Title: Intro to Dworken (GI)
1Intro to Dworken (GI)
- Intern Boot Camp
- Jacob Sadik, PGY3
2What You Will Learn
- How to survive Dworken
- How to recognize when a GI patient is sick
- How to diagnose/manage a few commonly-encountered
GI diseases - (Biliary disease, transaminitis, comprehensive
discussion on GIB, hepatitis and cirrhosis
covered in other boot camp lectures)
High-Yield Slides
3Dworken
- Lksd 55 is your home
- 2 interns, 1 senior, 2 fellows, 2 attendings
(liver, GI) - Spend time in the endoscopy lab when you can!
- Your senior/fellow are always there to help!!
The only stupid question is the one you didnt
ask!
4Dworken Patients
- Take a GI-focused history
- Prior GI diagnoses
- Prior endoscopic studies (EGD, C-scope, CE, ERCP)
- NSAIDs, anti-platelets, anticoagulation
- Shadow of a doubt?...make NPO!
- Know your overnight admissions well!!!
- Notify primary gastroenterologist re admission
- Rectal exams on all bleeding patients (even if
done in the ED) - No consults for hemoccult positive stools!!!
- OARRS. is.everything
5The OARRS Report
- Ohio reporting system for narcotics and other
controlled substances - Get access today!
- https//www.ohiopmp.gov/Portal/Registration/Defaul
t.aspx
6Case 1
- A 56 y/o M with a h/o DMT2, DLD, PUD and EtOH
abuse arrives on Lksd 55 from the ED with a
1-week h/o progressively worsening, gnawing
epigastric abdominal pain radiating to his back. - VS T 36.1, P 118, R 20, BP 100/80, SpO2 96 RA
- Orthostatics negative
- FOCUSED EXAM
- HEENT Sclera anicteric, no palatal jaundice
- SKIN No jaundice, axillary sweat, no truncal
ecchymoses - ABD Soft, ND, significant TTP over epigastrium
without peritoneal signs, no organomegaly - NEURO AAOx3
- PERTINENT LABS
- Hgb 15
- BUN 10, Cr 0.9, lipase 4600
7(No Transcript)
8Acute Pancreatitis
Classification
- Type
- Edematous, interstitial acute pancreatitis
- Necrotizing acute pancreatitis
- Severity
- Mild-mod (absence/transient organ failure lt48
hrs) - Severe (persistent organ failure gt48 hrs)
9Acute Pancreatitis
Diagnosis
- Requires 2 or more of the following
- 1) Acute, persistent, severe epigastric abdominal
pain (often radiating to the back) - 2) Elevated serum lipase or amylase 3x upper
limit of normal - 3) CT/MRI/ultrasound evidence of AP
- (NOTE imaging is not required for uncomplicated
mild AP if 1 and 2 are present)
10Acute Pancreatitis
Initial Evaluation
- Assess severity. ICU transfer may be indicated if
1 or more of the following are present - P lt40 or gt150
- SBP lt80
- RR gt35
- PaO2 lt50 mmHg
- pH lt7.1
- Anuria
- Coma
11Acute Pancreatitis
APACHE II SCORING SYSTEM
12Acute Pancreatitis
Surgical Abdomen
- Be concerned about
- Rigidity, guarding, rebound tenderness,
ill-appearance - Portable KUB STAT
- Acute care surgery consult STAT
- ICU transfer
- If no acute surgical intervention per ACS
- Your senior/fellow will help you with this
13Acute Pancreatitis
Think About Etiology
- Gallstones
- EtOH
- Hypertriglyceridemia (TG gt1000s)
- Trauma (e.g. panc laceration, post-ERCP)
- Drugs
- Steroids, azathioprine, Januvia, tetracycline,
furosemide, thiazides, flagyl, valproate, HAART,
etc.. - Infection
- Other mechanical
- Autoimmune
- Toxins (e.g. scorpion sting)
- Hypercalcemia
- Idiopathic
14Acute Pancreatitis
Supportive Workup
- RFP(includes Ca) and CBC
- LFTs
- Lipid panel (for TG level)
- Lactate
- Blood EtOH level (if indicated)
- Abdominal ultrasound
- ABG (if altered, SpO2 lt90, bicarb low, etc)
- CT abd/pelv with contrast
- CAUTION in those with AKI
- Diagnostic or to assess for complications in
severe AP - EUS/MRCP vs. ERCP (in suspected or overt
gallstone pancreatitis)
15Acute Pancreatitis
Management
- 1) Fluid resuscitation!!!
- Generally gt200 cc/hr
- Decreases morbidity/mortality w/in the 1st 12-24
hrs - Monitor for improvement (via VS, BUN, Cr, Hct,
UOP) - 2) Pain control
- IV opiates
- 2) Bowel rest
- NPO ? CLD ? Soft, low-residue, low-fat, soft diet
- NJ feeding (post-ligament of Treitz) gt TPN/PPN
- 4) Metabolic/electrolyte correction
16Acute Pancreatitis
AP Sequelae
- Non-discrete peri-pancreatic fluid collections
- Walled off fluid collections (or pseudocysts)
- Necrotizing pancreatitis (/- secondary
infection) - Pancreatic ascites
- Hemorrhagic pancreatitis
- Abdominal compartment syndrome
- Pseudoaneurysms
17Acute Pancreatitis
Non-Discrete Fluid Collections
18Acute Pancreatitis
Walled-Off Fluid Collections
19Acute Pancreatitis
Pancreatic Necrosis
20Acute Pancreatitis
Management of Infected Necrosis
- Empiric antibiotics with good pancreatic
penetration (e.g. carbapenems, quinolones,
flagyl) - Cover GNRs and anaerobes
- Trend towards conservative management with ABx
and observation for several weeks vs. immediate
surgical resection - Limited role for CT-guided FNA
- Open/endoscopic partial/total necrosectomy may
eventually be required
21Acute Pancreatitis
Hemorrhagic Pancreatitis
Cullens Sign ?
? Grey Turners Sign
22Acute Pancreatitis
Pancreatitis Take Home Points
- Once Dx is known, assess severity first
- Does your patient need ICU level care?
- FLUIDS!
- Close monitoring (VS, UOP, BUN, lactate, etc.)
- Etiology will help guide management
- Be mindful of complications
23Case 2
- A generous NF resident gives you an overnight
patient. Pt is a 56 y/o M who presents to the ED
with a 1-week h/o progressively worsening left
quadrant/flank pain and fever. Endorses
associated anorexia, nausea and fatigue. Had a
colonoscopy 1 week ago, revealing scattered,
non-bleeding diverticuli. - VS T 38.2, P 100, R 22, BP 128/86, SpO2 100 on
RA - FOCUSED EXAM
- GEN Well-nourished CM in mod distress d/t pain
- SKIN No jaundice
- ABD Soft, ND, mild TTP over LLQ without
peritoneal signs, no organomegaly - NEURO AAOx3
- PERTINENT LABS
- WBC 13K with left shift, CRP 10
24What is your DDx?
- Pyelonephritis
- Acute uncomplicated/complicated diverticulitis
- Nephrolithiasis
- Iatrogenic microperforation
- Acute pancreatitis
- Infectious colitis
- Crohns disease
- CRC
- Acute appendicitis
What do you order next?
25A CT scan! What is the Dx?
26Acute Diverticulitis
Presentation
- Mean age 60s
- LLQ abd pain
- Fever
- Leukocytosis
- N/V/constipation
- Recurrence is 20-40 after initial attack and
20 may have chronic abd pain
27Acute Diverticulitis
Classification
- 1) Uncomplicated
- 2) Complicated
- Perforation
- Abscess
- Fistulas
- Obstruction
- Peritonitis
28Acute Diverticulitis
Management
- Bowel rest
- Antibiotics covering GNRs and anerobes
- Amp/sulbactam, pip/tazo
- May be transitioned to PO Augmentin prior to
discharge - Pain control with IV opiates
- /- Surgery consult
- Indicated for acute complications
- Surgery decided on case-by-case basis
- lt40 y/o, R-sided disease, immunocompromised
29Acute Diverticulitis
Management
- Colonoscopy due at least 6-8 weeks out from onset
to exclude CRC - NOT during acute flare given risk of iatrogenic
perforation
30Acute Diverticulitis
Your patient asks, I read that seeds, nuts and
popcorn are bad for my diverticulitis. What do
you think?
31Case 3
You get called from the DACR at 650 because a 68
y/o F with a h/o osteoarthritis and SLE (on
chronic hydroxychloroquine and prednisone) is in
the ED complaining of a 2-day h/o frequent black,
tarry stools and lightheadedness. She has been
taking Ibuprofen for the past 7 days because of
knee pain. VS T 37, P 120, R 24, BP 104/80, SpO2
99 on RA Orthostatics negative FOCUSED
EXAM GEN Lethargic, in NAD HEENT Conjunctival
pallor, dry mucous membranes ABD Soft, ND,
epigastric TTP without rebound/rigidity/guarding N
EURO AAOx3 LABS Hgb 6.4 (baseline 12) BUN 18,
Cr 1.34, bicarb 18, K 3.2 Lactate 1.8
32GIB
What else do you want to know?
- Use of NSAIDs, anti-platelets, anticoagulants
- Abdominal pain? Relation to food?
- Stool color, character, quantity
- Previous GIB
- Previous EGD/colonoscopy/CE?
- EtOH abuse
- H/o cirrhosis or visualized varices
- Primary thrombophilia
- Recent pepto or iron ingestion ? darkens stools
33GIB
Initial Management
- NPO
- CBCs q6h and active TS with blood consent
- RFP, LFTs, coags
- 2 18-gauge (large-bore) PIVs
- Bolus NS/LR for orthostatic hypotension
- Stop all NSAIDs, anti-platelets and
anticoagulants - Hold pharmacologic DVT prophylaxis
- /- NG lavage
- Oxygen as needed
- Abdominal pain? ? KUB prior to endoscopy
- Transfer to ICU? (discuss with your senior)
34GIB
Transfusion Goals
- Transfuse pRBCs for Hgb lt7 (consider lt8 in
patients with cardiac disease) - Transfuse platelets for
- Active bleeding with PLT lt50K
- Pre-procedural PLT lt50K with/without bleeding
- Any PLT lt10K
- Transfuse FFP for INR gt1.5 in the setting of
active bleeding or pre-procedural in some cases
35GIB
Prep Basics
- EGD
- NPO
- /- erythromycin 3 mg/kg IV q8h (off-label) to
clear stomach contents for better visualization
ask GI - Flexible sigmoidoscopy or ileoscopy
- Tap water enemas 30 minutes apart x 3 or until
clear - Colonoscopy
- Golytely split-prep (2L in the evening, 2L in
the early morning i.e. 7PM, 3AM) - Movi-Prep (Gatorade)
- NG tube if refusing PO
36GIB
Concerning GIB
- Active bloody bowel movements
- Hemodynamic instability
- Drop in Hgb gt/ 2 gm/dL or poorly incrementing
Hgb after transfusion (1 unit pRBCs should bump
Hgb by 1-1.5 g/dL) - Change in mental status or symptomatic anemia
- REMEMBER! Blood is a laxative. Hemodynamically-sig
nificant GI blood loss will present itself.
37Case 4
- Your covering the Dworken team pager on NF when
you are paged by nursing about a 36 y/o F with a
h/o ulcerative colitis who is having multiple,
small-volume bloody bowel movements. She has been
taking Keflex for the past week for a soft tissue
infection. What do you do?!? - Examine the patient
- VSS? Pain? Mentation? Abd exam? DRE?
- Show me the stool!
- CBC STAT
- Orthostatics
- Send C.diff PCR!
38IBD
IBD
- 2nd-3rd decade of life
- Crohns disease has bimodal distribution (7th-8th
decade) - Disease predilection for developed countries and
the northern hemisphere - Look for extraintestinal manifestations
- Episcleritis, uveitis, iritis
- Ankylosing spondylitis
- Pyoderma gangrenosum
- Eythema nodosum
39IBD
Genetic Predisposition
IBD
Immune System Dysregulation
Environmental Triggers
40IBD
Crohns Disease
- Risk factors smoking, western diet
- Protective factors high-fiber diet
- Transmural bowel wall inflammation
- Entire GI tract (TI most commonly involved)
- Skip cobblestone lesions
- Rectal sparing
- Abdominal pain, diarrhea, fatigue, weight loss,
kidney stones
41IBD
Diagnosis of CD
- Colonoscopy with intubation of the terminal ileum
and biopsy acquisition is the gold standard - MRE is preferred for initial Dx of small bowel CD
- Consider CE in difficult-to-diagnose cases
- MRI or EUS to evaluate perianal CD
42IBD
Tx Strategies in CD
- Biologic agent
- Immunomodulator
- Slow-release 5-ASA for ileitis
- Sulfasalazine for colitis
- Slow-release 5-ASA for ileitis
- Sulfasalazine for colitis
- Antibiotics if not improving
- Biologic agent
- Immunomodulator
43IBD
Ulcerative Colitis
- Bloody diarrhea, tenesmus, fecal urgency, fatigue
weight loss and sometimes fever - DDx infectious, ischemic, CD, radiation-induced
- High CRC risk
- Predisposition to C.diff colitis
- Erythematous, engorged mucosa
- Rectal involvement with continuous progression
- Crypt abscesses
44IBD
Dx of UC
- Consider flex sig if inpatient for severe active
flare due to risk of iatrogenic complications
with colonoscopy - Colonoscopy if flare not severe
45IBD
Acute IBD Flares
- Severe flares
- Fever (gt/ 37.5C)
- Tachycardia
- Anemia (Hgb lt7 g/dL)
- Elevated inflammatory markers (ESR, CRP)
- Corticosteroids
- NPO
- Fluid resuscitation
- Electrolyte correction
- Consider 5-ASA compound (for those who are not on
maintenance therapy)
46IBD
Back to our Patient
- Initiate supportive care
- CRP, ESR, CBC, RFP, LFTs
- C.diff PCR, stool studies first
- If C.diff PCR negative, would start steroids
- High-dose 5-ASA compound (e.g. sulfasalazine)
47Now you know a little bit about.
- The Dworken team
- How to recognize a sick patient
- Prep Basics
- Acute pancreatitis
- Diverticular Disease
- GI bleeding (briefly)
- IBD (briefly)