GI Review2020 EMRAM In-Service Review Course

Olga Dewald, MD, MAEPMG/Sparrow Hospital

Question #1What is the most common cause of oropharyngeal

dysphagia?

Esophagus: dysphagia causes

Credit: Merck manuals

OropharyngealNeuromuscular disorder

Upper esophagealWebs, Zenker

Lower esophagealCarcinoma, achalasia

***Odynophagia=esophagitis(infectious, inflammatory)

Question #2What is the most common cause of esophageal perforation?

Question #2What is the most common cause of esophageal perforation?

#1: Iatrogenic perforation (EGD, intubation, bougie)

+

Foreign body

Caustic agent

Violent and repeated vomiting

Question #3What is the most common site of foreign body impaction in

the esophagus in children versus adults?

Esophagus: foreign bodies

CHILDREN

● True foreign bodies● Cricopharyngeus muscle

(C6)● ⅓ of patients have no

symptoms = high index of suspicion

ADULTS

● Food● Lower esophageal

sphincter (T10 -11)

Question #4What is the difference between esophageal and tracheal

foreign body aspiration radiographically?

Esophagus or trachea?

Credit: Tiedeken, SH., Shaffer SE., Worrisome chronic cough in a 3-year old girl. Contemporrary Pediatrics, 2014.

Esophagus or trachea?Clue: coin in the trachea is oriented sagittally after passage through the vocal cords.

Credit: Rosh Review

What is the next step in management?

Credit: Northwestern University EM

Esophagus: foreign bodies management

Button (alkaline disk) batteries

MUST BE REMOVED WITHIN 4 HOURS OF INGESTION IF LODGED

IN THE ESOPHAGUS

Multiple magnets should be removed too

Everything elseLow risk objects can be observed in the esophagus x 24 hours

Once object passes GE junction, there is > 90% chance of passage

Sharp, pointed objects or objects bigger than 5x2 cm, must be removed endoscopically

Question #5What is the difference between Mallory-Weiss and Boerhaave

syndromes?

Question #5What is the difference between Mallory-Weiss and Boerhaave

syndromes?Credit: Maimonides Emergency Medicine

Question #6Name two main causes of peptic ulcer disease (PUD).

PUD: causes

#1: H Pylori and NSAIDs

+

Steroid use

Gastrin-secreting tumors

Credit: Health.harvard.edu

Question #7Identify the mechanism of action, dosing and side effects of the following PUD treatment options: antacids, H2-antagonists, PPI, sucralfate, and bismuth subsalicylate.

PUD treatment: antacidsExample: MaAlox

● Taken at bedtime and between meals

● Decrease absorption of warfarin, digoxin, antibiotics, anticonvulsants

Credit: Tulane University SOM

PUD treatment: H2-antagonistsExample: Famotidine

● Dosed once or twice daily

● First line therapy● Cimetidine inhibits

P450 and increases levels of warfarin, digoxin, phenytoin, etc

Credit: Dr. Korawuth Punareewattana

Credit: Dr. Korawuth Punareewattana

PUD treatment: proton-pump inhibitorsExample: omeprazole

● Once or twice daily● Indicated if

H2-antagonists fail● Side effects: headache,

dizziness, increased risk of C Diff and pneumonia, decreased efficacy of Plavix

Credit: Dr. Korawuth Punareewattana

PPI inhibits H/K ATPase enzyme at the proton pump of the parietal cell

PUD treatment: sucralfate and bismuth

Sucralfate

Dosing: 1 g QID and no significant side effects

Bismuth

Has antibacterial effect on H. pylori, may cause

encephalopathy in CKD with chronic use

● Require acidic environment (pH < 4)● Do not administer with antacids● Bind at the base of the ulcer and create protective

gel coating and decrease pepsin activity

Question #8What is a treatment regimen for H pylori-induced PUD in a

penicillin-allergic patient?

PUD: treatment of H pylori

Clarithromycin + Amoxicillin + PPI +/- Bismuth

If penicillin allergy, then

Clarithromycin + Metronidazole + PPI +/- Bismuth

Question #9Name factors predictive of upper gastrointestinal bleed (UGIB). Which physical examination finding has the highest positive likelihood ratio (LR)?

UGIB: predictive factors

Question #10What is the most common cause of UGIB?

Credit: Palmer, Kenneth. “Acute upper gastrointestinal bleeding is a common medical emergency which carries hospital mortality in excess of 10 %.” (2004).

UGIB: specific treatment

PUD-induced

● IV PPI● Reverse anticoagulation● EGD hemostasis

Variceal bleed

● IV octreotide● IV ceftriaxone● EGD band ligation● Embolization of the

gastric vein● TIPS placement

Question #11What are typical laboratory findings in acute alcoholic

hepatitis (WBC, Hgb, platelets, liver profile)?

Liver: acute alcoholic hepatitisLaboratory studies:

● Macrocytic anemia● Leukocytosis● Thrombocytopenia● Elevated bilirubin● Elevated alkaline phosphatase● AST>ALT (both 2-10 times normal)● Elevated INR

Complications of cirrhosis: esophageal variceal bleeding in 25-40% of patients with 30% mortality in massive hematemesis and SBP (E Coli and Strep, PMNs > 250) with 30-100% mortality

HEPATITIS

Credit: Clinicalgate.com

Hepatitis A● Anti-HAV IgM = acute infection● Anti-HAV IgG = prior infection = immunity

○ 50% of urban dwelling adults are positive● Fecal shedding prior to symptom onset● Incubation period: 15-50 days● Post-exposure prophylaxis of close contacts (daycare,

home) with immune globulin or vaccine within 14 days● Vaccination for travelers (lifelong immunity after 20 days)

Question #12A 39-year-old African-American man comes to the physician because of anorexia,

malaise, dark urine and upper abdominal discomfort. His temperature is 37.9ºC

(100.2ºF). Physical examination shows scleral icterus and moderate right upper

quadrant tenderness. The liver is palpable below the right costal margin.

Laboratory studies show:

● HBsAg: positive● HBsAb: negative● Anti-HBc IgM: positive● HBeAg: positive

Credit: AMA-ASSN.org

Question #12 - cont.Which of the following will most likely change in his serologic findings when this

patient enters the window period?

A. He will become HBcAg-positive

B. He will become HBc IgG-positive

C. He will become HBeAg-negative

D. He will become HBsAb-positive

E. He will become HBsAg-negative

Credit: AMA-ASSN.org

Current results:

● HBsAg: positive● HBsAb: negative● Anti-HBc IgM:

positive● HBeAg: positive

Credit: AMA-ASSN.org

Hepatitis B serology

HBcAg - present in hepatocytes only, not in serumCredit: MedLecturesMadeEasy

Hepatitis B serology

IgM IgG

HBeAg = high infectivity, while HBeAb = low infectivityCredit: MedLecturesMadeEasy

Question #13What are current CDC recommendations for post-exposure prophylaxis (PEP) for a unvaccinated health care provider exposed to blood of a patient with unknown Hepatitis B status?

Hepatitis B PEP for HCP (health care provider)CDC:

Question # 14What is mechanism of action of N-acetylcysteine (NAC)?

NAC mechanism of action

Credit: Emedicine:Medscape.

● NAC is a precursor to glutathione -> it increases rate of NAPQI conjugation,

● Antioxidant,● Increases

microvascular blood flow and O2 delivery via increasing nitric oxide concentration

Toxic hepatitis etiology● Hepatic necrosis

○ Acetaminophen, Amanita mushroom● Hepatocyte injury

○ Halothane (2 days after general anesthetic), Methyldopa (<1% of patients develop acute hepatitis), Isoniazid (3% of older patients develop hepatitis), Phenytoin

● Hepatic cholestasis○ Steroids, OCPs, Haldol, Verapamil, Phenobarbital

Question # 15What is clinical significance of Cullen and Grey Turner signs?

Cullen and Grey Turner signs = retroperitoneal hemorrhage

Credit: 60 second EM

Pancreatitis: Ranson criteria

Credit: Rosen’s

Biliary tract disorders

Credit: Dr. Kaveh Mojtahed

Calculous cholecystitis - 95% of cases

Credit: Dr. Samir Haffar

Acalculous cholecystitis - 5% of cases

Credit: Dr. Samir Haffar

Emphysematous cholecystitis - rare

Diagnostic study of choice: CT abd/pelvisCredit: Dr. Samir Haffar

Question #16Name the most common causes (MCC) of diarrhea and food poisoning:

● 2 MCC of viral diarrhea● 2 MCC of bacterial food poisoning● MCC of traveler’s diarrhea● MCC of bacterial diarrhea● MCC of non-bacterial fish-associated food poisoning● MCC of parasitic disease in the US● 2 MCC of diarrhea in AIDS patients

Question #16 answers:

● 2 MCC of viral diarrhea: Rotavirus and Norovirus● 2 MCC of bacterial food poisoning: Staph and Salmonella● MCC of traveler’s diarrhea: Enterotoxigenic E Coli● MCC of bacterial diarrhea: Campylobacter● MCC of non-bacterial fish-associated food poisoning:

Ciguatera● MCC of parasitic disease in the US: Giardia● 2 MCC of diarrhea in AIDS: CMV and Cryptosporidium

Viral GI infections

Rotavirus

● Winter outbreaks● 6-24 month old kids● N/V/D, low grade fever● NO abdominal pain● Vaccine at 2, 4 and 6

months● Fecal-oral and

respiratory transmission

Norwalk (norovirus)

● Water-borne: cruise ship ● Food-borne: shellfish● N/D and abd cramping● NO vomiting typically

Bacterial GI infections

Invasive = bloody

● Campylobacter● Salmonella● Shigella● Vibrio parahaemolyticus and

vulnificus● E Coli Enteroinvasive and

Enterohemorrhagic (O157:H7)● Clostridium difficile ● Yersinia enterocolitica

+ Positive fecal leukocytes +

Non-invasive = watery

● Staph aureus● Bacillus cereus● Aeromonas hydrophila● Vibrio cholera● Ciguatera● Scombroid● E Coli Enterotoxigenic● Clostridium perfringens

Enterohemorrhagic E Coli - serotype O157:H7

● Shiga-toxin producing: destruction of intestinal vascular endothelium

● Small amount of feces on undercooked beef, fruits, vegetables, raw milk or person-to-person

● Severe abdominal pain ~ acute abdomen● Dx: fecal Shiga-toxin and culture for E Coli O157:H7● NO ANTIBIOTICS (increase risk of HUS)● Complication: HUS in 10% of kids and 40% of elderly

Bacterial GI infections - cont.Shigella

● Very small inoculum required● Causes seizures in young children● Quinolones in adults, ceftriaxone in kids● Complications: Reiter syndrome, HUS

Salmonella

● 10-15% develop septicemia● S typhi: virulent, bradycardia despite intractable fever, no

diarrhea, “rose spots” on skin (non-specific maculopapular lesions), treat with ceftriaxone

Bacterial GI infections - cont.Campylobacter

● Fever, severe abd pain → 2 days later diarrhea ● Azithromycin● Complications: Reiter syndrome, HUS, GBS (later)

Yersinia Enterocolitica

● Recent exposure to farm or wild animals● Severe abdominal pain → terminal ileitis ~ appendicitis ● Post-infection: erythema nodosum, polyarthritis● Bactrim or fluoroquinolones

Bacterial GI infections - cont.Clostridium perfringens

● Source: heat-resistant spores in meat● N/V/D: self-limiting disease

Staph Aureus

● Vomiting 1-6 hours after barbeque attendance

Bacillus cereus

● Heat-stable toxin: vomiting 1-6 hours after fried rice meal● Heat-labile toxin: N/V/D after ingestion of meat/vegetables

Bacterial GI infections - Vibrio

Cholera

● Fecally contaminated water supplies

● Enterotoxin-mediated● Watery diarrhea● Hypokalemic

hyperchloremic acidosis● IVF, doxy/azithromycin,

zinc to decrease diarrhea

Parahaemolyticus

● Seafood gastroenteritis or wound infection

● Invasive● Supportive treatment

Bacterial GI infections - poisoning

Ciguatera

● Heat stable neurotoxin: affects Na channels

● Grouper, snapper● GI and neurological

symptoms (paresthesia, weakness, coma)

● “Hot-cold reversal” ● Avoid alcohol, fish, nuts

Scombroid

● Bacteria induced histamine-like toxin

● Mahi mahi, tuna● Histamine toxicity (NOT

an allergic reaction)● Treat like an allergic

reaction● Metallic or peppery taste

Parasitic GI infections - Giardia lamblia● 1.2 million cases per year in the US● Most common parasitic disease● “Backpackers diarrhea”● Outbreaks in every state● Classic case: “Traveler who developed flatulence, colicky

abdominal pain, greasy, foul-smelling explosive diarrhea 1-3 weeks after returning from Colorado, Nepal, Russia”

● Metronidazole● Association: IgA deficiency

Parasitic GI infections - Entamoeba histolytica● Protozoa● Chronic colitis

is common with intermittent diarrhea

● Amoebic liver abscess

● Iodoquinol and Flagyl

Parasitic GI infections - Coccidia● Spore-forming single-celled obligate intracellular parasites● Cause self-limited disease in healthy people● Immunocompromised hosts have severe protracted

course and require longer treatment○ Cryptosporidium

■ Treat underlying cause○ Cystoisospora (Isospora)

■ Fecal leukocytosis and eosinophilia in 50%■ Bactrim

○ Cyclospora■ Tropical environment, treat with Bactrim

Parasitic GI infections - Helminths

Necator americanus

● Hookworm larvae penetrate through skin

● Hypochromic microcytic anemia and eosinophilia in kids

● Mebendazole and iron supplement

Enterobius vermicularis

● Pruritus ani at night +/- enuresis, UTI, vaginitis

● All family members must be treated

● Single dose of mebendazole, repeat in 2 weeks

Diagnosis? Treatment?

Credit: Suzanne O’Hagan

Credit: Suzanne O’Hagan

Cecal vs Sigmoid Volvulus

● 40 %● Younger● Congenital● Gangrenous in 20%● Early surgery

Credit: Suzanne O’Hagan

● 60 %● Older● Acquired or associated

with chronic constipation● Sigmoidoscopy →

elective resection

Question #17

What is the most common cause of acute mesenteric ischemia? Which branch of abdominal aorta is most commonly affected?

Question #17

What is the most common cause of acute mesenteric ischemia?

Arterial emboli due to atrial fibrillation

Which branch of abdominal aorta is most commonly affected?

SMA

Credit: Dr. Debayan Chowdhury

Mesenteric IschemiaRisk factors:

○ Atrial Fibrillation○ Prior thromboembolic events○ Hypercoagulable state○ Low flow state: CHF, hypotension, digitalis

Treatment:

Depends on etiology, but STAT surgery consult, resuscitate, treat underlying cause or anticoagulation

Question # 18What is the most common cause of lower gastrointestinal

bleeding (LGIB)?

Credit: New England Journal of Medicine

Question #19What are clinical features of Osler-Weber-Rendu syndrome?

Appendicitis: fast facts● #1 surgical emergency in children, pregnant women and

adults < 40 years of age● Fecalith is the most common cause of appendiceal

obstruction● ⅓ of patients does not present with classic symptoms● Perforation is likely in a case of sudden increase in pain

followed by resolution of symptoms● CT abd/pelvis with contrast - study of choice● Yersinia gastroenteritis mimics appendicitis

Hernias… match them

Umbilical

Femoral

Obturator

Direct Inguinal

Indirect Inguinal

Spigelian

More common in women

Lateral to rectus abdominis

Hesselbach triangle

Decreased sensation of medial thigh

Newborn

Lateral to inferior epigastric vessels

Hernias… match them

Umbilical

Femoral

Spigelian

Direct Inguinal

Indirect Inguinal

Obturator

More common in women

Lateral to rectus abdominis

Hesselbach triangle

Decreased sensation of medial thigh

Newborn

Lateral to inferior epigastric vesselsCredit: Dr. Andrew Kiu

Credit: Memorangapp.com

Question #20What are some extraintestinal manifestations of Crohn’s

disease?

Extraintestinal manifestations of Crohn’s disease

Ankylosing spondylitis

Vasculitis

Colelitheasis, hepatitis

Erythema nodosum, pyoderma gangrenosum

Uveitis, iritis, conjunctivitis

Increased frequency of renal calculiCredit: Slideshare

THANK YOU!

PUD treatment: antacidsExample: MaAlox

● Taken at bedtime and between meals

● Decrease absorption of warfarin, digoxin, antibiotics, anticonvulsants

Credit: Tulane University SOM

HEPATITIS

Credit: Clinicalgate.com

Hepatitis B PEP for HCP (health care provider)CDC:

Pancreatitis: Ranson criteria

Credit: Rosen’s

Biliary tract disorders

Credit: Dr. Kaveh Mojtahed

Credit: Memorangapp.com

Credit: Slideshare