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TRANSCRIPT
GI Cocktails: Cases to Remember
Zachary Hartsell, PA-C, DHAWake Forest Baptist Medical Center
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• At the conclusion of this session, the participant will be able to:
– Distinguish between upper and lower GI bleeds based on clinical
presentation
– Develop a cost-effective, evidence-based approach to evaluation of
elevated LFTs
– Identify indications for surgical intervention in hospital patients
diagnosed with small bowel obstruction
– Differentiate between uncomplicated and complicated diverticulitis
and discuss how this differentiation affects management
Objectives
Mr. Roberts
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ABG
• 42 yo male, with past medical history of HTN and
osteoporosis presents to ER with one week of
black stools and lightheadedness who passed out
in the shower while getting ready for work.
• Brought in by wife.
• Hit his head but he is awake and talking.
• Reported heartburn at night which he was taking
OTC Pepcid.
• Current medications include HCTZ and Naproxen.
• Non smoker, denies alcohol or drug use.
Mr. Roberts
3
ABG
• Vitals: HR: 101, RR: 12, BP: 90/60, Temp: 38.9 C
O2 sat: 95% on RA
• Has a small scalp laceration on back of head
• Conjunctival pallor
• Heart and lungs: CTA
• Abd: Epigastric tenderness to
palpation. No rebound.
No hepatomegaly.
• Rectal exam: good sphincter tone,
no masses, hemoccult positive.
Mr. Roberts
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CXR: Normal cardiac silhouette.
No lung space pathology
identified. No free air.
A. Place 2 large bore IV
B. Call GI
C. Repeat CBC
D. Emergent CT scan of the Abdomen and Pelvis
What is the most appropriate next step?
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• Upper- proximal to the ligament of Treitz
– Esophageal
– Small Intestine
• 5-10%
• Lower- distal to
the ligament of Treitz
– Large Intestine
• Obscure
– Source of bleeding
cannot be identified
GI Bleeding
Jmarchn.2019
• Variceal bleeding most common
– Liver patients
• Esophageal ulcers
GI Bleed: Esophageal
• Distal to ampulla of Vater, proximal to ileocecal
valve
• Overt
– Melena or hematochezia
– Small bowel source
• Occult
– Iron deficiency anemia
– +/- guaiac positive stool
– Small bowel source
GI Bleeding: Small Bowel
GI Bleeding: Small Bowel
Under 40 Over 40
IBD Meckel’s
diverticulum Polyposis
syndromes
Dieulafoy’slesions
Malignancy
Angioectasia Anti-inflammatory
induced
• Comorbidities
– Bleeding diathesis
– Diabetes (increase risk of peptic ulcer bleeding )
– Liver disease
• Prior procedures
• Medications
– NSAIDS
• Family history
– Polyposis syndrome
• Alcohol use
GI Bleeding: History
Peng et al 2013
• Vital signs
– Orthostatic
• Dermatologic
– Mucous membranes
• Stigmata of liver disease
GI Bleeding: Physical Exam
• Labs
• Radiology
– Tagged RBC Scan
– IR
• Endoscopy
GI Bleeding: Evaluation
• General considerations
– 2 large bore IV
– ICU vs Floor
• Medications
– H2 Blockers vs PPI
– Octreotide
– Others
• Role of antibiotics in variceal bleeding
GI Bleed: Management
• Mrs. Daniels is a 42 year old female with a history
of alcohol abuse who presents to the ER with
jaundice for the past two weeks.
• She also has mild RUQ pain. She denies fevers,
chills, or N/V or diarrhea.
• The patient has not drank alcohol in approximately
2 weeks because she has been feeling so poorly.
Mrs. Daniels
• On physical examination:
BP 98/50, HR 120, RR 18, O2 97% RA
– General → WDWN. Appears older than her stated age. NAD but only
awakens to verbal stimuli briefly and is unable to engage in a
conversation. Smells of alcohol.
– HEENT → Non-icteric sclera. PERRLA.
– Heart → Tachycardic without MRG.
– Lungs → CTA B/L.
– Abdomen → +BS. Soft. ND. NT.
– Extremities → Peripheral pulses 2+ B/L. No edema B/L.
– Neurologic → Opens eye to verbal stimuli. Does not consistently
follow commands. Moves all four extremities. No tremor or asterixis
Mrs. Daniels
• Wide range of definitions
– Asymptomatic ↑ LFT’s → fulminant failure
• Typically present in 40-50’s
• Heavy drinkers, long-standing drinkers
– 6+ drinks/day for approximately 20 years
• Mortality variable depending on severity
– Up to 35%
• 20% proceed to ESLD even if they stop drinking
Alcoholic hepatitis
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• Model for End-stage Liver Disease (MELD)
– Validated to predict 90-day mortality for patients with
alcoholic hepatitis
• Maddrey’s discriminant function (MDF)
• Glasgow alcoholic hepatitis score
• ABIC score
Classification Systems
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• Anorexia
– Enough to even stop drinking
• Fever
• Jaundice
Alcoholic hepatitis
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• Hepatomegaly
‒ +/- tenderness to
palpation
‒ Bruit over liver
• Ascites
• Encephalopathic
Signs and symptoms
13.9 133 101 18.0
15.2 41.7 130 3.9 28 1.0
Mrs. Daniels
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Magnesium 1.9 Total bilirubin 7.2
Calcium 9.1 Albumin 2.0
AST 251 Total protein 6.9
ALT 120 INR 1.80
Alk phos 115 MCV 105
BAL 0 UA (-)
98
• Moderately ↑ LFTs
– AST>ALT
– ↑ total bilirubin
• ↑INR
– Mean INR 2.1
• ↓ Albumin and pre-albumin
– Liver function or nutritional status?
• Leukocytosis
– ↑↑ acute phase reactants
Laboratory Findings in Alcoholic Hepatitis
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• ALT:
• AST:
• Alkaline phosphatase: Zinc metalloproteinase
• Bilirubin: Breakdown of RBCs
– Unconjugated (Indirect): Predominant
– Conjugated (Direct)
• Albumin: Plasma protein synthesized by liver
Hepatic Panel
Aminotransferases
• AST and/or ALT
– Borderline: <2x ULN
– Mild: 2-5x ULN
– Moderate: 5-15x ULN
– Severe: >15x ULN
– Massive: >10,000 IU/l
• Fulminant hepatic failure / Acute liver failure
– Rapid development acute liver injury with severe
impairment of synthetic function (prolonged PT) and
hepatic encephalopathy
Degree of AST/ALT Elevation
• R ratio:
(ALT value/ALT ULN)
(Alkaline Phosphatase value/Alkaline Phosphatase ULN)
• Interpretation:
– >5 hepatocellular
– <2 cholestatic injury
– 2-5 mixed
Patterns of Elevation
• Albumin
– Reduction generally indicates decline in function > 3wks *
• Prothrombin time
– More sensitive
– Changes may be seen within 24 hours
– COAGULATION CASCADE!
• Extrinsic pathway
Markers of Liver Function
• “Normal” range of ALT/AST varies widely
–Defining normal population for reference range
• Account for comorbidities
–Guides clinical decision making
–Normal values ≠ absence of liver disease
–Morbidity and mortality risk
Standardization of Normal Ranges
• Acetaminophen level
• Hepatitis panel
– Hepatitis A IgM
– Hepatitis B surface antigen
– Hepatitis B core IgM
– Hepatitis C virus (HCV) antibodies & RNA
• US liver
• Liver biopsy is rarely needed in alcoholic hepatitis
but the gold standard in severely elevated LFT
without obvious etiology
Evaluation: Beyond the Basics
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• Viral hepatitis
• Non-alcoholic fatty liver disease (NAFLD)
• Alcoholic liver disease
• Autoimmune
• Metabolic/Genetic disorders
• Drug/Supplement
Differential Diagnosis of Elevated LFTs
• Supportive
– Alcohol Cessation
• COMPLETE ABSTINENCE
– Fluid support
– Nutritional support
– Correct coagulopathy?
– Treat encephalopathy
• Prednisolone vs. Pentoxifylline
– Mixed studies
– Optimal treatment depends on comorbid conditions
– MDF score ≥32
Treatment
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Ms. Williams
29
ABG
• 38 yo female, with no past medical history who
presents to ER with 3 days of abdominal pain,
nausea and vomiting.
• History of C- section
• Denies taking any current medications
• Non smoker, denies alcohol or drug use.
Ms. Williams
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ABG
• Vitals: HR: 101, RR: 12, BP: 1030/60, Temp: 37.2
C, O2 sat: 95% on RA
• Abd: Scar across lower pelvis. Distended. General
tenderness to palpation. Tympanic to percussion.
Scattered high pitch bowel sounds. No rebound.
No hepatomegaly.
Ms. Williams
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• Etiologies
– Adhesions
• 60-70%
• History
– Abdominal pain
– Distention
– Vomiting
– Obstipation
– Previous surgery
• Physical
Small Bowel Obstruction
• Diagnostics
– Labs
• CBC
• BMP
• Lactate
– Image
• Supine and erect AXR
• Abdominal US
• Abdominal CT
• Abdominal MRI
Small Bowel Obstruction
• Classification
– Adhesional
– Non-adhesional
– Early
– Late
– Partial
– Complete
– Low-grade
– High-grade
Small Bowel Obstruction
• Nonsurgical management
– Shorter LOS
– Higher recurrence
– Shorter time to readmission
– Controlled symptoms
– Partial obstruction
– No e/o peritonitis, strangulation, bowel ischemia
– Recurrent episodes, multiple prior laparotomies
– NG tube
– IVF
– Monitoring of clinical status
Small Bowel Obstruction
• Surgical intervention
– Delay may lead to increased morbidity and mortality
– Repeated laparotomy and adhesiolysis may worsen adhesion formation and
severity
– Laparoscopy?
– Lack of resolution with conservative management
• NG tube output >500mL on hospital day 3
– Peritonitis
– E/O bowel ischemia on CT
– Strangulation of bowel
– Complete
– Surgery within prior 6 weeks
Small Bowel Obstruction
Colonel Wilkens
37
ABG
• 93 yo male World War 2 Veteran with past medical
history of TIA, HTN, Osteoporosis, who presents
to the ER for evaluation of abdominal pain,
diarrhea and low grade fever for 10 days.
• Primary care physician saw him three days ago
and diagnosed him with diverticulitis and started
him on Cipro but symptoms continued to worsen
over the last 24 hours.
Colonel Wilkens
38
ABG
• Vitals: HR: 90, RR: 12, BP: 103/60, Temp: 39.1 C,
O2 sat: 95% on RA
• Abd: Non distended. General tenderness to
palpation with increased tenderness in left lower
quadrant. No rebound. No hepatomegaly.
Colonel Wilkens
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• Increasing prevalence of diverticulosis in US
– Increases with age
– 20% develop diverticulitis
• 300,000 hospitalizations per year
– 1.5 million inpatient days
• 1.5 million oupatient visits per year
Diverticular Disease
• History and Physical
– LLQ discomfort/tenderness
– +/- peritoneal findings, fever
• CBC
– Leukocytosis?
• UA
– Exclude UTI, kidney stones
• Abdominal radiographs*
– Exclude obstruction
Diverticulitis
• CT abdomen/pelvis
– Most appropriate initial imaging if suspected diverticulitis
– Diverticulosis with
• Colon wall thickening
• Fat stranding
• Phlegmon
• Extraluminal gas *
• Abscess
• Stricture
• Fistula
– Eval for alternative dx
Diverticulitis
Severity on CT correlates with:- Risk of failure of nonoperative mgmt- Long-term complications
• Uncomplicated
• Complicated
– Perforation
– Abscess
– Fistula
– Stricture
Diverticulitis
• Treatment
– Non-operative
• Oral or IV antibiotics: Gram negatives and anaerobes
• Diet modifications
• Outpatient
– Stable patients, uncomplicated disease
– Able to tolerate oral antibiotics
• Inpatient
– Complicated disease
– Unable to tolerate oral medications/hydration
– Comorbidities *
– Lack of adequate home support
Diverticulitis
• Pathophysiology
– Microperforation and bacterial infection
VS
– Primary inflammatory process
• AVOD study: 623 inpatients with uncomplicated, left-sided
diverticulitis
– IV fluids
– IV fluids + antibiotics
» Did not prevent complications
» Did not accelerate recovery
» Did not prevent recurrences
Diverticulitis
• Treatment
– Operative
• Image-guided percutaneous drainage
– Large diverticular abscess (>4cm)
– Accessible
– Poor response to medical therapy
• Urgent sigmoid colectomy
– Diffuse peritonitis
– Failed nonoperative mgmt
Diverticulitis
• Follow up
– Flex sigmoidoscopy or Colonoscopy
• First episode
• No recent endoscopic evaluation of colon
– Flexible Elective colectomy
• Not to be recommended for prevention of recurrence
• Not dependent on number of recurrences
• Not dependent on age
• Immunocompromised
• Mesocolic abscess ≥ 5cm or pelvic abscess
• Stricture or fistula
Diverticulitis
• Prevention of recurrence
– Supplemental fiber
– Rifaximin
– Antispasmodics
– Mesalamine
– Probiotics
* Evidence?
Diverticulitis
• Full history and physical should not be limited in
lieu of diagnostic testing
• Identifying abnormal liver studies as either liver
injury or decreased function will guide further
work-up
• Trend in diverticulitis management favors
conservative management
Lessons for Practice