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GI Gems From the ER

GI Gems From the ER. Gigi Faryar RN Jewish Hospital. What is Your Emergency Today?. What were those people in the ER thinking? No appointment necessary…but a possible wait Triage – What is it? Who can do it?. Abdominal Pain. 1. Diffuse or Periumbilical Pain. AAA Ischemic Bowel

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GI Gems From the ER

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  1. GI Gems From the ER GigiFaryar RN Jewish Hospital

  2. What is Your Emergency Today? • What were those people in the ER thinking? • No appointment necessary…but a possible wait • Triage – What is it? Who can do it?

  3. Abdominal Pain

  4. 1. Diffuse or Periumbilical Pain • AAA • Ischemic Bowel • Bowel Obstruction (esp. small bowel) • Pancreatitis • Gastroenteritis • Metabolic Disturbances

  5. 2. Right Upper Quadrant • Cholecystitis • Biliary Colic • Hepatitis • Pyelonephritis

  6. 3. Right Lower Quadrant • Appendicitis • Nephrolithiasis • Crohn’s Disease of the Terminal Ileum

  7. 4. Left Upper Quadrant • Splenic Rupture • Pyelonephritis (UTI)

  8. 5. Left Lower Quadrant • Diverticulitis • Nephrolithiasis • IBS

  9. 6. Gynecologic Sources of Pain • PID • Ovarian Torsion • Ectopic Pregnancy

  10. 7. Metabolic Diseases • Acute Intermittent Porphyria • DKA • Narcotic Withdrawal • Lead Toxicity

  11. A & P • History • Physical Exam

  12. Upper GI Bleed • Incidence 100 cases per 100,000 population per year • Bleeding from the upper GI tract is 4X’s more common than from the lower GI tract • Mortality rate 6-10% overall

  13. Variceal Bleeding • Initial management • O2 • 2 large bore IV’s • Resuscitate first with IV normal saline • Start blood transfusion (goal HCT 30% in nonvariceal bleed, 24% in variceal bleed)

  14. Variceal Bleeding(Cont.) • Surgery consult • If cirrhosis is known or suspected: • Antibiotics: Norfloxacin or Ceftriaxone • Octreotide (Sandostatin) drip

  15. Variceal Bleeding(cont.) • Treatment • Therapeutic endoscopy (Emergent MainStay) • Variceal ligation or banding • Sclerotherapy • If refractory bleeding, Blakemore tube usually as a bridge

  16. Non Variceal Bleeding • Peptic ulcer disease • Ruptured Arteriovenous Malformations (AVM’S) • Mallory – Weiss tears

  17. Lower GI Bleed

  18. Sources of Lower GI Bleed • Diverticulosis : 5 - 42% • Ischemia : 6-18% • Anorectal (hemorrhoids, anal fissures, rectal ulcers) 6 – 16% • Neoplasia (polyps & cancers) 3 – 11% • Angiodysplasia : 0 – 3%

  19. Etiology of Lower GI Bleed in Adults • Postpolypectomy : 0 – 13% • Inflammatory Bowel Disease : 2 - 4% • Radiation Colitis : 1 – 3% • Other Colitis (infectious, antibiotic associated colitis of unclear etiology) : 3 -29% • Small bowel / Upper GI Bleed : 3 – 13% • Other Causes : 1 – 9% • Unknown Causes : 6 -23%

  20. Trauma

  21. Blunt vs Penetrationg Trauma • Signs & symptoms • Abdominal Pain • Tenderness • Rigidity • Bruising of the external abdomen • Ultrasound, CT, Peritoneal lavage • Treatment may include surgery

  22. Penetrating Abdominal Trauma (PAT) is usually obvious and based on clinical signs. • Blunt trauma is more likely to be delayed or missed.

  23. Blunt trauma is more common in rural areas. • Penetrating trauma is more common in urban areas.

  24. Pathophysiology of Abdominal Trauma • Liver • Spleen • Pancrease • Kidneys • Bowel

  25. Management / Treatment of the GI Patient

  26. Quick & Timely Triage to Doc • Stabilization • O2 • 2 large bore IV’s / Type & Cross • Appropriate Testing • GI or Surgical Referral as appropriate

  27. Pearls

  28. Don’t be fooled: The patient with the Upper GI pain (especially female) could be an MI (Go with Your Gut) • Bile is Never Good – Gallbladder Pain is the Worst! • Blood is bad – Control / Stop it! • Think worst case scenario & Prepare For it • Always Keep Your Sense of Humor!

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