Week 13: Acute GI dysfunction

Question 1

upper GI type of bleeding?

Answer 1

arterial, hematemesis and melena

Question 2

lower GI type of bleeding?

Answer 2

venous bleeding, hematochezia

Question 3

Hematemesis bright and dark

Answer 3

bright: upper, higher up
darker: old bleed from jejunum where bile is breaking it down

Question 4

melena

Answer 4

• black tarry stool
• foul smelling, black (can happen only with 50 cc of bleeding)
• from small or ascending colon

Question 5

hematochezia

Answer 5

-bright blood in stool=lower GI blood (from colon)

Question 6

clinical manifestation of GI bleed

Answer 6

hematemesis, melena, hematochezia, fatigue, dyspnea, syncope, angina

Question 7

Most common cause of upper GI bleeding

Answer 7

peptic ulcer disease

Question 8

peptic ulcer disease

Answer 8

Causes: NSAIDS,H. Pylori, cigarette smoking
Types: Duodenal and gastric
Dx: H. pylori testing, visualization with endoscopy, barium x-ray, combination antibiotic (amoxy, clarithromycin, tetracycline, and metronidazole)
Treatment: H2 blockers, PPI

Question 9

Acute erosive or hemorrhagic gastritis

Answer 9

• Severe inflammation of the gastric mucosa (NSAID gastritis, alcohol gastritis, stress gastritis)
• treatment: endoscopic sclerotherapy (inject something to make varices coagulate), vasopressin IV or intraarterial

Question 10

esophageal and gastric varices

Answer 10

• associates with cirrhosis, portal htn, and portal or splenic vein thrombosis
• massive bleeding
• treatement: sclerotherapy or esophageal balloon (creates pressure to stop bleeding), can also band the verice or pollup
• this is often how end stage hepatic pts die

Question 11

mallory-weiss tears

Answer 11

• a small tear in the mucosal lining at the gastro-esophageal junction (often preceded by vomit, most bleeds stop without intervention)
• DX with endoscopy
• If bleeding is excessive may treat with vasopressin, usually stops on its own

Question 12

acute lower GI bleeds

Answer 12

Causes: diverticular bleeding, ischemic bowel disease, inflammatory bowel disease, neoplasms

Question 13

Diverticular bleeding

Answer 13

-only occurs in about 3% of those with diverticulosis
-when occurs, may have massive loss of blood that is life threatening
-artery ruptures to fill diverticula
-dx with colonoscopy to determine reason for bleeding
25% require surgical intervention to stop bleed

Question 14

ischemic bowel disease

Answer 14

• interruption of colonic blood supply (bowel obstruction, occlusion of blood flow through vascular system)
• risk factors: surgical procedure to vasculature and bowel resection, afib, atherosclerosis, hypotn, sickle cell, DM, lupus, pacreatitis, anticoagulant therapy
• S/S:* intermittent bleeding*. A pt. who’s h&h is dropping and we don’t know why, mixed dark and bright red bleeding, fever, abd pain
• DX: endoscopy shows purple color bowel, xray may show air sacks, barium contrast shows thumbprints
• TX: fix blood flow to bowel (fluid resuscitation), Antibiotic tx for infection, bowel resection as needed to remove necrotic bowel
• FINAL EXAM “THUMBPRINTS” PICTURE OF ISCHEMIC BOWEL DISEASE

Question 15

inflammatory bowel disease

Answer 15

• S/S: bloody diarrhea, light to moderate bleeding
• TX: Stop bleeding, administration of corticosteroids to control inflammation, anti-TNF tx (immune biologic therapy), surgical resection as needed

Question 16

what is anti-TNF used for

Answer 16

helps with inflammation in IBS, it is an immune biologic therapy

Question 17

neoplasms

Answer 17

• up to 20% benign and malignant tumors are associated with bleeding
• slow, chronic, and self-limiting
• DX: barium x-rays, ct scan, mri, pet scan, endoscopy
• TX: dependent on type, stage, patient wishes

Question 18

management of acute GI bleeding unstable pt.

Answer 18

• is the patient stable? (hypotn, tachy, altered LOC, cap refill delayed= unstable)
• urgent interventions: hemodynamic resuscitation and oxygen delivery
• establish cause of the bleeding once stabilized
• Is it upper or lower?
• Upper: hematoemesis and melana
• Lower: hematochezia (bright)

Question 19

management of acute GI bleeding stable pt.

Answer 19

• stable? (bloody diahrrea, bp normal, AO=stable)
• Look at labs, get a really good history, meds (NSAIDS), alcohol consumption, cigarette smoking, sickle cell, clotting factor disorders
• is it upper or lower

Question 20

initial assessment of GI bleed

Answer 20

Laboratory changes

• H&H
• Platelets
• Electrolytes
• BUN/Creat (helps differentiate upper and lower. If greater than 35 think upper GI, less than 35 is probably lower GI)
• PT/INR
• liver functions test
• cardiac enzymes (might be getting ischemic to heart muscle itself bc of blood loss)
• every pt. who comes in with GI bleed should be typed and crossed

Fluid Volume Status

• hypotension (SBP less than 90)
• narrowed pulse pressure (MAP less than 60)
• orthostatic hypotension (concerned with drop in BP 20mmhg or rise in HR of 20bp/min)
• tachycardia
• ST changes (only when the pt is becoming ischemic. Need tele monitor)
• cap refill delayed
• mucous membranes dry
• UO dropping below 30cc/hr
• mental status changes

Question 21

interventions in GI bleed

Answer 21

• Maximized 02 carryping capacity, keep 02 sat above 92%
• restore normovolemia: 2 large bore lvs, administer 2 liters of crystalloids (LR, normal saline, should see improvement in 20min), followed by PRBCs as needed, FFP, Platelets, Factor VIII
• Patient positioning to maintain SBP
• NG tube placement
• Erythromycin 3mg/kg over 20 minutes one hour prior to procedures
• PPI’s
• Reglan 10 mg IV
• Bowel Prep

Question 22

what guage in a pt. going to surgery or hemodynamically unstable

Answer 22

18 gauge

Question 23

if hemoglobin is less than 7, then?

Answer 23

give blood no matter what, even if they have had a fluid challenge

Question 24

If they are anticoagulated, and their PT is going to be greater than 13, and INR greater than 1.5, you are going to give them?

Answer 24

-FFP or platelets (provider preference)

Question 25

Platelets less than 5,000 or after 10 units of PRBCs?

Answer 25

platelets

Question 26

patient may need what if they're anticoagulated or on coummadin?

Answer 26

Vitamin K

Question 27

PT positioning for systolic BP (will be on test)

Answer 27

patient is hypotensive, put them in supine or supine with legs elevated (head flat)

Question 28

NG tube placement bright blood, coffee ground,no blood or bile, or bile no blood means for each?

Answer 28

- if you get bright blood on your NG placement, think upper GI - coffee ground, upper GI but probably not active - No blood and no bile, GI bleed is below the pyloric sphyncter - bile but no blood, thinking no upper GI bleed at all

Question 29

What does erythromycin do?

Answer 29

helps gastric motility to clear out stuff in upper GI so they can actually see what's happening

Question 30

bowel prep to clean out bowel, most used?

Answer 30

go lightly

Question 31

proceedures

Answer 31

endoscopy: colonoscopy, sigmoidoscopy, - injection therapy - thermal coagulation therapy (light that causes coagulation) - clip them

Question 32

Obstruction

Answer 32

a mechanical blockage arising from a structural abnormality that presents a physical barrier to the progresssion of gut contents -can be partial or complete, simple or strangulated

Question 33

Ileus

Answer 33

is a paralytic or functional variety of obstruction

Question 34

patho of obstruction

Answer 34

results in - initial overcoming of the obstruction by increased peristalsis - increased intraluminal pressure by fluid and gas - vomiting - sequestration of fluid into the lumen from the surrounding circulation - lymphatic and veous congestion resulting in oedematous tissue - factors 3,4,5 result in hypovolaemia and electrolyte imbalance - further: localized anoxia, mucosal depletion necrosis and perforation and peritonitis - bacterial overgrowth with translocation of bateria and toxins causeing bacteraemia and septicaemia What do we do? - decomplress with NGT to low/intermittent suction - replace lost fluid - correction electrolyte abnormalities - recognize strangulation and perforation (strangulation no passage of flatulance, severe pain, fever, peritoneal tenderness and swelling rigidity, leukocytosis, increases in amylase levels as well) - systemic antibiotics

Question 35

partial obstruction

Answer 35

classic sign, loose watery stool (passing around the blocking fecal matter)

Question 36

a simple

Answer 36

obstruction that causes it to become ischemic

Question 37

Small bowel adhesions

Answer 37

- accounts for 60-70% of all SBO - results from peritoneal injury, platelet activation and givrin formation - associated with starch covered gloves, intraperitoneal sepsis, haemorrhage and wash with irritant solutions iodine and other foreign bodies. - As early as 4 weeks post laparotomy. The majority of patients present between 1-5 years - 70% of patients had a single band - patient with complex bands are more likely to be readmitted - readmission in surgically treated patients is 35% - common surgeries you see them in: (25% colorectal surgery, 20% gynaecological, 14% in appendectomies)

Question 38

hernia

Answer 38

- accounts for 20% SBO - common: femoral, ID inguinal, umbilical, incisional and internal - the site of obstruction is the neck of the hernia - compromised viscus is with in the sac - ischemia occurs initially by venous occlusion followed by edema and arterial compromise - strangulation noted by: persistent pain, discoloration, tenderness, constitutional symptoms

Question 39

Large Bowel obstruction

Answer 39

- distinguishing ileus from mechanical obstruction is challenging - according to leplacs law: maximum pressure is at it's maximum diameter. CECUM is at the greatest risk of PERFORATION - perforation resultes in release of feces with heavy bacterial contamination

Question 40

Role of CT

Answer 40

- used with IV contrast, oral and rectal contrast (tripple contrast: IV, oral, and rectal contrast) - able to demonstrate abnormallity in the bowel wall, mesentery, mesenteric vessels and peritoneum - can show: level of obstruction, degree, causes, degree of ischemia, free fluid and gas

Question 41

Barium bastrografin studies

Answer 41

- should not be used in pts with peritonitis - used in acute abdomen but is diluted - useful in recurrent and chronic obstruction

Question 42

Initial dagnostics for LBO

Answer 42

Lab - CBC - clotting - arterial blood gasses - U& CRT, na, K Amylase, LFT and glucose, LDH - group and save (x-match if needed) - optional (ESR< CRP< Hepatitis profile) Radiological - x-rays - USS ECG (cardiac ischemia)

Question 43

Clinical finding BO high

Answer 43

- pain is rapid - vomiting copiuous and contains bile jejunal content - abdominal distention is limited or localized - rapid dehydration from vomiting

Question 44

Distal SBO

Answer 44

- pain: central and colicky - vomitous is feculunt - distension is severe - visible peristalsis - may continue to pass flatus and feacus before absolute constipation

Question 45

Colonic BO

Answer 45

- ? pre-existing change in bowel habit - colicky in lower abdomen - vomiting is late (has to back all the way up) - distension prominent - cecum ? distended

Question 46

persistent pain may be a sign of

Answer 46

strangulation

Question 47

Clinical examination general, abdominal, and others

Answer 47

general - vital signs, P, BP, Sat, RR, T - dehydration - anemia, jaundice, LN - assessment of vomitus if possible - full lung and heart exam Abdominal - abdominal distension and it's pattern - hernial orifieces - visible peristalsis - cecal distention - tenderness, guarding and rebound - organomegaly - bowel sounds (high pitched, absent) - rectal examination Others - systemic examination - if deemed necessary (CNS, vascular, gynecological, musculoskeletal)

Question 48

Initial management of LBO

Answer 48

- resuscitate (60-100%), insert 2 lines, IVF (120ml and hour crystalloids), add K+ at 1mmmol/kg bc of vomiting (dropping K) - draw blood - inform senior member in team - NPO, NG placement, urinary cath - IV antibiotics - If concern exist about fluid overloading a central line should be inserted - follow-up lab results and correction of electrolyte imbalance - pt should be nursed in intermediate care - rectal tubes should only be used in Sigmoid volvulus

Question 49

Indications for surgery

Answer 49

- Evidence of strangulation - signs of peritonitis (bowel has ruptured) - if the obstruction won't clear in 24-48 hours - not sure why there is an obstruction or what is going on - try to stabilize pt. before surgery

Question 50

Ileus

Answer 50

Associated with the following conditions: - postop and bowel resection - ischemia - infection inside and outside the stomach - endocrine - spinal and pelvic fractures - retro-peritoneal hematoma - metabolic abnormalities - bed ridden - drug induced (morphine, tryciclic meds)

Question 51

Ileus or obstruction?

Answer 51

Clinical features: - is there an underlying cause? - is the abdomen distended but tenderness is not marked - is the bowel sounds diffusely hypoactive Radiological features - is the bowel diffusely distended - is there gas in the rectum - are further investigations helpful in showing an obstruction Does the pt. improve on conservative measures?

Question 52

Types of IAH/ACS primary, secondary, recurrent

Answer 52

- Primary: injury/disease of abdomino-pelvic region, "surgical" - Secondary: sepsis, cap leak, burns, "medical" - Recurrent: ACS develops despite surgical intervention

Question 53

IAP interpretation

Answer 53

Pressure Interpretation 0-5 Normal 5-10 Common in most ICU pts >12 (grade 1) Intra-abdominal HTN 16-20 (grade 2) Dangerous IAH- begin non- invasive intervention >21-25 (grade 3) Impending, decompressive lappi

Question 54

patho

Answer 54

ischemia leads to inflammatory responses, cap leakage, coupled with our fluid resuscitation, tissue edema, increases abd pressure, leads back to more ischemia creating this cycle

Question 55

causes of IAP elevation and findings

Answer 55

- major abdominal/retroperitoneal problem - ischemic insult/SIRS requiring fluid resuscitation with a positive fluid balance of 5 OR MORE LITERS within 24 HOURS (10lb weight gain) -temp, HR, and resp increases, WBC .12,000 (elevates)

Question 56

physiologic sequelae cardiac

Answer 56

- increased ABD pressure cause compression of vena cava with reduced venous return - elevated intra-thoracic pressure with multiple negative cardiac effects Result: - decreased cardiac output, increased SVR - increased cardiac work loads - decreased tissue perfusion - misleading elevations of CVP and PAWP - cardiac insufficiency, cardiac arrest

Question 57

physiologic sequalae pulmonary

Answer 57

incrased intra-abd pressure casuses -elevated diaphragm, reduced lung bolumes and alveolar inflation, stiff thoracic cage, increased intersitial fluid Results: - elevated intrathoracic pressure - incread peak pressure, reduced tidal volumes - Barotrauma-atelectasis, hypoxia, hypercarbia - ARDS

Question 58

physiologic sequalae gastrointestinal

Answer 58

increased intra abd pressure causes - compression and congestion of mesenteric veins and capillaries - reduced cardiac output to the gut result - decreaes gut perfusion incresaed gut edema and leak - ischemia, necrosis - bacterial translocation - development and perpetuation of SIRS - further increase in IAP

Question 59

physiologic renal

Answer 59

elevated IAP causes - compression of renal veins, parenchyma - resuced cardiac output to kidneys result - reduced BF to kidney - renal congestion and edema - dereaed glomerular filtration - renal failure, oliguria/anuria

Question 60

physiologic neuro

Answer 60

elevated IAP causes - increased intrathoracic pressure - increases in superior vena cava pressure with reduction in drainage of SVC into the thorax result: increaed central venous pressure and IJ pressure -increased ICP -decreaed CPF -cerebral edema, brain anoxia, brain injury

Question 61

APP

Answer 61

abdominal perfusion pressure = MAP-IAP - reflects actual gut perfusion bettter than IAP alone - optimizing APP.60 mm HG should probably be primary endpoint

Question 62

Decompressive laparotmy

Answer 62

-delay in abd compression may lead to intestinal ischemia, decompress early

Question 63

bladder pressure monitoring how to?

Answer 63

insert catheter to bladder, hook to transducer, read pressures off of the bladder -make sure transducer is level with the bladder

Question 64

patient meets one of the following criteria and has at least two risk factor for IAH:

Answer 64

- new intensive care until admission - evidence of clinical deterioration or new organ failure risk factors: - Diminished abd wall compliance - increased intraluminal contents - increased abdominal contents - capillary leak/fluid resuscitation

Question 65

how you messure

Answer 65

- messure in expiration, pt. laying supine - put in 25 ml fluid to measure it against - wait 30 seconds and measure it