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Intro to Dworken (GI)

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Intro to Dworken (GI) Intern Boot Camp Jacob Sadik, PGY3 These are present within 4 weeks from onset of pancreatitis and are not yet appear walled off. – PowerPoint PPT presentation

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Title: Intro to Dworken (GI)


1
Intro to Dworken (GI)
  • Intern Boot Camp
  • Jacob Sadik, PGY3

2
What 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
3
Dworken
  • 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!
4
Dworken 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

5
The OARRS Report
  • Ohio reporting system for narcotics and other
    controlled substances
  • Get access today!
  • https//www.ohiopmp.gov/Portal/Registration/Defaul
    t.aspx

6
Case 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)
8
Acute 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)

9
Acute 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)

10
Acute 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

11
Acute Pancreatitis
APACHE II SCORING SYSTEM
12
Acute 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

13
Acute 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

14
Acute 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)

15
Acute 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

16
Acute 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

17
Acute Pancreatitis
Non-Discrete Fluid Collections
18
Acute Pancreatitis
Walled-Off Fluid Collections
19
Acute Pancreatitis
Pancreatic Necrosis
20
Acute 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

21
Acute Pancreatitis
Hemorrhagic Pancreatitis
Cullens Sign ?
? Grey Turners Sign
22
Acute 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

23
Case 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

24
What 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?
25
A CT scan! What is the Dx?
26
Acute 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

27
Acute Diverticulitis
Classification
  • 1) Uncomplicated
  • 2) Complicated
  • Perforation
  • Abscess
  • Fistulas
  • Obstruction
  • Peritonitis

28
Acute 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

29
Acute Diverticulitis
Management
  • Colonoscopy due at least 6-8 weeks out from onset
    to exclude CRC
  • NOT during acute flare given risk of iatrogenic
    perforation

30
Acute Diverticulitis
Your patient asks, I read that seeds, nuts and
popcorn are bad for my diverticulitis. What do
you think?
31
Case 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
32
GIB
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

33
GIB
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)

34
GIB
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

35
GIB
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

36
GIB
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.

37
Case 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!

38
IBD
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

39
IBD
Genetic Predisposition
IBD
Immune System Dysregulation
Environmental Triggers
40
IBD
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

41
IBD
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

42
IBD
Tx Strategies in CD
  • Step-Up
  • Top-Down
  • 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

43
IBD
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

44
IBD
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

45
IBD
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)

46
IBD
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)

47
Now 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)
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