Upload
stuart-freeman
View
221
Download
0
Tags:
Embed Size (px)
Citation preview
Intro to Dworken (GI)
Intern Boot CampJacob Sadik, PGY3
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
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 didn’t ask!
Dworken
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
Ohio reporting system for narcotics and other controlled substances
Get access today! https://www.ohiopmp.gov/Portal/Registration/Def
ault.aspx
The OARRS Report
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% RAOrthostatics negativeFOCUSED EXAM:HEENT: Sclera anicteric, no palatal jaundiceSKIN: No jaundice, +axillary sweat, no truncal ecchymosesABD: Soft, ND, significant TTP over epigastrium without peritoneal signs, no organomegalyNEURO: AAOx3PERTINENT LABS:Hgb 15BUN 10, Cr 0.9, lipase 4600
Case 1
Type Edematous, interstitial acute pancreatitis Necrotizing acute pancreatitis
Severity Mild-mod (absence/transient organ failure <48
hrs) Severe (persistent organ failure >48 hrs)
Acute Pancreatitis
Classification
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)
Assess severity. ICU transfer may be indicated if 1 or more of the following are present: P <40 or >150 SBP <80 RR >35 PaO2 <50 mmHg pH <7.1 Anuria Coma
Initial Evaluation
Acute Pancreatitis
Acute Pancreatitis
APACHE II SCORING SYSTEM
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
“Surgical” Abdomen
Acute Pancreatitis
Gallstones*** EtOH*** Hypertriglyceridemia (TG >1000s) 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
Think About Etiology…
Acute Pancreatitis
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 <90%, 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)
1) Fluid resuscitation!!! Generally ~>200 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) > TPN/PPN
4) Metabolic/electrolyte correction
Management
Acute Pancreatitis
Non-discrete peri-pancreatic fluid collections Walled off fluid collections (or “pseudocysts”) Necrotizing pancreatitis (+/- secondary
infection) Pancreatic ascites Hemorrhagic pancreatitis Abdominal compartment syndrome Pseudoaneurysms
Acute Pancreatitis
AP Sequelae
Non-Discrete Fluid Collections
Acute Pancreatitis
Walled-Off Fluid Collections
Acute Pancreatitis
Pancreatic Necrosis
Acute Pancreatitis
Management of Infected Necrosis
Acute Pancreatitis
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
Acute Pancreatitis
Cullen’s Sign
Grey Turner’s Sign
Hemorrhagic Pancreatitis
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
Pancreatitis Take Home Points
Acute Pancreatitis
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 RAFOCUSED EXAM:GEN: Well-nourished CM in mod distress d/t painSKIN: No jaundice ABD: Soft, ND, mild TTP over LLQ without peritoneal signs, no organomegalyNEURO: AAOx3PERTINENT LABS:WBC 13K with left shift, CRP 10
Case 2
Pyelonephritis Acute uncomplicated/complicated
diverticulitis Nephrolithiasis Iatrogenic microperforation Acute pancreatitis Infectious colitis Crohns disease CRC Acute appendicitis
What is your DDx?
What do you order next?
A CT scan! What is the Dx?
Presentation
Acute Diverticulitis
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
Classification
Acute Diverticulitis
1) Uncomplicated 2) Complicated
Perforation Abscess Fistulas Obstruction Peritonitis
Management
Acute Diverticulitis
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 <40 y/o, R-sided disease, immunocompromised
Management
Acute Diverticulitis
Colonoscopy due at least 6-8 weeks out from onset to exclude CRC NOT during acute flare given risk of iatrogenic
perforation
Acute Diverticulitis
Your patient asks, “I read that seeds, nuts and popcorn are bad for my diverticulitis. What do you think?
Case 3You get called from the DACR at 6:50 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 RAOrthostatics negativeFOCUSED EXAM:GEN: Lethargic, in NADHEENT: Conjunctival pallor, dry mucous membranesABD: Soft, ND, epigastric TTP without rebound/rigidity/guardingNEURO: AAOx3LABS:Hgb 6.4 (baseline 12)BUN 18, Cr 1.34, bicarb 18, K 3.2Lactate 1.8
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
GIB
What else do you want to know?
GIB
Initial Management NPO CBCs q6h and active T&S 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)
GIB
Transfusion Goals Transfuse pRBCs for Hgb <7 (consider <8 in
patients with cardiac disease) Transfuse platelets for…
Active bleeding with PLT <50K Pre-procedural PLT <50K with/without bleeding Any PLT <10K
Transfuse FFP for INR >1.5 in the setting of active bleeding or pre-procedural in some cases
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
GIB
Concerning GIB Active bloody bowel movements Hemodynamic instability Drop in Hgb >/= 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-significant GI blood loss will present itself.
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!
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
IBD
IBD
IBD
Immune System
Dysregulation
Genetic Predispositi
on
Environmental Triggers
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
IBD
Abdominal pain, diarrhea, fatigue, weight loss, kidney stones
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
IBD
Tx Strategies in CD
IBD
“Step-Up” “Top-Down”
Slow-release 5-ASA for ileitis
Sulfasalazine for colitis
Antibiotics if not improving
Biologic agent Immunomodulat
or
Slow-release 5-ASA for ileitis
Sulfasalazine for colitis Biologic agent
Immunomodulator
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
IBD
Erythematous, engorged mucosa
Rectal involvement with continuous progression
Crypt abscesses
Dx of UCConsider flex sig if inpatient for severe active flare due to risk of iatrogenic complications with colonoscopyColonoscopy if flare not severe
IBD
Acute IBD Flares Severe flares
Fever (>/= 37.5C) Tachycardia Anemia (Hgb <7 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)
IBD
Back to our Patient…Initiate supportive careCRP, ESR, CBC, RFP, LFTsC.diff PCR, stool studies firstIf C.diff PCR negative, would start steroidsHigh-dose 5-ASA compound (e.g. sulfasalazine)
IBD
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)