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85 Cards in this Set
- Front
- Back
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what are some common causes of UPPER GI bleed
LOWER GI |
UPPER GI (esophagous to duodenum): peptic ulcer, esophagitis, gastritis, esophageal varicie, mallory Weiss tear
LOWER GI (past duodenum to anus): diverticular disease, angiodysplasia, hemorrhoids, anal fissure, malignancy, IBD, infectious diarrhea |
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whats the best way to know what causes upper/lower GI bleed
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know the uppers (there are only 4)
esophageal varicie mallory weiss tear peptic ulcer esophagitis/gastritis all others are lower: diverticula, angiodysplasia, hemorrhoids, anal fissure, IBD, infectious diarrhea |
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bright red blood per rectum, caused by...
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1. lower GI (diverticular, angiodysplasia, hemorrohoids, malignancy, IBD, infectious diarrhea)
2. UPPER GI that is REALLY FAST |
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whats peptic ulcer disease? tx
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upper GI bleed, ulcerated tissue bleeds (self limited bleed)
Tx: h2 block, PPI to decrease acid endoscope to coagulate, injection, hemostatic clip surgery if perforation |
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what is mallory weiss tear
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upper GI bleed
longitudinal lacteration in lower esophagous and stomach cuased by vomit hx will be non blood vomit followed by bloody vomit **blood loss is self limited |
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what are the phases of bleeding assoicated with varicies
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1. Acute- onset of active hemorrhage
2. Latter- recurrent bleed is common. **this is the upper GI that only stops on its own 50% (the other almost always stop on their own) **this isthe one that is an emergency. MUST GET BLEEDING TO STOP |
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what is teh tx for varicies
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1. replace lost blood. IV fluids, blood
2. Octreotide (long acting somatostatin): decrease portal blood flow, 3. PPI 4. ENDOSCOPY- definitive tx for active hemorrhage 5. variceall band ligation: when endoscopy fails, do balloon tampenode, risk of exsanguination (die from bleeding out) |
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if I want to replace blood in a pt with a varacie what size needle
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we want a large needle to do it FAST
so choose a small gague needle 14 is wider than 22 gague |
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if you dont die from blood loss associated with varicies what will kill you (4)
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1. aspiration pneumonia
2. sepsis 3. hepatic encepalopathy 4. renal failure |
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what is the definitive tx for actively bleeding varicies
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endoscopy
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if you are treating varicies with variceal band ligation whats the risk
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its like the last resort, its the balloon tamponade
risk of die from blood loss- exsanguination |
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what is angiodysplasia
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lower GI bleed aka AVM (atrioventricual malformation)
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wht is the theory of pathogensis of angiodysplasia
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not well understood
intermittent low grade onstruction of submucosal veins at muscularis propria. over years the obstruction results in dilation and turtous BV . aka AVM- arterioventricular malformation **this causes lower GI bleed, |
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what is the bleeding associated with angiodysplasia like
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bleed from dilated tortous VEINS in colon
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if you have painless melena/hematochezia from a venous origin in the colon whats the deal
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angiodysplasia, dilated BV from years of intermitent obstruction
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colorectal cancer
sx dx complications |
sx: blood loss, change in bowel, anemia, weight loss, dull achy pain
ddx: diverticulosis, hemorrhoids, infectious diarrhea etc **get a colonsocopt to be sure **R sided- more blood loss **L sided- change in bowel |
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what can be on the ddx for colorectal cancer? how can you be fore sure if its cancer
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lots of benign conditions- hemorrhoids, diverticulosis, infectious diarrhea, Inflammatory bowel disease
MUST have colonoscopy to determine |
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if you ahve a person >50 w/overt bleeding, unexplained anemia, abd pain, change in bowel, bloating what are you going to do and why
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COLONOSCOPY, exclude cancer
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whats true for cecal/ascending cancers
what about left sided (descending) |
Ri sided: more blood loss
L side: bowel changes |
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what does a surgical adhesion cause
what about malignancy **in terms of obstruction |
Adhesion: small bowel obstruction
Malignancy: large bowel obstruction |
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do you get a colonoscopy for a LBO or SBO
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LBO- LBO is commonly caused by cancer
SBO- adheions |
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what are the causes of SMO
what are the causes of LBO |
SBO- adhesion, hernia, cancer, intussusception. dx with x ray or ct, labs determine hydration status.
LBO: cancer, colonic volvulus, diverticular disease, almost NEVER adhesions. |
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tx for SBO
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NPO
IV hydration antiemetics pain meds NG tube surgical consult- kinda blows bc adhesions are most common cause of SBO |
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whats colonic volvulus
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colon twists on mesentary and blocks blood flow (art and venous)
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whats cecal volvulus
whats sigmoid volvulus include who gets it, treatment, |
cecal: congenital peritoneal defect that lets cecum be mobile. seen in 70's. treat surgically
sigmoid: old debilitated ppl in institutions who have had chronic constipation. treat by advancing flexible endoscope up sigmoid colon, if its gangrenous stop and do surgery **same frequency |
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tell me about diverticuLOSIS
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mm hypertrophy of colon, inflammation cuases fibrosis --> narrow lumen --> obstruction (LBO)
**high intraluminal pressure causes weak spots to bleb out into diverticula **sigmoid is most common spot to get diverticula bc its naturally the smallest lumen |
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where is the most common place in the colon to get diverticula
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sigmoid
**its an area of mm hypertrophy, chronic inflammation --> fibrosis and decreased lumen diameter **increased pressure with areas a relative weakness leads to blebs (usually false diverticula) |
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what are the complications of diverticular disease (2)
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1. Bleeding: lower GI bleed
2. Inflammation |
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tell me about the bleeding assoicated with diverticular disease
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lower GI bleed
MASSIVE bleed that stops spontaneously, managed with supportive therapy painless bleed arterial bleed diverticulosis- right colon diverticulitis- left colon |
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what is the lower GI bleed that is arterial in nature, painless, and LOTS of blood that resolves spontaneously
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diverticular- right sided
diverticulitis- left sided |
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what does it mean diverticuLitis Left
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LL- litis bleeds from the L side of the colon
losis- bleed from right |
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whats the tx for bleeding from diverticula
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1. ABC
2. usually resolves spontaneously 3. if not resolved: colonscopy, imagins, angiography, surgery |
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diverticular disease is associated with 1-bleeding and 2- inflammation, tell me about the inflammation
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now its diverticuLITIS and will bleed from the left
when poo gets stuck in the diverticula, painful (diverticulosis bleed is painless) |
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can you get fecal contamination of peritoneum from diverticulitis
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not usually
*perforation is into the mesentary or contamination gets walled off **if there is a free perforation there CAN be peritonitis |
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what is the clinical presentation of diverticulitis
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older ppl
PAINFUL LLQ fever dysuria obstruction WBC increased can have air,, ileus, obstruction, thickening, inflammation, fluid accumulation on imaging |
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whats the tx for diverticulitis
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depends on how sick the pts is
ie was there a free perforation and now there is fecal peritonitis or is it just limited? asmission- pain contol, oral AB not tolerated AB Bowel Rest Surgery- if perforation Drain abcess (interventional radiologist) **repeat episodes, take out the affected bowel |
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what is the diff btwn AVM (angiodysplasia) and diverticular disease
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AVM- venous, cecum
Diverticular- arterial bleed from R side, sigmoid, inflammation is most common side effect |
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what is the underlying cause of many anal abcesses
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block anal glands
*located at dentate line **if deeper may only visualize with DRE or CT (too painful for DRE many times) **painful- aggrevated by cough, sneeze, walking sitting |
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whats the best way to visualize anal abcess
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blocked anal gland that gets infected its up at the dentate line. get CT, often cant palpate (too painful)
**GET INTO SURGERY ASAP! AB as adjunct |
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my pt has an anal abcess... I think, i couldnt do the DRE but I started AB
whats teh deal? whats the tx |
GET A CT!!!! surgery to drain, AB as adjunct but alone is not enough
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whats a complication of anal abcess
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fistula, ick
lots of drainiage, can get infected. surgical removal :) |
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what are the 2 types of rectal prlapse
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rectal mucosa falls through ext anal sphincter
I- false, mucosal projection only <2cm, radial folds at jct w anal skin II- true, complete, extrusion of full thickness of rectal wall, concentric folds in prolapsed mucosa **painless but discomfort **common in kids |
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whats this doc? "my son was a little constipated and pushed really hard, then something red like came out!"
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rectal prolapse
I- false, radial folds II- complete, concentric folds |
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whats the tx for rectal prolapse
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1. figure out what caused it: constipation, CF, parasite etc
2. manual retraction, can become ulcerated, inflammed, irritated and bleeds lots if left to rub in teh underpants 3. surgery only if you cant retract manually or if recurrent |
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what is a common cause of blunt abd trauma (BAT)
what damage is common who is most likey to sustain such injuries |
MVA
tissue damage to solid organs: spleen liver kidney etc old and EtOH * |
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when is it good to be an old EtOH
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with BAT- abdominal laxity so will sustain injury likely
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tell me about the workup for BAT
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ALWAYS! after an MVA do you look at abdoment
**often there are no visible signs, adn there are other distracting signs (like a broken leg) DO NOT forget to check the abdomen **abdominal injusy can be source of hypotension (visceral hemorrhage, vascular accident) |
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does a head injury explain shock after an MVA
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NO! must do workup for BAT
*head trauma in rare cases can be the sole cause of shock: profound intracranial trauma or infants with secere intracranial trauma or cephalohematoma |
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ok so we said that often after MVA the abdomen looks benign despite significant trauma. what would overt BAT signs look liek
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echymosis
abd distension decreased bowel sounds seat belt sign |
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whats the work up for BAT
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1. blood/chemistry: CBC, metabollic panel, liver enzymes, pancreatic enzymes, UA, preg test, blood type, toxicology screen include EtOH levels
2. bedside US! other imaging once stable 3. potential spinal cord injury- protect during transfer/imaging |
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what is an US used for after BAT
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non invasive- look for blodo accumulations
hepatorenal space- morrisons pouch splenorenal recess inferior part of intraperitoneal cavity (pouch of douglas) pericardium |
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what is an invasive test for BAT
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dx peritoneal lavage (we could use US to look for blood, now we are going in and taking it!)
used when small amts of fluid are visualized and the pt is febrile/peritonitis gets a better look, dx blood in hemodynamically unstable pt |
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do you do CT for BAT
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YES!
defines organ injury detects hemoperitoneum- locates site of active hemorrhage *can also look at retroperitoneal structures like spinal cord |
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what are the dx tests for BAT
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US
DPL- diagnostic peritoneal lavage CT- Laprascopy- used when things are REAL bad: unexplained hypotension/blood loss in unstable pt, peritoneal irritation, pneumoperitonem w/viscous rupture, diaphragm rupture, |
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what usually causes esophageal perforation in the hospitalized pt
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procedures we do!
out of hopsital its trauma or spontaneosu |
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whats boerhaaves Syndrome
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spontaneous perforation of esophagous
PAINFUL!!!, results from vomit/straining (its a pressure thing) **dont need to have existing esophageal disease |
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what are the sx of boerhaaves
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its a spontaneous rupture of esophagous related to pressures and not necessarily preexisting esophageal disease
PAIN- odonophagia tachypenia, dyspnea, cyanosis, fever, shock **common to have hx of EtOHism **common to have hx of gastric/duodenal ulcer also |
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how is the spontaneous rupture of esophagous dx
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boerhaaves syndrome
PE- not helpful Subcu emphysema- crepitence Cxr suggests, Chest CT w/water soluble esophageal contrast is DX |
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do you do surgery to fix boerhaaves (spontaneous rupture of esophagous)
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only in thoracic, cervical will work itself out
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ok so you think there was a foerign body (FB) aspiration
whats the first step |
CXR- is it in the esophagous or trachea
coins in esophagous: circular, coronal plane in AP film coins in trachea: lateral position seen, orient in saggital plane **often objects wont show on XRAY, get a CT |
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how do you make the dx of foerign body (FB) aspiration
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high suspicion
caregiver says so abrupt onset cough, no other signs of URI |
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whats the PE look like for FB (foerign body)
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look at airway/breathing
neck swelling, edema, crepitance, erythema inspiratory stridor, expiratory wheeze ABD- perforation or obstriction in Sm intestine |
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what FB need to removed right away
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sharp in esophagous, stomach
disk batters in esophagous airway comprimise esophageal obstruction inflammation/intestinal obstruction- fever, abd pain, vomit if none of theses things and object is stomach or beyond follow with xrays and look for it in the poop |
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tell me about kids who swallow disk batteries
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its an emergency, it conducts electricity in the esophagous! GET IT OUT! can cause liquification necrosis (will look like a circle on xray)
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is it a bigger emergency to have a disk battery in the esophagous or stomach
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esophagous, both poles have contact to can conduct eletricity and cause liqifative necrosis
in stomach ther eis less risk for electrical conduction but still a risk for leakage of caustic material |
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alright, what druggie is at higher risk
stuffers or packers |
packers- plan ahead to smuggle. not risk, drugs are wrapped
stuffers- in the heat of the moment (the moment beign caught) they just stuff them in. high risk! |
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WHO def of abortion, spontaneous or otherwise
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expulsion or extraction of embryo or fetus from mom, weighs less thatn 500g
20-22 weeks or less |
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when are there lots of spontaneous abortions
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before weeks 15
8-20% of pregnancies end this way (1 in 5!) **caused by structural or chromosomal abnormalities |
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what are maternal risk factors for spontaneous abortion
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age
previous miscarriage smoke EtOH cocaine fever NSAIDS ceffeine |
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what are the 5 types of abortion
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1. threatened
2. inevitable 3. complete/incomplete 4. missed 5. septic |
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what is a threatened abortion
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bleeding through CLOSED cervix in first 1/2 of pregnancy
uterus is AGA may NOT loose the fetus (threatend) |
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a woman comes in with vaginal bleeding at 20 weeks, her cervix is closed and she has mild suprapubic pain/. whats the deal
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threatened abortion, may NOT loose the fetus!
Uterus is AGA |
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what is an inevitable abortion
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abortion WILL occur (contrast to the close cervix threatened abortion)
more bleeding than threatened cervex is DILATED, gestational tissue is felt/visualized through internal cervical os painful |
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a woman comes in with abd pain and bleeding. her cervix is dilated and gentational tissue can be visualized, whats the deal
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inevitable abortion
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what is it called when before 12 weeks the entire contents of uterus is expelled
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complete abortion
**mostly complete, few are incomplete **uterus is small and contracted *cervix is closed *minimal bleed/cramp |
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what is this
at 10 weeks a womans uterus expels all of its contents. the uterus is small adn contracted nad the cervix is closed. there is scant vaginal bleeding and minimal cramping |
complete abortion
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what is a complete abortion
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before 12 weeks
cervic is closed, uterus is small and contracted there is minimal bleeding and mild pain **the entire contents of the uterus is expelled |
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what is an imcomplete abortion
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AFTER 12 weeks (complete was before)
**significant uterine contents is expelled but some remains **aka, abortion with retained products of conception **cervix is OPEN, uterus is small but NOT contracted **LOTS of bleeding, can cause hypvolmic shock , lots of pain |
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what is more traumatic a complete or incomplete abortion
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incomplete- there is LOTS of blood, LOTS of pain, retained product of conception in the uterus. Small uterus but not contracted. Os is OPEN. after 12 weeks
*complete:before 12 weeks. entire uterine contents is expelled. cervic is closed. uterus is small and contracted. minimal bleed/cramps |
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whats a missed abortion
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in utero death BEFORE 20 weeks, pregnancy is retained.
cervix is closed. |
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what type of abortion did Tami have
What about mom |
Tami- missed. baby dies in utero before 20 weeks, preg retained
Mom- incomplete. Lots of blood, after 12 weeks. cervix is open uterus is small and not contracted. products of conception remain in uterus |
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shoudl you US abortions
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ya, look for other pregnancy retained product of cenception
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whats the work up for a preg female with vaginal bleeding
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1. HGB, HCT
2. serum QUANTATATIVE hCG 3. pelvic US 4. Rh factor 5. Blood type and screen |
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what is teh hCG discriminatory zome
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the hCG conc that means there shoudl be something in the uterus
**1500-2000 with transvaginal US |
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what is dysfunctional uterine bleeding
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uterine bleed. ask...
1. preggo? 2. blood from uterus for sure 3. personal/family hx of bleeding disorder **causes: vWF disease thrombocytopenia acute leukemia antiocoagulants advanced liver disease Neoplasms: endometrial adenocarcinoma, uterine sarcoma Structural lesions: leiomyoma (uterine fibroids), adenomyosis, polyps |
