxin
Inflammatory disease, membrane - like yellow
plaques
Treatment by stopping precipitating antibiotics
Treat with metronidazole or vancomycin orally
No anti-diarrheals
UNSOM: EMR
114. Botulism
• Characteristics
Heat-labile neurotoxin, short onset (half hour)
Inadequately processed canned foods
Bulbar symptoms / descending paralysis /
anticholinergic findings
• Infantile
Floppy baby, constipation, feeble cry
Honey can be source
Most common in breast-fed / also less severe in
this subset
• Adult
Diplopia (most common early finding), dysphonia,
ptosis, dysarthria, dysphagia
Anticholinergic symptoms - urinary retention, pupil
abnormalities, dry mouth, abd. cramps, nausea
and vomiting
1/16/2007
UNSOM: EMR
115. Rectal Prolapse
• Full thickness protrusion of rectum through anal
canal
• Sensation of rectal mass
• In children, intussusception more likely
• Differentiation from internal hemorrhoids &
intussusception
Intussusception – can place finger between
protruding rectum and anus
Internal hemorrhoids – fold of mucosa radiates
out like spoke on a wheel
Rectal prolapse – folds of mucosa circular
1/16/2007
UNSOM: EMR
117. Hemorrhoids
• Engorgement, prolapse, or thrombosis of the
hemorrhoid veins
• Internal located at 2, 5, 9 o'clock position
• Risk factors: constipation, pregnancy, ascites, portal
hypertension
• Painless ,self limited, BRBPR,common presentation
• Treatment
Non complicated (nonsurgical): sitz bath, laxatives,
topical steroids, fiber
Complicated: large, incarcerated, strangulated,
intractable pain require surgery
Thrombosed: elliptical incision to remove clot
1/16/2007
UNSOM: EMR
118. Anal Fissure
• Most common causes of painful rectal bleeding in
adults and children
• 90% posterior midline
• Non-midline fissures should suggest more serious
conditions
IBD, CA, sexual abuse
• Sharp cutting pain, especially with bowel movement,
blood-streaked stool
• Perianal hygiene, sitz baths
Fistula in Ano
Tract between rectum and skin
Causes drainage and itching
Consider Crohn’s Disease
1/16/2007
UNSOM: EMR
120. Rectal Trauma
• Causes:
Penetrating 80%
Blunt 10%
Iatrogenic
Foreign body
• Must consider GU & colon injuries
• Rectal foreign body
60% removed in ED
High-riding or sharp require general anesthesia
Sigmoidoscopy after removal
1/16/2007
UNSOM: EMR
122. GI Miscellaneous (1)
• BE and colonoscopy are relatively
contraindicated in diverticulitis (fear of
perforation)
• Hypoglycemia in alcoholics may not respond to
glucagon because liver glycogen stores are
depleted
• AIDS patients with diarrhea usually have stool
specimens positive for pathogens; due to the
numerous causes, empiric therapy is not
advised
1/16/2007
UNSOM: EMR
123. GI Miscellaneous (2)
• Extension of a perirectal abscess = ischiorectal
abscess
• Prolapsed, irreducible internal hemorrhoids
require urgent surgery
• In most alcoholics with low-grade amylase
elevations, the source is non-pancreatic
• Most common serious complication of a
Sengstaken - Blakemore tube = aspiration /
suffocation
1/16/2007
UNSOM: EMR
