Upper Gastrointestinal Emergencies

Author: Andrew McDonald MD, FRCP, Assistant Professor

Date Created: January 2012

Learning Objectives

Understand the approach to GI bleeding

Understand the approach to esophageal injuries from caustics and foreign bodies

Understand the approach to peptic ulcer disease and gastritis

Case example

A 31 year old man is brought by his family after vomiting black material for two days

He appears unwell and lethargic

HR 130 BP 90/50 RR 30 T 35°C

Family says he has a history of chronic liver disease

GI bleeding – How patients present

History of vomiting blood or rectal blood

Shock +/- passing blood

Decreased LOC +/- passing blood

Challenges in these patients

Management of hypovolemic shock

Vomiting and aspiration

Hepatic encephalopathy

Coagulation disorder

Causes of Upper GI bleeding

Peptic ulcer disease Gastritis Varices Mallory – Weiss tear rare Malignancies

Causes of Lower GI bleeding

Hemorrhoids Diverticulosis Malignancies/polyps Angiodysplasia (AVM) of aging Inflammatory bowel disease Complications of Typhoid fever

Upper GI bleeding Bloody diarrhea

Epidemiology

Little is documented on the epidemiology of GI bleeding in developing countries

Clinical features

Hematemesis = upper GI source

Hematochezia = lower GI source

Melena = don’t know source

Clinical features (continued)

Weight loss -- Think of malignancy Bleeding following vomiting -- Think of

Mallory Weiss tear Medications can cause bleeding:

NSAID/ASA Steroids Anticoagulants

Alcohol use/abuse associated with various types of bleeding

Clinical features (continued)

Establish vascular volume status Confirm bleeding by site

Do a rectal exam to look for bright red blood or melena; perform a guaiac test if available

Role for NG tube?

Look for signs of liver disease Look for generalized bleeding problem

Management

Assess for airway management Prompt large bore iv access Volume resuscitation if necessary as

patients can deteriorate rapidly CBC, cross match, LFT, coagulation, renal Reverse any coagulopthy if possible Access to endoscopy as diagnostic and

therapeutic procedure (Ideal <24 hours)

Management (cont.) - Medications

Reducing gastric acidity via H2 blockers or PPI meds

Reducing portal pressure for varices Antibiotics may improve survival Use of Sengstaken-Blakemore tube not

recommended due to complications Need for surgery uncommon

Case continued

Patient’s airway reflexes were intact Given Oxygen for shock state Monitored vascular/respiratory status closely Administered fluids to improve perfusion Cross matched for blood and plasma to

restore hemoglobin and coagulation PPI and antibiotics given while waiting for

endoscopy

Esophageal Emergencies

Esophageal emergencies

Causes:

Varices

Ingestion of corrosives

Foreign bodies

Caustics – how patients present

Pain

Difficulty swallowing

Airway compromise

Challenges in these patients

Protecting healthcare workers

Pain masking complications

Systemic effects of chemical/co-ingestion

Mental health issues

Causes

Intentional self harm versus accidental

Sources of chemical information

Causes (continued)

Alkali – liquefaction necrosis, thrombosis

Acids – coagulation necrosis, eschar, systemic absorption

Clinical features

Pain – range of severity Respiratory/airway symptoms GI symptoms

Absence of oral injury does not preclude GI injury!

Management

Protect yourself Airway assessment – direct vision

technique Treat shock = GI bleed, perforation,

delayed sepsis, metabolic Decontaminate eyes and skin as needed Surgical consult if perforation

Esophageal FB – How patients present

Usually based on history

Chest pain, retching, can’t swallow

Beware of children, mental health, “prisoners”

Clinical features

Problems with handling secretions Location in esophagus

Pediatric typically proximal Adults typically distal

Perforation is uncommon Endoscopy is diagnostic and therapeutic

procedure

Diagnosis

X-ray can show the location of a foreign body

Management

Endoscopy preferred Time +/- sedation often works Meds:

Glucagon 1 mg IV Nifedipine 10 mg SL Nitroglycerine SL

Management (continued)

Button batteries and coins: Remove if in esophagus if endoscopy available Remove if still in stomach after 24 h

Sharp objects Endoscopy preferred if available

Ulcers and Gastritis

Ulcers and gastritis – How patients present

Pain GI bleeding Perforation (shock)

Causes H. pylori infection Meds:

NSAID/ASA Alcohol

Spices Severe physiological stress

Clinical features

Pain Often epigastric tenderness without

peritonitis Tests not really useful except to rule out

other things

Management

Perforation, bleeding discussed elsewhere Antacids H2 blockers, PPI Antibiotic therapy Avoidance of NSAID and alcohol

Quiz

Quiz Question 1

Which is the most common cause of upper GI bleeding?

A. Malignancy

B. Intestinal perforation

C. Peptic ulcers/gastritis

D. Mallory Weis tear

Quiz Question 2

GI bleeding can present as:A. Melena

B. Hematemesis

C. Shock without obvious blood loss

D. Hematochezia

E. All of the above are correct

Quiz Question 3

In managing patient after a caustic ingestion:A. They usually present with shock

B. Those without any pain are the sickest

C. Their vomit can be harmful to care givers

D. An NG tube should always be placed

Quiz Question 4

Regarding esophageal obstruction:A. Endoscopy is never indicated

B. If batteries are not obstructing the esophagus, they can be left there for up to three days

C. Adults and children usually obstruct proximally

D. All patients with obstruction should be intubated

E. Medications may sometimes prevent the need for endoscopy

Quiz Question 5

Regarding patients with peptic ulcer disease:A. Abdominal pain is usually constant

B. Alcohol use is one of the causes of ulcers

C. Acetaminophen is a common cause of ulcers

D. The usual treatment is surgical repair

Summary

GI bleeding can be a cause of life-threatening shock requiring resuscitation

Esophageal injuries should be managed in conjunction with endoscopy experts

Peptic ulcer disease and gastritis can present as life-threatening complications

General References

Tintinalli, JE et al (2011) Chapters 78, 79, 80, 81, 194. McGraw Hill Publishers Emergency Medicine – A study guide 7th Edition, USA

Manson’s Tropical Diseases, Chapter 10. Saunders Elsevier, 22nd edition.