1. Upper Gastrointestinal Emergencies Author: Andrew McDonald MD, FRCP, Assistant Professor Date Created: January 2012

2. 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

3. 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

4. GI bleeding – How patients present  History of vomiting blood or rectal blood  Shock +/- passing blood  Decreased LOC +/- passing blood

5. Challenges in these patients  Management of hypovolemic shock  Vomiting and aspiration  Hepatic encephalopathy  Coagulation disorder

6. Causes of Upper GI bleeding  Peptic ulcer disease  Gastritis  Varices  Mallory – Weiss tear rare  Malignancies

7. 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

8. Epidemiology  Little is documented on the epidemiology of GI bleeding in developing countries

9. Clinical features  Hematemesis = upper GI source  Hematochezia = lower GI source  Melena = don’t know source

10. 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

11. 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

12. 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)

13. 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

14. 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

15. Esophageal Emergencies

16. Esophageal emergencies  Causes: Varices Ingestion of corrosives Foreign bodies

17. Caustics – how patients present  Pain  Difficulty swallowing  Airway compromise

18. Challenges in these patients  Protecting healthcare workers  Pain masking complications  Systemic effects of chemical/co-ingestion  Mental health issues

19. Causes  Intentional self harm versus accidental  Sources of chemical information

20. Causes (continued)  Alkali – liquefaction necrosis, thrombosis  Acids – coagulation necrosis, eschar, systemic absorption

21. Clinical features  Pain – range of severity  Respiratory/airway symptoms  GI symptoms Absence of oral injury does not preclude GI injury!

22. 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

23. Esophageal FB – How patients present  Usually based on history  Chest pain, retching, can’t swallow  Beware of children, mental health, “prisoners”

24. Clinical features  Problems with handling secretions  Location in esophagus Pediatric typically proximal Adults typically distal  Perforation is uncommon  Endoscopy is diagnostic and therapeutic procedure

25. Diagnosis  X-ray can show the location of a foreign body

26. Management  Endoscopy preferred  Time +/- sedation often works  Meds: Glucagon 1 mg IV Nifedipine 10 mg SL Nitroglycerine SL

27. 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

28. Ulcers and Gastritis

29. Ulcers and gastritis – How patients present  Pain  GI bleeding  Perforation (shock)

30. Causes  H. pylori infection  Meds: NSAID/ASA Alcohol  Spices  Severe physiological stress

31. Clinical features  Pain  Often epigastric tenderness without peritonitis  Tests not really useful except to rule out other things

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

33. Quiz

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. General References  Tintinalli, JE et al (2011) Chapters 78, 79, 80, 81, 194. McGraw Hill Publishers Emergency Medicine – A study guide 7 th Edition, USA  Manson’s Tropical Diseases, Chapter 10. Saunders Elsevier, 22 nd edition.